Gabriele Badano

This thesis discusses how societies should allocate clinical care resources. The first aim of the thesis is to defend the idea that clinical care resource allocation is a matter for deliberative democratic procedures. I argue that deliberative democracy is justified because of its ability to implement equal respect and autonomy. Furthermore, I address several in-principle objections to the project of applying deliberative democracy to clinical care resource allocation. Most notably, I respond to the narrow view of the scope of deliberative democracy and the critiques of explicit rationing. The second aim of the thesis is to determine what is required by deliberative democracy in clinical care resource allocation. I identify the general requirements that resource allocation agencies should meet, namely public reason, public involvement, transparency, accuracy and revisability. I then examine what is required by deliberative democracy with regard to two particularly salient specific topics, namely the substantive values that should govern resource allocation and the involvement of scientific experts in decision-making. I demonstrate that public reason imposes severe constraints on the substantive values that should be employed. Most of these constraints are rooted in the idea that, under a regime of scarcity, public reason requires that resources be allocated so as to minimise the strongest complaint anyone may have. Out of the variety of values that are commonly proposed as relevant, only priority to the worst-off, ability to benefit, specialness of clinical care and cost are consistent with public reason. Turning to expert involvement, I argue that deliberative democracy can overcome several formidable threats, such as the opacity of expert opinions to laypersons and the tendency to hide uncertainty and disagreement from the public. I also discuss how my proposals on substantive values and expert involvement could be implemented, in order to add to the plausibility of my theory.

Originally proposed by John Rawls, the idea of reasoning from conjecture is popular among the proponents of political liberalism in normative political theory. Reasoning from conjecture consists in discussing with fellow citizens who are attracted to illiberal and antidemocratic ideas by focusing on their religious or otherwise comprehensive doctrines, attempting to convince them that such doctrines actually call for loyalty to liberal democracy. Our goal is to criticise reasoning from conjecture as a tool aimed at persuasion and, in turn, at improving the stability of liberal democratic institutions. To pursue this goal, we use as case study real-world efforts to counter-radicalise at-risk Muslim citizens, which, at first glance, reasoning from conjecture seems well-placed to contribute to. This case study helps us to argue that the supporters of reasoning from conjecture over-intellectualise opposition to liberal democracy and what societies can do to counter it. Specifically, they (i) underestimate how few members of society can effectively perform reasoning from conjecture; (ii) overlook that the burdens of judgement, a key notion for political liberals, highlight how dim the prospects of reasoning from conjecture are and (iii) do not pay attention to the causes of religious persons’ opposition to liberal democracy. However, not everything is lost for political liberals, provided that they redirect attention to different and under-researched resources contained in Rawls’s theory. In closing, we briefly explain how such resources are much better placed than reasoning from conjecture to provide guidance relative to counter-radicalisation in societies (i) populated by persons who do not generally hold anything close to a fully worked out and internally consistent comprehensive doctrine and (ii) where political institutions should take responsibility for at least part of the existing alienation from liberal democratic values.

Normative political theorists have been growing more and more aware of the many difficult questions raised by the discretionary power inevitably left to public administrators. This article aims to advance a novel normative principle, called ‘principle of restraint’, regulating reform of established administrative agencies. I argue that the ability of public administrators to exercise their power in accordance with the requirements of public reason is protected by an attitude of restraint on the part of potential reformers. Specifically, they should refrain from any reform of an administrative agency that involves a switch to a considerably more loosely interconnected system of values underlying the work of that agency. To illustrate the importance of the principle of restraint, I examine a case from British health policy, showing that a recent reform of the National Institute for Health and Care Excellence well exemplifies the serious problems brought by any violation of that principle.

This article discusses the growth of the populist radical right as a concrete example of the scenario where liberal democratic ideas are losing support in broadly liberal democratic societies. Our goal is to enrich John Rawls’ influential theory of political liberalism. We argue that even in that underexplored scenario, Rawlsian political liberalism can offer an appealing account of how to promote the legitimacy and stability of liberal democratic institutions provided it places partisanship centre stage. Specifically, we propose a brand-new moral duty binding ‘reasonable’ partisans committed to pluralism. This duty establishes conditions where partisans must strategically transform society’s public reason (i.e. transform the visions for society their parties campaign on) in ways that promise to attract back support from illiberal and antidemocratic competitors. While this strategic behaviour might seem impermissible, we show that Rawls’ distinctive account of sincerity in democratic deliberation is uniquely placed to justify it as perfectly ethical.

Public reason liberalism is defined by the idea that laws and policies should be justifiable to each person who is subject to them. But what does it mean for reasons to be public or, in other words, suitable for this process of justification? In response to this question, Kevin Vallier has recently developed the traditional distinction between consensus and convergence public reason into a classification distinguishing three main approaches: shareability, accessibility and intelligibility. The goal of this paper is to defend the accessibility approach by demonstrating its ability to strike an appealing middle course in terms of inclusivity between shareability and intelligibility. We first argue against Vallier that accessibility can exclude religious reasons from public justification. Second, we use scientific reasons as a case study to show that accessibility excludes considerably fewer reasons than shareability. Throughout the paper, we connect our discussion of accessibility to John Rawls’s model of public reason, so as to give substance to the accessibility approach and to further our understanding of Rawls’s influential model.

