You are the Principal Secretary, Health, in a state. A state-run super-speciality hospital has 6 paediatric heart-transplant slots a year; demand is 80 children, of whom 22 are critically waitlisted. The current first-come allocation favours those who reach the registry early — often urban, educated families. A proposed revision would weigh medical urgency (40 per cent), age-prognosis (30 per cent), waitlist time (20 per cent), and geographical equity (10 per cent). The medical fraternity is divided; an industrialist offers ₹30 crore in CSR to fund 4 additional slots in a private hospital tie-up. The State Cabinet wants a memo in 14 days. What course of action would you take? Justify with the values involved.

Dilemma: A Principal Secretary, Health, must design an allocation rule for six paediatric heart-transplant slots a year against demand from 80 children, of whom 22 are critically waitlisted, and decide whether to accept a Rs 30 crore CSR offer to fund four extra slots through a private-hospital tie-up. The dilemma is twofold — designing a fair triage rule under irreducible scarcity, and using CSR-funded private capacity without commodifying access.

Stakeholders: 80 child patients and families, especially the 22 critically waitlisted; the divided medical fraternity; the state super-speciality hospital and its surgical team; the proposed private partner and the donor-industrialist; the State Cabinet; the State Medical Council and the State Human Rights Commission; the Law Department for MoU vetting; future paediatric cohorts whose access depends on this precedent.

Options analysed: (a) retain first-come allocation — entrenches social-capital and urban-literacy bias against rural families, breaches Rawlsian justice-as-fairness and Sen's capability approach, unlikely to survive an Article 21 challenge under the Puttaswamy (2017) line; (b) accept only the revised four-factor weighting (medical urgency 40, age-prognosis 30, waitlist time 20, geographical equity 10 per cent) — improves fairness but leaves supply at six when ten are feasible, sacrificing four lives a year on purist objection; (c) adopt the four-factor weighted rule and accept the Rs 30 crore CSR-funded four extra slots under a strict public-protocol MoU — the same triage rule applies in the private hospital, no donor-naming rights, prices capped at state rate, waitlist unified, donor has zero discretion over selection — the hard right.

Decision and reasoning: Option (c). The Cabinet memo proposes the four-factor weighting plus the CSR addition under a public-protocol MoU. An independent triage committee with paediatric cardiologists, an ethicist and an HRC nominee runs the unified waitlist; a transparency dashboard updates weekly. Three named values anchor it: Rawls's justice-as-fairness demanding explicit criteria over discretion; Sen's capability approach restoring child agency; and Beauchamp-Childress bioethics — beneficence, non-maleficence, justice, respect — endorsed by WHO triage protocols. THOTA 1994 fair-access norms, Article 21 with Puttaswamy (2017) give the constitutional foundation; Kerala's Mrithasanjeevani registry shows feasibility.

Safeguard / institutional fix: Publish triage criteria and weightings under RTI Section 4; weekly anonymised waitlist update; audit by the State Medical Council; appeal through the State HRC; CSR MoU vetted by the Law Department with explicit no-quid-pro-quo and no-naming-rights clauses; donor barred from selection; oversight board with a parent representative; annual weighting-matrix review; rule that any CSR-funded private capacity must operate under the same public protocol and triage committee.