J Butler. Cassell, 1999, £16.99, pp 248. ISBN 0304705829

This book is about scarcity and rationing in health care and the ethical questions they raise. It is based on the premise that if the aim of a responsible government is to balance the nation's varied claims upon the collective purse, then no government can be morally blamed for failing to remove the need of rationing from the National Health Service (NHS), and thus rationing as such cannot give rise to legitimate moral concerns. The question that needs to be addressed therefore is not whether rationing itself is unethical, or even whether any particular distribution mechanisms are unethical, but whether they are structured and work in morally acceptable ways, and lead to morally acceptable results.

In the first chapter Butler describes the gap between needs and resources. He describes what has been done (mainly) in the UK as a way of providing the background to the rationing debate. The second chapter addresses the moral basis of rationing by focusing on which personal qualities we are prepared to accept as a fair basis for discriminating between individual patients. The author could not have chosen a simpler and yet more effective example to drive us through the debate.

Chapters 3 to 5 tackle the debate on rationing from a different point of view. Here Butler explores the moral issues of fairness and justice through the structures, processes, and outcomes of health care. Given that health services will always be in short supply in relation to potential demand, he asks whether they are structured and organised in ways that will promote people's fair and equitable access to health care. This question is addressed by taking the reader through three competing theories of justice: those of Rawls (social justice), Daniels (fair equality and opportunity), and Doyal (human need). All three share a common feature in highlighting that the structure and organisation of health care cannot be left to chance or interest but must be planned and implemented in ways that make explicit the principle of justice they are seeking to achieve.

Butler then takes the reader through the various processes of health care. Starting with a description of Waele's theory of responsible or responsive government, he presents numerous arguments about, and examples of, implicit and explicit rationing, public involvement in, and political and professional accountability for, rationing decisions, pointing out the potential conflicts between different moral concerns at different levels. Clinicians have a primary obligation to treat the individual patients before them, managers to see that public resources are not wasted, and politicians to use the nation's resources fairly and to balance interests and expectations of different sections of society. Within a given budget constraint, are government and health authority decisions made on the basis of defendable ethical principles? Given that doctors and nurses are unable to do all they would like to do for their patients, are they making choices based on established ethical criteria?

Chapter 5 addresses the ethical issues of health care rationing and health outcomes. As Butler states, outcomes are elusive things. Even at the patient level measuring improvements in health may be tricky, but at population level, where ethical questions are more likely to be posed, the difficulties multiply. Moreover, improvements in health are likely to reflect a variety of social, economic, environmental, educational, and occupational changes among which delivery of care is only one. In situations where all objectives cannot be achieved and comparisons between different outcomes have to be made, how can we fairly establish that some objectives are morally to be preferred to others? Should outcomes be perceived in terms of meeting individual need, the maximisation of total health gain (utilitarianism for example, using quality adjusted life years) or as the narrowing of the health gap between rich and poor?

Chapter 6 singles out this book from others on the topic. This chapter contains a series of stories the author has gathered from professionals who deliver health care. In order to present an unbiased selection of stories, Butler's includes anecdotes from doctors, clinicians, nurses, and managers. Despite their differences, each story contains a common thread in that although none say so openly, each clearly describes a decision which implies rationing. These stories clearly bring out the conflict between moral concerns at the different levels.

From a professional point of view this book has much to offer both to those familiar with the subject and to those new to it. Moreover, although the book is mainly concerned with the UK what it has to say can apply equally to other countries, particularly other countries in Europe. Overall this book is comprehensive, thought-provoking, readable, and highly recommended.