The escalating cost of health care has forced people to confront the possibility of rationing—forgoing beneficial care for patients so that the resources might be used either for other current or prospective patients or for entirely different things in life than health care. Rationing of some sort makes eminent sense, not just economically; only those who are fanatics about health and medicine would urge that everything possible be spent on health care for even the slightest marginal benefit. Yet actual rationing of health care is usually thought to exact high, or at least disturbing, ethical costs.

I will examine four of these costs here: (1) the sacrifice of physician loyalty to patients, (2) the substitution of misleading and discriminatory numerical measurements of medicine's human benefit for more sensitive qualitative judgments, (3) the unfair bite that rationing is likely to take first out of poor people's care before it affects wealthier patients, and (4) the general Substitution of public, group standards about life and health for the values and decisions of individuals.