Space does not permit a complete description of the democratic deliberative process as I imagine it or of the moral and political arguments that would justify this mechanism as a fair and “just enough” approach to making health care rationing decisions. The interested reader should consult chapter five of my book (2009) referenced above in note 1. In brief, we cannot, as a practical matter, have 310 million deliberators. But the deliberative process ought to be transparent to our 310 million citizens. We could have a broadly representative deliberative group in every congressional district, perhaps with 50 members. These would be enduring groups, working for years into the indefinite future, as opposed to one-time community forums or commission-like groups that might work for a year. This is a “rational” or “informed” deliberative process. That means balanced, accurate, fair-minded information must be fed into these groups relative to specific rationing or priority-setting decisions. Likewise, facilitators of these deliberations must be scrupulously fair-minded. Further, we have to imagine that the work of these 435 deliberative groups would be fed into a top-level independent decision making body entirely distinct from congressional control, immune to deliberative corruption, whose decisions could not be revised through interest group politics in Congress. The closest analogue in the real world with which I am familiar is NICE, the National Institute of Clinical Excellence in Great Britain. They make recommendations to the National Health Service about whether or not, for example, these very expensive cancer drugs ought to be available to cancer patients in Great Britain and paid for by the NHS. For more information about NICE, see Rawlins, M. D.
and Culyer, A. J.
, “National Institute for Clinical Excellence and Its Value Judgments,” BMJ 329
, no. 7459
. See also Maynard, A.
, Bloor, K.
, and Freemantle, N.
, “Challenges for the National Institute for Clinical Excellence,” BMJ
329, no. 7459 (2004): 227–229. For evaluating the quality of democratic deliberative processes see my essay Fleck, L. M.
, “Creating Public Conversation about Behavioral Genetics,” in Parens, E.
, Chapman, A.
, and Press, N.
, eds., Wrestling with Behavioral Genetics: Science, Ethics, and Public Conversation
(Baltimore: Johns Hopkins University Press, 2006): 257–285.CrossRefGoogle Scholar