The idea that healthcare should become more person-centred is extremely influential. By using recent English policy developments as a case study, this article aims to critically analyse an important element of person-centred care, namely, the belief that to treat patients as persons is to think that care should be ‘co-produced’ by formal healthcare providers and patients together with unpaid carers and voluntary organizations. I draw on insights from political philosophy to highlight overlooked tensions between co-production and values like equality and liberty. Regarding equality, I argue that co-production compounds both problems of gender inequality in the distribution of care labour and the challenges associated with securing equal access to care. Turning to liberty, I identify important commonalities between co-production and republicanism in political philosophy, given their shared insistence on common citizens’ civic virtue. Then, I use against co-production some liberal arguments against republicanism, to highlight a problem of over-demandingness. In bringing my argument to a close, however, I wish to caution against hastily rejecting co-production as a policy programme.

William Smith’s recent article criticises the so-called orthodox approaches to the normative analysis of healthcare resource allocation, associated to the requirement that decision-makers should abide by strictly procedural principles of legitimacy defining a deliberative democratic process. Much of the appeal of Smith’s argument goes down to his awareness of real-world processes and, in particular, to the large gap he identifies between well-led democratic deliberation and the messiness of the process through which the intuitively legitimate Affordable Care Act was created. This reply aims to demonstrate that the ACA provides no counterexample to orthodox views, seizing this opportunity to explore the specific space that the procedural principles populating orthodox accounts are meant to regulate. Neither general questions of healthcare justice concerning, for example, universal access nor, relatedly, the activity of elected politicians falls within the natural scope of application of such principles, revealing a much more complex picture of the interactions between justice and legitimacy as well as substantive and procedural considerations than acknowledged by Smith. In the end, orthodox accounts of healthcare resource allocation turn out to provide a precious fund of theoretical resources for the normative study of administrators, which might be useful well beyond bioethics and health policy.

Norman Daniels’s theory of ‘accountability for reasonableness’ is an influential conception of fairness in healthcare resource allocation. Although it is widely thought that this theory provides a consistent extension of John Rawls’s general conception of justice, this paper shows that accountability for reasonableness has important points of contact with both utilitarianism and intuitionism, the main targets of Rawls’s argument. My aim is to demonstrate that its overlap with utilitarianism and intuitionism leaves accountability for reasonableness open to damaging critiques. The important role that utilitarian-like cost-effectiveness calculations are allowed to play in resource allocation processes disregards the separateness of persons and is seriously unfair towards individuals whose interests are sacrificed for the sake of groups. Furthermore, the function played by intuitions in settling frequent value conflicts opens the door for sheer custom and vested interests to steer decision-making.

Unlike his theory of justice as fairness, John Rawls’s political liberalism has generally been spared from critiques regarding what is due to the disabled. This paper demonstrates that, due to the account of the basic ideas of society and persons provided by Rawls, political liberalism requires that the interests of numerous individuals with disabilities should be put aside when the most fundamental issues of justice are settled. The aim is to accommodate within public reason the due concern for the disabled while upholding political liberalism. To achieve this aim, a revision of the basic ideas of persons and society is proposed. The idea of persons should be regarded as more fundamental than that of social cooperation, and persons should be defined in terms of minimal moral powers.

Recent epidemiological research on the social determinants of health has been used to attack an important framework, associated with Norman Daniels, that depicts healthcare as special. My aim is to rescue the idea that healthcare has special importance in society, although specialness will turn out to be mainly limited to clinical care. I build upon the link between Daniels's theory and the work of John Rawls to develop a conception of public justification liberalism that is suitable to the field of justice and health. I argue that, from the perspective of public justification liberalism, (clinical) healthcare deserves special status.

The involvement of the public in the governance of genomics has become a topic of growing interest among scholars, practitioners and policy-makers. The implementation of public involvement programmes may be quite expensive, and the design and evaluation of public participation is a matter of controversy. Thus, this paper examines the justifications for public participation in the governance of genomic research to help understand whether public involvement is worthwhile and to provide a guide to the design of public participation. I identify four primary justifications in support of public involvement. I argue that three of them have serious flaws: neither an increase in the stability of institutions, nor the positive effects on the virtues of individuals, nor the epistemic merits of participatory activities provide a solid ground for the engagement of the public in the governance of genomics. However, the ideal of legitimacy in the exercise of coercive power appears to lend strong support to public involvement programmes. Given that the reasons why public involvement is sought shape the design of the participatory activities, restricting the range of valid justifications promises to simplify the task of designing and evaluating public involvement.