The Allocation and Rationing of High-Cost Services

To the Editor.—

The editorial by Knaus¹entitled "Rationing, Justice, and the American Physician" in the March 7 issue ofJAMAreached an appropriate conclusion that physicians should be involved in both allocation and rationing decisions in hospitals and in our health care system. I believe it is particularly important that physicians be involved in the allocation decisions primarily because physicians will have to make the crucial rationing decisions. From my experience, directly and in working with medical directors of many intensive care units, I do not believe that rationing decisions are "painless," as suggested by Dr Knaus. Dr Knaus suggested that rationing at Harborview Hospital was "ineffective at reducing costs." Although I was not at Harborview, I believe that anytime effective rationing occurs, institutions avoid further allocation of resources. I believe that rationing does reduce costs by reducing the amount of care that would be potentially provided. Rationing