# Who decides who goes first? Taking democracy seriously in micro-allocative healthcare decisions

## TL;DR

This paper explores who should decide how scarce healthcare resources are distributed, arguing that democratic processes with political representatives are fairest.

## Contribution

The paper proposes that political representatives, supported by experts, should define healthcare allocation criteria to ensure democratic legitimacy.

## Key findings

- Allocation criteria should be defined by political representatives to ensure democratic legitimacy.
- Three alternatives—attending physician, physician team, and expert team—are rejected due to fairness and legitimacy concerns.
- The proposal addresses critiques of specificity and catastrophic outcomes to strengthen its democratic argument.

## Abstract

The structural scarcity of healthcare resources has deeply challenged their fair distribution, prompting the need for allocation criteria. Long under the spotlight of the bioethical debate with an extraordinary peak during the recent COVID-19 pandemic, micro-allocation of healthcare has been extensively discussed in the literature with regard to issues of substantive and formal justice. This paper addresses a relatively underdiscussed question within the field of formal justice: who should define micro-allocation criteria in healthcare? To explore this issue, we first establish formal requirements that must be met for allocation criteria to be considered fair and legitimate. Then, we introduce three possible answers to the research question: the attending physician, the team of physicians, and the team of experts. We discuss and then reject all of them, arguing that the task of defining allocation criteria should be assigned to a political representative, supported by a cross-disciplinary team of experts. This proposal is based on the need to take democracy seriously as a tool for making substantive allocative decisions in light of the inevitable disagreement on such matters within a community. To support this claim, we present two key arguments—the democracy argument and the consistency argument. We also pre-emptively respond to two significant critiques: the too-specificity of the decision critique and the catastrophic outcomes critique. In conclusion, we argue that our proposal offers the fairest and most legitimate decision-making process for healthcare micro-allocation.