Although the sunk‐cost effect is a well‐documented psychological phenomenon in monetary investments, existing literature investigating behavioral investments (e.g., time, effort) has not replicated this effect except when such investments relate to monetary values. The current explanation for this discrepancy proposes that purely behavioral sunk‐cost effects are unlikely to be observed because they are difficult to book, track, and balance in a mental account. Conversely, we argue that, through an effort‐justification mechanism, people account for the (...) amount of behavioral resources invested when selecting an alternative, in which case they may fall prey to purely behavioral sunk‐cost effects. The results of two experiments support this prediction. Because many decisions involve behavioral investments, behavioral sunk‐cost effects should be pervasive psychological phenomena. (shrink)

Optimal foraging theory has been criticized for underestimating patch exploitation time. However, proper modeling of costs not only answers these criticisms, but it also explains apparently irrational behaviors like the sunk-cost effect. When a forager is sure to experience high initial costs repeatedly, the forager should devote more time to exploitation than searching in order to minimize the accumulation of said costs. Thus, increased recognition or reconnaissance costs lead to increased exploitation times in order to reduce the (...) frequency of future costs, and this result can be used to explain paradoxical human preference for higher costs. In fact, this result also provides an explanation for how continuing a very costly task indefinitely provides the optimal long-term rate of gain; the entry cost of each new task is so great that the forager avoids ever returning to search. In general, apparently irrational decisions may be optimal when considering the lifetime of a forager within a larger system. (shrink)

There is growing interest in whether and how sunk-cost effects for purely behavioral investments occur. In this article, we further discuss Cunha and Caldieraro’s (2009) Behavioral Investment Sunk Cost (BISC) model and reconcile Otto’s (2010) results with the BISC model predictions. We also report new data from two unpublished experiments that are consistent with the BISC model, and we discuss the conditions under which purely behavioral sunk-cost effects are likely to be observed.

The present study describes the mechanism of need regulation, which accompanies the so-called “biased” decisions. We hypothesized an unconscious urge for psychological need satisfaction as the trigger for cognitive biases. In an experimental study (N = 106), participants had the opportunity to win money in a functionality test. In the test, they could either use the solution they had developed (sunk cost) or an alternative solution that offered a higher probability of winning. The selection of the sunk- (...) class='Hi'>cost option was the most chosen option, supporting the hypothesis of this study. The reason behind the majority of participants choosing the sunk-cost option seemed to be the satisfaction of psychological needs, despite a reduced chance of winning money. An intervention, which aimed at triggering self-reflection, had no impact on the decision. The findings of this study contribute to the discussion on the reasons for cognitive biases and their formation in the human mind. Moreover, it discusses the application of the label “irrational” for biased decisions and proposes reasons for instrumental rationality, which exist at an unconscious, need-regulative level. (shrink)

Cunha and Caldieraro (2009) investigated whether sunk-cost effects, which are well documented in hypothetical situations involving monetary investments, also occur in choice situations with purely behavioral investments. Their results suggest that decision makers indeed fall prey to behavioral sunk-cost effects under certain circumstances. I have been unable to replicate their pattern of results in three separate investigations. In these studies, I attempted to recover the effect using two other behavioral effort manipulations in addition to the (...) manipulation used by Cunha and Caldieraro. This failure to replicate the pattern of results calls into question the robustness of the initial findings. (shrink)

The all too common sunk cost effect is apparent when an investor influenced by what has been spent already persists in a venture, committing further resources or foregoing more profitable opportunities, when the economically rational action is to quit. Less common but arguably just as much a sunk cost effect is the mistake of giving up on a failed or failing venture too readily, sometimes out of nothing but pique at what has been lost, (...) or perhaps through the more subtle psychological forces posited by Kahneman, Tversky, Thaler and others within prospect theory and related work on ``mental budgeting''. Two case examples are considered, wherein decision makers dissatisfied with the results of their investments, and having lost money, appear to compound their losses by selling out at prices less than their own estimates of the remaining financial worth of the failed assets. These decisions are evaluated from the perspectives of both behavioral and prescriptive economics, and are found to have possible explanations in both. Their prescriptive rationale assumes a portfolio theory of investment decisions, and is demonstrated within both expected utility (economics) and mean-variance (finance) frameworks. (shrink)

