Intended for healthcare professionals


Where are we in the rationing debate?

BMJ 2008; 337 doi: (Published 10 October 2008) Cite this as: BMJ 2008;337:a2047
  1. Susan Dorr Goold, director, bioethics programme1,
  2. Nancy M Baum, doctoral candidate2
  1. 1University of Michigan Medical School, Ann Arbor, MI 48109-0429, USA
  2. 2University of Michigan School of Public Health, Ann Arbor, MI 48109-2029, USA
  1. sgoold{at}

    Improved tools and public participation can inform fair systems

    Three linked articles (doi:10.1136/bmj.a1850; doi:10.1136/bmj.a1872; doi:10.1136/bmj.a1846) take different perspectives on the need to allocate limited resources for human health fairly.1 2 3 Norheim examines clinical priority setting, which occurs implicitly or explicitly in clinicians’ daily practice. He courageously proposes that clinicians should integrate concern for cost effectiveness and health inequalities into decisions about clinical priority setting, and describes an elegant way of measuring inequalities. Donaldson and colleagues argue convincingly that explicit attention to comparative costs and relative values, using methods like programme budgeting and marginal analysis, can allow “genuine” reallocations. Finally, Daniels and Sabin draw on experience using their framework, “accountability for reasonableness,” as a guide for priority setting in three different locations.

    The articles present valuable arguments, although a few types of methods of resource allocation are missing. While Donaldson and colleagues dismiss incentives as “smokescreens” used to avoid hard decisions, market-like approaches to allocation can be found in almost every system. User fees, privately purchased services or insurance, and competitive bidding comprise just some of …

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