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The recent decision of the secretary of state concerning how sildenafil (Viagra) will be made available within the National Health Service1 will have angered most men with erectile dysfunction and has caused grave disquiet among doctors.2 In dressing up a rationing decision as a clinical one, the secretary of state has ended up with the worst of all possible worlds: a decision that makes no sense on clinical, equity, or cost effectiveness grounds and has alienated communities that need to be engaged if rationing is to be acceptable.

Sildenafil was licensed for use in the United Kingdom on 15 September 1998. The previous day the NHS Executive issued guidance about the drug, stating that ministers would be considering the evidence and drawing up substantive policy proposals within the next few weeks; as an interim measure, the Standing Medical Advisory Committee had advised that doctors should not prescribe sildenafil.3 At that time most doctors complied with the interim guidance, explaining to their patients that a definitive ruling on the availability of sildenafil within the NHS would be made within weeks. However, it subsequently became known that the Standing Medical Advisory Committee (which advises the secretary of state on medical matters) …