How does the operation of PHARMAC's 'Community Exceptional ...

that the treatment may not be available, and in such circumstances a conscious
decision may be taken by administrators that the service is restricted or simply
not offered (Ubel, 2000).
The term ‘rationing’ has also been used to mean societal toleration of
inequitable access to services deemed necessary, as defined by reference to
appropriate clinical guidelines (Hadorn & Brook, 1991). Early in the health
rationing debate, Hadorn (1991) introduced the connection between equity and
the provision or prohibition of needed health services. His central idea was to try
to show what was considered ‘necessary’ and by whom it was considered
‘necessary’. This approach has been challenged by many attempts since 1991
to define the term necessary. This has not proved to be simple. Neither has it
always been easy to be explicit about who benefits from rationed health funds-
the patients, the doctors and staff, the service owners or the funders.
There are, however other ways of thinking about what health care provision
might be considered necessary and unnecessary. Malin, Wilmot, and
Manthorpe (2002) divided the elements of distributive justice relating to the
fairness of distributing health care into four areas: need, rights, desert and
utility. I present these four categories here. Need was described as the ability
to benefit from a treatment and is associated with the level of severity of the
condition and the effectiveness of the remedy. However, this is problematic
because of the existence of layers of need. Malin et al. point out that a person
may need a pair of shoes or we could say they need education and up-skilling
to be able to enter the labour market to earn enough income to buy a pair of
shoes. There appears no obvious method of analysing needs and efficiency in
such terms.
The second element of distributive justice described by Malin et al. (2002) is
rights. Two types of rights are described. Firstly ‘ideal’ rights which are claimed
on the basis of general moral principles and stand independently and prior to
laws as ideal arrangements for human societies. This too is problematic
because the exercise of such rights in terms of the right to life or the right to
adequate health care is generally determined by access to adequate resources.
Therefore, the gatekeeper who provides such access has power over the rights
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