The Process Is Not the Point: Moral Uncertainty and Substantive Justice in Health Care Priority Setting

Health actors must ration care due to resource constraints. But even when decision makers know the relevant empirical facts about an allocation decision-including how many patients will benefit from a service, which patients will benefit, how much each patient will benefit, and so on-these facts may not provide a clear answer about how to make allocation decisions. This is because competing moral principles recommend different courses of action: for instance, maximizing health benefits may involve deprioritizing more disadvantaged groups. Facing this moral uncertainty, many ethicists and policymakers have embraced using "fair processes" that emphasize procedural justice over substantively just outcomes. This paper challenges the proceduralist consensus on two grounds. First, I argue that designing fair processes generates as much moral uncertainty as making allocation decisions directly, while also failing to address the substantive allocation question that must ultimately be answered. Second, both theory and empirical evidence suggest that fair processes favor less cost-effective interventions, risk compounding health inequities, and divert resources that might otherwise be used for health care. As an alternative approach, I argue that health actors should pursue substantive justice through Maximizing Expected Choiceworthiness (MEC)-a decision framework that aims to choose options based on their expected value across different possible moral principles, weighted by the confidence decision makers have in each principle. I demonstrate that MEC can yield practical, intuitive answers to some resource allocation questions, while providing a helpful framework for approaching others. I conclude that health actors can and should pursue substantive-rather than procedural-justice in setting health priorities.