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NICE discrimination
  1. M Rawlins,
  2. A Dillon
  1. National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA, UK
  1. Correspondence to:
 Professor SirMichael Rawlins
 National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA, UK; michael.rawlins{at}

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The authors refute Harris’s criticism of the work of NICE and in turn criticise his description of the institute’s position

Harris’s recent editorial,1It’s not NICE to discriminate, is long on both polemic and invective but short on scholarship. He offers nothing to illuminate the debate about allocating health care in circumstances of finite resources; he has no understanding of the quality adjusted life year (QALY) and its use in health economic evaluation; and he makes ill researched, unsubstantiated charges against the institute and its advisory bodies.


The British National Health Service (NHS), like every other healthcare system in the world, has finite resources. How the NHS’s budget should be most appropriately allocated is a very specific example of the more general problem of distributive justice.2

The NHS, with its requirement3 to provide all care that is “necessary and appropriate”, was founded with an egalitarian purpose. Yet despite its laudable emphasis on fairness, the implementation of the NHS’s egalitarian approach remains uncertain. What is necessary? What is appropriate? How should the tensions between the service’s egalitarian aspirations, and the need to provide health care from finite resources, be resolved? On what principles should these allocative decisions be made?

Utilitarianism, with its goal to maximise overall good, is another approach. Yet experience with the original Oregon plan demonstrated that, when rigidly applied, it can yield solutions that most find unacceptable—for example, tooth capping taking precedence over emergency appendectomy.4 Moreover, some versions of utilitarianism can allow the interests of minorities to be overridden by the majority; and it has next to nothing to offer in eradicating health inequalities.

There is no single, broadly accepted, theory of distributive justice …

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