THE ETHICS OF RATIONING

Rationing can occur at three levels of health care choice: the individ ual, the institutional and the social, with each level posing its own ethical problems. The institutional level is the focus of this paper. The principle of effectiveness may seem attractive, since it promises to ease the institutional dilemmas of rationing, but it is not straigh tforward to implement in the face of uncertainty. Greater efficiency a lso promises much, but concepts of benefit are contested and improving contractual performance has complications. Fairness can be a powerful criterion, but there are contested cases, for example age, where its meaning is unclear. Democratic responsiveness, for all its difficultie s, is important to maintain in whatever process of rationing is chosen and this can be done by adopting some procedural devices.