Despite its necessity, rationing raises troublesome questions about fairness. We ration in situations in which losers, as well as winners, have plausible claims to have their needs met. When we knowingly and deliberately refrain from meeting some legitimate needs, we had better have justification for the distributive choices we make. Not surprisingly, health planners and legislators appeal to bioethicists for help, asking what justice requires here. Can we help them? I think we are not ready to yet, and I will support this claim by noting four general rationing problems that we remain unsure how to solve, illustrating how they plague Oregon's rationing plan.

Before turning to the four problems, I want to make several preliminary remarks. First, philosophers (including me) have traditionally underestimated the importance of rationing, thinking of it as a peripheral, not central, problem. Since we simply cannot afford, for example, to educate, treat medically, or protect legally people in all the ways their needs for these goods require or the accepted distributive principles seem to demand, rationing is clearly pervasive, not peripheral.

Rationing decisions share three key features. First, the goods we often must provide - legal services, health care, educational benefits - are not divisible without loss of benefit, unlike money. We thus cannot avoid unequal or “lumpy” distributions. Meeting the educational, health-care, or legal needs of some people, for example, will mean that the requirements of others will go unsatisfied.