ABSTRACT The determination of death by neurologic criteria (brain death) has increasingly become a topic of controversy. Here we address a question that provokes clinical ethics consultations and scholarly debate: “how should objections to the declaration of neurologic death be handled?” While much of the discourse on this question has focused on the legitimacy of the criteria for brain death determinations or the motivations of individuals' objections to declarations of death, our analysis addresses a deeper issue inherent in the conflicts in clinical settings. We argue that some objections to brain death cannot be explained away as grief, misunderstanding, or different religious beliefs. Rather, tensions between worldviews—fundamental standpoints or lenses through which humans experience and conceptualize the world around them—may drive conflicts around brain death. In what follows, we introduce the concept of worldview silencing as a means of recognizing the injustice that can occur when brain death objections grounded in alternative ontologies of death are unfairly dismissed or disrespected. Ultimately, we contend that the concept of worldview silencing offers moral guidance for just recognition of objections to brain death in practice, education, and policy.
ABSTRACT Current fashion supports aligning health policy with the recommendations of deliberative forums, or mini‐publics. These forums' participants are selected randomly from the general public (sometimes with overrepresentation of direct stakeholders or of underrepresented sectors). After being informed and exchanging public reasons with fellow participants under discursive rules that engage all as equals, participants vote on and sometimes rank policy recommendations. According to supporters, a deliberative democratic process that holds such forums and translates their recommendations to policy legitimizes resulting policy. That's thanks to this process's tendencies to strengthen democratic consent, to uncover which policy option is objectively best, to align policy with lay normative outlooks, and to educate the public. I argue that one tri‐partite feature of nearly all instances of democratic deliberation on regional, national, and global health policy under current best practice, which I call the “Scaleup costs, Size, and Statistics” (“3S”) challenge, largely blocks these alleged welcome tendencies. In particular, barring radical changes, true democratic deliberation is expensive to scale, keeping feasible mini‐publics small and irregular. That makes concluding from mini‐public recommendations about the population's hypothetical consent, values, and will statistically unreliable. It also caps low mini‐publics' contribution to public education. In these ways and in others, the long list of alleged welcome tendencies of proper democratic deliberation on health policy, and the related contribution to political legitimacy, is largely a fiction. Public deliberation does have modest true merit, for example, providing relevant qualitative input about the lay public's occasional factual insights and many endemic errors; and making the public feel “listened to,” whether or not it is. But those merits are modest, contingent, and most accentuated under different institutions than envisaged in deliberative democratic literature. Certainly there is room for democratic deliberation, potentially of new breeds, but only as part of the mosaic of health policy design, alongside familiar methods like general elections, public surveys, representative government, and expert decisionmaking. The main question is which method to use when.
ABSTRACT 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.
