But the deliberative process is occurring among citizens who are essentially

But the deliberative process is occurring among citizens who are essentially healthy, who are behind what Rawls [45] would think of as a order ML240 health care veil of ignorance. Virtually none of us know what the health problems are that we might have to face over the next thirty or forty years. We might have inklings based upon family history or even some actual genetic testing. But these are just inklings to which great uncertainty is attached. We might be especially anxious about cancer, so we might endorse paying 200,000 for that three-drug combination. We might be opposed to those who would want to deny access to those drugs at social expense. We might be less concerned about heart disease. So we might oppose a new drug for end-stage heart disease that cost 200,000 and yielded on average only five extra months of life. We might argue that was not worth it. But this isJ. Pers. Med. 2013,where moral and rational consistency must shape this deliberative process. Can a good reason, a morally compelling justice-relevant reason, be offered for making a distinction between these two sets of circumstances? It is not obvious that such a reason could be offered. Hence, if someone was concerned now about controlling present and future health care costs to them, they would have to reject these hyper-expensive drugs in both circumstances. We should make clear that the deliberative process is informed by the best medical knowledge available at a point in time. This is also part of what makes the deliberative process rational. As for ragged edge issues, as noted earlier, lots of possible choices could be made, all of which would be morally acceptable. That is, they would be roughly just because there would be no perfectly just choice that could be made. The world of health care is just too complex for that to be possible. Still, what is necessary is a collective social choice that reflects what the deliberative process judged to be a fair and reasonable trade-off. This is not something that can be left to the self-serving whims and rationalizations of individuals. Suppose that someone at age forty participated in these democratic deliberations and was opposed to any limitations on access to marginally beneficial cancer, but his views reflected a very BQ-123 site minority position. He is now eighty and has a late stage cancer for which he is being denied at social expense one of these combinations of cancer drugs that will yield only five extra months of life for 200,000. Has he been treated unjustly? We could say he was unfortunate, though he has achieved age eighty. All others in similar circumstances are faced with the same denial; he is not a victim of some form of social discrimination. In the forty intervening years, in fact, thousands of individuals were denied similar drugs for similar reasons. The money saved was put into cancer research aimed at improving dramatically the effectiveness of advanced cancer therapy for some individuals who happened to have the right genotype or whose cancer proved to be especially responsive. In fact, we can imagine that this gentleman was a beneficiary of this research at age seventy. Under these circumstances he cannot reasonably claim that the deliberative process yielded an outcome that was unjust for him. Ultimately, a well-constructed democratic deliberative will yield outcomes that are respectful enough of individual liberty while protecting the framework of justice that must hold a society together. It is also congrue.But the deliberative process is occurring among citizens who are essentially healthy, who are behind what Rawls [45] would think of as a health care veil of ignorance. Virtually none of us know what the health problems are that we might have to face over the next thirty or forty years. We might have inklings based upon family history or even some actual genetic testing. But these are just inklings to which great uncertainty is attached. We might be especially anxious about cancer, so we might endorse paying 200,000 for that three-drug combination. We might be opposed to those who would want to deny access to those drugs at social expense. We might be less concerned about heart disease. So we might oppose a new drug for end-stage heart disease that cost 200,000 and yielded on average only five extra months of life. We might argue that was not worth it. But this isJ. Pers. Med. 2013,where moral and rational consistency must shape this deliberative process. Can a good reason, a morally compelling justice-relevant reason, be offered for making a distinction between these two sets of circumstances? It is not obvious that such a reason could be offered. Hence, if someone was concerned now about controlling present and future health care costs to them, they would have to reject these hyper-expensive drugs in both circumstances. We should make clear that the deliberative process is informed by the best medical knowledge available at a point in time. This is also part of what makes the deliberative process rational. As for ragged edge issues, as noted earlier, lots of possible choices could be made, all of which would be morally acceptable. That is, they would be roughly just because there would be no perfectly just choice that could be made. The world of health care is just too complex for that to be possible. Still, what is necessary is a collective social choice that reflects what the deliberative process judged to be a fair and reasonable trade-off. This is not something that can be left to the self-serving whims and rationalizations of individuals. Suppose that someone at age forty participated in these democratic deliberations and was opposed to any limitations on access to marginally beneficial cancer, but his views reflected a very minority position. He is now eighty and has a late stage cancer for which he is being denied at social expense one of these combinations of cancer drugs that will yield only five extra months of life for 200,000. Has he been treated unjustly? We could say he was unfortunate, though he has achieved age eighty. All others in similar circumstances are faced with the same denial; he is not a victim of some form of social discrimination. In the forty intervening years, in fact, thousands of individuals were denied similar drugs for similar reasons. The money saved was put into cancer research aimed at improving dramatically the effectiveness of advanced cancer therapy for some individuals who happened to have the right genotype or whose cancer proved to be especially responsive. In fact, we can imagine that this gentleman was a beneficiary of this research at age seventy. Under these circumstances he cannot reasonably claim that the deliberative process yielded an outcome that was unjust for him. Ultimately, a well-constructed democratic deliberative will yield outcomes that are respectful enough of individual liberty while protecting the framework of justice that must hold a society together. It is also congrue.