Toward a just policy on healthcare rationing. Ethical principles must inform the debate concerning the distribution of services.

Perceptions of inequity and excess have given rise to a debate over whether policymakers should consider some form of rationing as a means of achieving a more just healthcare system. Three factors will be critical in determining whether the policies ultimately developed will be just and equitable. First, participants must grasp relevant facts involving the current distribution of healthcare services in the United States. Second, the debate must be based on a clear understanding of who has ultimate responsibility for making decisions regarding healthcare rationing. Finally, those committed to implementing a just approach to the issue must ensure that ethical principles relevant to policy-making are clear to everyone and affect the debate's outcome. The controversy over whether to ration healthcare services obscures the fact that healthcare is, in reality if not in policy, rationed now. A key advantage of promoting formal public policy decisions about the provision and limitation of healthcare services is that it shifts responsibility for these decisions from providers to society. Applying four classic bioethical principles to the question of rationing can also help ensure implementation of an appropriate public policy on healthcare rationing. For the debate on rationing to be meaningful, it must be conducted in a way that respects and promotes participants' autonomy. Policymakers should also observe the principle of nonmaleficence, which dictates that their policies not harm those they affect. A proper rationing policy should also fulfill the criterion of beneficence (i.e., actively promote the good of others). Last, such a policy should conform to the principle of justice by being fair and impartial.