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.