The debate over whether and how to ration health care resources is an issue of major national concern. Some would hold that any limitation on access to health care services should be eliminated. One obvious problem with this absolutist position is that it would provide no check on health care expenditures relative to other societal priorities. There is also no evidence that unlimited expenditures on health care necessarily yield better health outcomes, regardless of how "better health outcomes" is defined.

If health and behavioral health expenditures are to be limited, by what criteria should limits be set, and by whom? Many argue that health care expenditures effectively are rationed now, pointing to the millions of Americans with no or too little health insurance, the disparities in care based on socioeconomic status, and the uneven distribution of health care resources. However, to the degree rationing may exist, it is not based on any agreed-upon criteria. The State of Oregon, which after a lengthy and comparatively open public process assigned priorities in its Medicaid program for the treatment of various conditions, might provide an exception. However, no other State to date has followed Oregon's lead.

In the absence of explicit criteria, we have allocated health care through the exercise of "medical" or "clinical" judgment in millions of individual cases. However, while it might theoretically be possible to construct practice guidelines of sufficient scientific merit and force that the exercise of judgment would fall within comparatively narrow and predictable parameters, reliance on this criterion does little to meet other principles (fairness, equitable access) that most believe should characterize a health care system.

Criteria for allocating health care resources can also be created by government, or by the market; the health care system today is an uneasy amalgam of market forces, government regulation, clinical judgment, and widely varied consumer behavior. Government has been reluctant to assume the task of establishing formal criteria to allocate health care resources at a macro level. Private providers and payers have been less reluctant to create criteria to govern allocation of the resources they control. However, those decisions have not tended to make the health care system more equally accessible, particularly given the inclination of providers and payers to avoid the undue risk often perceived as characteristic of serving the uninsured, or those with chronic needs.

The Clinton administration attempted to address this problem by prefacing its health care reform proposal with a statement of ethical principles and values (Brock and Daniels 1994). It relied on four core principles: universal access, equal and comprehensive benefits, quality care, and individual choice. The statement of ethical principles and values also held that a society reforming its health care system should:

1. Consider health care to be of fundamental importance;
2. Spread costs and burdens equally across the community, with payments based on ability to pay;
3. Provide for "generational solidarity" with benefits and burdens being shared fairly across generations;
4. Balance health care expenditures wisely with other national priorities;
5. Provide effective services, while avoiding ineffective services;
6. Be managed efficiently;
7. Reward personal responsibility;
8. Protect professional integrity and the integrity of the professional-patient relationship; and
9. Provide fair procedures for making decisions about the health care system and for resolving disputes.

As Michael Graetz and Jerry Mashaw (1994) observed in a commentary on the Clinton plan, a number of these ethical principles and values are at odds. For example, the emphasis on universal and equal access to comprehensive benefits suggests that health care is an entitlement or right, while the emphasis on balancing health care expenditures against other priorities suggests that health care is something less. However, as Graetz and Mashaw also point out,

No single ethical perspective is likely to provide an acceptable solution to either of the two critical issues that confront any health care system: the determination of the total proportion of national resources to be expended on health care, and the allocation of health care resources within that global resource commitment...the choice of a single ethical principle to guide global budget-setting in a health care system would lead fairly quickly to the unworkability or moral bankruptcy of that system.

Therefore, Graetz and Mashaw saw the effort to frame the health care plan in a set of seemingly irreconcilable ethical principles as an overdue recognition of the impossibility of anchoring something as complex and varied as the health care system on one or two core ethical bases.

The task of creating a coherent ethical base for the behavioral health care system is also complicated by two additional factors. The first is that, despite recent parity legislation, behavioral health care benefits have lagged behind general health care benefits in both privately and publicly insured plans (Hastings Center 1993). Questions of equal access, and of a "just" allocation of resources, are perhaps even more difficult to address in behavioral health care systems. The second is the issue of coercion. The availability of coercion and the conditions under which it properly may be used have long been significant issues in public behavioral health policy debates; in the views of at least some consumers, the availability of coercion calls into question the ethical foundations of behavioral health care. This is not to endorse that view, but it is clear that coercion is an issue of great significance in ethical and legal debates regarding behavioral health care.

While it may not yet be possible to create a generally agreed-upon ethical framework for the health or behavioral health care systems, there are certain principles to which most would agree a health care system should aspire in allocating resources. Many of these are the principles that prefaced the Clinton health care plan; regardless of one's judgment about the merits of that plan, those principles are likely to be the touchstone of society's continuing debate regarding the future allocation of health and behavioral health care benefits.