When drug budgets are unable to accommodate all new drug requests, a dilemma arises when additional funds become available - which drugs should receive priority? The drug committee at Royal Adelaide Hospital devised a scheme, which they describe here, to rank drug requests to obtain the greatest benefit for the most patients for each dollar spent. We asked a health economist, a clinical pharmacologist, and a moral philosopher to give their perspectives on this form of rationing, and we then gave the authors an opportunity to respond.

The cost of all aspects of health care in developed countries is increasing at an alarming rate.1 Meeting these costs is becoming more difficult, and a variety of cost containment measures is being considered at national and regional levels.^2,3 The continuing introduction of new technologies and drugs is one of the factors in the escalating cost of health care. These new treatments are often incompletely evaluated, and estimates of cost-benefit are lacking or poorly documented. This situation has resulted in a vigorous debate about the need for, ethics of, and possible methods for cost containment and rationing of health services.*RF 4-8*

Hospitals have responded to shrinking financial resources by increasing day patient or outpatient services; transferring outpatient services to the community; imposing waiting lists; making services available only as long as funds are available; and withdrawing some services altogether. The last two options, and to some extent the imposition of waiting lists, are usually unplanned since cuts in hospital or divisional budgets often occur with little warning, and they can be regarded as arbitrary and unfair. Those patients who are excluded from the curtailed or reduced service are often those who were the last to join the queue.

The Royal Adelaide Hospital is a tertiary referral hospital of about 900 beds. …