ABSTRACT
Objectives: This article seeks to review debates about age-based rationing in health care. Methods: The article identifies four different levels (or types) of decisionmaking in health resource allocation—societal, strategic, programmatic, and clinical—and assesses how the issues of rationing vary in relation to each level. Results: The article concludes that rationing is least defensible at the clinical level, where it is also most covert. The role of rationing at other levels is more defensible when based on grounds of cost-effectiveness rather than equity. The article emphasizes the importance of fairness in health allocation and suggests that efficiency criteria need to be considered in that context. Discussion: The article suggests that rationing is most problematic where it is least overt. This raises further questions about how rationing can be made more explicit at different levels of decision making.
