Contemporary Political Theory

, Volume 12, Issue 4, pp 296–317 | Cite as

Procedural justice and democratic institutional design in health-care priority-setting

  • Claudia Landwehr


Health-care goods are goods with peculiar properties, and where they are scarce, societies face potentially explosive distributional conflicts. Animated public and academic debates on the necessity and possible justice of limit-setting in health care have taken place in the last decades and have recently taken a turn toward procedural rather than substantial criteria for justice. This article argues that the most influential account of procedural justice in health-care rationing, presented by Daniels and Sabin, is indeterminate where concrete properties of rationing institutions are concerned. Such properties inscribe substantial norms into institutions. These norms can derive validity only from democratic majority decisions, which must be seen as an instance of pure procedural justice. We therefore have to move the discussion to a meta-level and ask how concrete properties of institutions are being chosen. I suggest four criteria for sufficiently democratic institutional design choice and conclude that as institutional properties are likely to have effects on the resulting distribution of health care, design choices should be empirically informed and taken both democratically and deliberately.


distributive justice procedural justice health care institutional design democratic legitimacy 



The author thanks three anonymous reviewers and the editors for helpful comments on earlier versions of this article, as well as the VolkswagenStiftung for funding the research that this article is based on through a Schumpeter Fellowship.


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Copyright information

© Palgrave Macmillan, a division of Macmillan Publishers Ltd 2013

Authors and Affiliations

  • Claudia Landwehr
    • 1
  1. 1.Johannes Gutenberg UniversitätMainzGermany

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