From Justification to Legitimacy: A Deliberative Framework for Decisions Around Expensive Drugs for Rare Diseases

Decisions about expensive drugs for rare diseases (EDRDs) raise complex ethical challenges beyond the allocation of limited healthcare resources. This paper examines the ethical dimensions of EDRD decision-making, arguing that the framing of such decisions as simply ethical or unethical is inadequate. In complex healthcare systems characterized by diversity and inequality, no single normative theory provides an incontrovertible solution. EDRD decisions require both ethical justification (grounded in carefully interpreted and balanced values) and ethical legitimacy (achieved through fair processes that respect autonomy). Interest-based accounts of procedural justice are insufficient because they mischaracterize how people form identities and interests. Deliberative democratic approaches that engage multiple perspectives through reflective, inclusive processes are more promising, though they face challenges of complexity, time constraints, and resistance to transparency. Transparency is essential, and courageous leadership is needed to establish processes that accommodate diverse perspectives while addressing the practical realities of healthcare systems. Such leadership can help create ethically defensible EDRD decisions that balance patient needs with system sustainability.