Tough Decisions
March 20, 2020
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Notes on A4R

Framing a Framework: A4R

About A4R

Accountability for reasonableness (A4R) is a highly influential resource allocation framework developed by Daniels and Sabin in 2002. The purpose of the framework is to achieve procedural fairness in resource allocation, in other words to ensure that the process by which resource allocation decisions are made is ethically sound. This does not mean that by following this framework that one will necessarily achieve the optimal resource allocation strategy, but rather seeks to ensure that decisions are made in minimally just conditions (that they are reasonable). By following the steps of the A4R framework, healthcare organizations can clearly justify the resource decisions being made and stand up to ethical scrutiny.

The conditions of reasonable policy making

Originally Daniels and Sabin created 4 conditions under which resource allocation decisions can be deemed to be reasonable. The conditions are:

  1. Relevance: Decisions should be based on reasons or evidence that reasonable persons would agree are relevant given the circumstances of the decision.
  2. Publicity: The decision and the reasons for said decision should be made publicly available.
  3. Revision: Opportunity for revision and a mechanism for resolving disputes should be available.
  4. Enforcement: Voluntary or public regulation should exist to ensure these principles are met.

After a joint article by Jennifer Gibson, Martin Douglas, and Peter Singer was published a few years later in 2005, another condition 5th condition was added to the framework:

  1. Empowerment: Effort should be made in minimizing power differences between stakeholders in order to ensure effective stakeholder participation.

By ensuring these conditions are met, resource allocation decisions are justifiable and can be said to be reasonable. But are they optimal?

A4R in practice: a framework for a framework

As mentioned, this framework is highly influential and has been adopted or incorporated into many health organizations decision making processes. However, A4R is noticeably non-specific, it provides general principles to be adhered to, but does not provide steps or details when it comes to actually making a resource allocation decision. This is not necessarily a criticism, as A4R serves its purpose well as providing the conditions necessary to achieve procedural fairness. What it means though is that A4R is often used in tandem with another decision-making framework or integrated into another framework in order to be specifically tailored to a particular healthcare organization’s needs; it frames the framework. By using A4R in conjunction with a more specific ethical decision making framework, one gains from the general applicability and soundness of A4R while also gaining specific direction in decision-making. Having a solid foundation is necessary, but houses have more functionality. If you are interested in learning more about ethical decision making frameworks, please check out our Resources page, we have provided brief explanations of dozens of frameworks, ranging from resource allocation to step by step case analysis along with links to published articles.


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