Until recently, generous third-party reimbursements enabled physicians to pursue each patient's interests with little regard to costs. Conscious rationing was required only episodically as some particular commodity, eg, transplant organs, was too scarce to meet demand, or as some patients lacked basic access to the health care system. Cost containment and the economic reorganization of medicine introduce a new sort of scarcity, requiring a different sort of rationing. "Fiscal scarcity," the general contraction of health care dollars, means that because every medical decision has its cost, every decision is now subject to scrutiny for its economic as well as its medical wisdom. Therefore, every detail of medicine is an allocation problem. Many observers argue that physicians can nevertheless avoid directly trading patients' interests against economic considerations: through "efficiency protocols" that eliminate marginal benefits, through turning economic rationing decisions over to outside parties, through avoiding cost constraints until society has established a just health care allocation system. This article shows that none of these proposals permits the physician to escape cost-cutting at the bedside.