Intended for healthcare professionals

Education And Debate

The rationing debate: Maximising the health of the whole community. The case for

BMJ 1997; 314 doi: (Published 01 March 1997) Cite this as: BMJ 1997;314:667
  1. A J Culyer, professora
  1. a Department of Economics and Related Studies University of York York YO1 5DD


    It seems a pity to compromise what seems uncompromising, but let us begin with some health warnings. Firstly, “principal” does not mean “only” and some of the other things the NHS does (and ought to do) turn out to be necessary anyway if it is to achieve this prime objective. Moreover, efficiency (which is what maximising is about) needs always to be tempered by consideration of equity in both process and outcome. Secondly, let's remind ourselves that most moral objectives (of which this is one) do not lose their force by virtue of being impossible to attain–one of the reasons for having moral rules about anything is that they provide bases for judging how well one is doing with respect to what one ought to be doing.


    Thirdly, let's remember that there are good reasons for our having taken health care out of the “ordinary” market place. These include a solidarity-type case that ensures no one is excluded from benefit on grounds of lack of portable, transparent, and comprehensive entitlement; protection from professional dominance in the determination of both general healthcare priorities and specific patient-doctor relations (in any system of health care it is primarily the doctor who determines the demand for care, not the patient); equity in funding arrangements, processes, and outcome (mainly health); and the provision of care that is more likely to confer benefit than harm.

    Fourthly, maximising such an objective involves not only a commitment to the ethicality of that which is being maximised but also embodies within it a host of other ethical issues; these often take the form of trade offs, whose exposure, discussion, and resolution by people with legitimate rights to be involved is important. Fifthly, maximising anything implies the need for particular sorts of knowledge: for information about health status, …

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