So, for example, in our day, it is too often global markets and multinational corporate interests that determine whether old-growth forests are logged, not the local communities affected by the decision. In much the same way, it is too often insurance companies and health care managers who specify the ends of medical practice and who determine the normative contours of a healthy life, not real and potential patients, not health care providers, not those who actually care for the sick. When this happens, judgments about tolerable and intolerable distribution of drug benefits will not be made by those most affected by them, and they will not be assessed by the particular standards of excellence implicit in these local practices.22