The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)

In his impressive and wide?ranging new book, Sources of the Self, Charles Taylor argues that modern moral philosophy, at least within the Anglo?American tradition, . offers a ?cramped? view of morality. Taylor attributes this problem to three distinctive features of contemporary moral theory ? its commitment to procedural rather than substantive rationality, its preference for basic reasons rather than qualitative distinctions, and its belief in the priority of the right over the good. According to Taylor, the result of these features (...) is that contemporary moral theories cannot explain the nature of a worthwhile life, or the grounds for moral respect. Indeed, they render these questions unintelligible. I argue that Taylor has misunderstood the basic structure of most modern moral theory, which seeks to relocate, rather than suppress, these important questions. In particular, he fails to note the difference between general and specific conceptions of the good, between procedures for assessing the good and specific outcomes of that procedure, and between society's enforcement of morality and an individual's voluntary compliance with morality. Each of these distinctions plays an important role in contemporary moral theory. Once they are made explicit, it is clear that many contemporary theorists operate with a more sophisticated account of moral sources than Taylor attributes to them. (shrink)

The publication of Political Liberalismhas allowed John Rawls to bring to the fore issues that remained in the background of A Theory of Justice. His explicit attention to the concept of ‘the reasonable’ is a welcome development. In a more recent publication, he affirms the importance of this concept, ‘while [granting] that the idea of the reasonable needs a more thorough examination than Political Liberalism offers.’ In this paper, I will present a critical exposition of the senses of the reasonable (...) on which justice as fairness relies. Rawls employs the term in four main contexts. I will outline these various senses and argue that in each case, a controversy in the secondary literature can be resolved by close attention to the concept of the reasonable. In three of these contexts, Rawls relies on what I will call a ‘strong’ sense of the reasonable, while in one he sometimes seems to rely on a ‘weak’ sense. I argue that justice as fairness is best served by relying on a strong sense throughout. (shrink)

The aim of this essay is to reflect on the Millian, utilitarian argument from truth that is held as one of the most conspicuous answers to the question Why tolerate? This argument postulates that only in a free market of ideas may the truth be discovered. Even the most unpopular idea may contain some truth in it and may contribute to the advancement of knowledge. It further commands us to contest those opinions which are believed to be true vigorously and (...) earnestly to explore some further truth, and to acknowledge their false aspects. The results of free exchange of opinions will either confirm our idea, or bring some doubt to our attention, to cast accounts and maybe change our opinion, at least to some extent. After reflecting on some of the common arguments that are frequently mentioned in this connection, I discuss Mill's formulation of the Truth Principle as it came into expression in his writings. Here I reflect on his article "Law of Libel and Liberty of the Press" which did not receive adequate attention by scholars. I show that it is difficult to reconcile what Mill had to say in this article with what he later said in On Liberty. I further maintain that the Millian view of truth as superior to all other social values might endanger the very ground which the Truth Principle is intended to safeguard, i.e., tolerance. The holding of truth as the most important value might result in harming individuals, and in generating an atmosphere of intolerance. (shrink)