Rationing versus rationality: Observations from outside the United States

This commentary takes up A. David Paltiel's invitation to reflect on how to promote the use of decision analysis and cost-effectiveness analysis in he alth. From the perspective of a health services researcher outside the U.S. system, I make 3 arguments. First, the unthinking use of the term rationin g for all applications of cost-effectiveness analysis distorts research pri orities and may jeopardize wider public support. Second, public skepticism about decision and cost-effectiveness analysis (and thus the skepticism of decision makers) is well founded when ethical dimensions of these methods a re not considered. We must continue to refine our methods to take account o f societal values. Third, the United States may have particular problems in adopting more rational decision making in health care. The dominance of fo r profit institutions in the U.S. health care system erodes the social legi timacy on which other systems depend to improve the rationality of health c are decision making.