INCONTINENCE, HONOURING SUNK COSTS AND RATIONALITY According to a basic principle of rationality, the decision to engage in a course of action should be determined solely by the analysis of its consequences. Thus, considerations associated with previous use of resources should have no bearing on an agent’s decision-making process. Frequently, however, agents persist carrying on an activity they themselves judge to be nonoptimal under the circumstances because they have already allocated resources to that activity. When this is the case, (...) agents are said to be honouring sunk costs. Honouring sunk costs is thus typically viewed as irrational economic behaviour. Two striking findings of the psychological literature on the sunk cost effect are that it is, in general, not lessened by having taken previously courses in economics, and that agents who did take such courses and that do honour sunk costs seem to be frequently aware of a cognitive dissonance in their behaviour. Davidson’s account of the possibility conditions of incontinent action renders continent action materially unfeasible. The very idea of incontinent action becomes thus a hollow one. I’ll present an alternative description of these possibility conditions that renders continent action materially feasible, and both, continent and incontinent action, cognitively plausible. In a nutshell, my proposal rests upon the drawing of an essential cognitive contrast between explicit processes of deliberative reasoning and lower level heuristic procedures. I conclude the paper arguing that my redescription of incontinent action accounts for the above mentioned cognitive dissonance effect better than the alternatives and that viewing at least an important subset of behaviours of honouring sunk costs as incontinent actions will enable us to consider them as peculiar manifestations of a more general and meaningful pattern in human behaviour. (shrink)

It is a commonplace in economics that we should disregard sunk costs. The sunk cost effect might be widespread, goes the conventional wisdom, but we would be better off if we could rid ourselves of it. In this paper, I argue against the orthodoxy by showing that the sunk cost effect is often beneficial. Drawing on discussions of related topics in dynamic choice theory, I show that, in a range of cases, being disposed (...) to honor sunk costs allows an agent to mimic a resolute chooser, someone who adopts the best plan at the outset of a decision problem and sticks with it, even when resoluteness is unfeasible. I discuss several kinds of cases in which honoring sunk costs coincides with resolute choice. (shrink)

We give a general method for producing various effective Null and Positivstellensätze, and getting new Positivstellensätze in algebraically closed valued fields and ordered groups. These various effective Nullstellensätze produce algebraic identities certifying that some geometric conditions cannot be simultaneously satisfied. We produce also constructive versions of abstract classical results of algebra based on Zorn's lemma in several cases where such constructive version did not exist. For example, the fact that a real field can be totally ordered, or the fact that (...) a field can be embedded in an algebraically closed field. Our results are based on the concepts we develop of dynamical proofs and simultaneous collapse. (shrink)

Business and Economic textbooks warn against committing the Sunk Cost Fallacy: you, rationally, shouldn't let unrecoverable costs influence your current decisions. In this paper, I argue that this isn't, in general, correct. Sometimes it's perfectly reasonable to wish to carry on with a project because of the resources you've already sunk into it. The reason? Given that we're social creatures, it's not unreasonable to care about wanting to act in such a way so that a plausible story (...) can be told about you according to which your diachronic behavior doesn't reveal that you've suffered, what I will call, diachronic misfortune. Acting so as to hide that you've suffered diachronic misfortune involves striving to make yourself easily understood while disguising any shortcomings that might damage your reputation as a desirable teammate. And making yourself easily understood to others while hiding your flaws will, sometimes, put pressure on you to honor sunk costs. (shrink)

Decision theorists generally object to “honoring sunk costs” – that is, treating the fact that some cost has been incurred in the past as a reason for action, apart from the consideration of expected consequences. This paper critiques the doctrine that sunk costs should never be honored on three levels. As background, the rationale for the doctrine is explained. Then it is shown that if it is always irrational to honor sunk costs, then other common and (...) uncontroversial practices are also irrational. Second, it is argued that there is no satisfactory way to make a distinction between the two kinds of cases. Third, a proposal is developed which would explain how it could be rational, under certain circumstances, to honor sunk costs. (shrink)

This chapter focuses on one of the common fallacies in Western philosophy called 'sunk cost'. In economics, a sunk cost is an investment that can never be recovered. Prime examples include money spent on research and development or advertising for a product. However, there is a way to think of cost in terms of time, energy, and even emotion. The way to avoid this fallacy is to not allow the fear of losing what was already (...) invested in something to influence one's rational, objective decision about a present or future investment. In Eric Nielsen's words, when making any decision, economic or otherwise, it “makes no sense to factor in sunk costs precisely because they are sunk; no present action can change them. No matter what happens, the sunk costs are always there”. (shrink)

The sunk cost fallacy is a well-established phenomenon where decision makers continue to commit resources, or escalate commitment, because of previously committed efforts, even when they have knowledge that their returns will not outweigh their investment. Most research on the sunk cost fallacy is done using hypothetical scenarios where participants make a single decision to continue with a project or to abandon it. This paradigm has several limitations and has resulted in a relatively limited understanding (...) class='Hi'>sunk cost behavior. To address some of these limitations, we created a dynamic repeated choice paradigm where sunk costs are learned over time and opportunity costs are explicit. Over three experiments we show that the sunk cost fallacy depends on the relative a priori importance of the goal being invested in. We observed escalation of commitment only when the sunk cost domain is more important than alternatives, and participants showed de-escalation of commitment to the sunk costs domain otherwise. (shrink)

Suppose that you are trying to pursue a morally worthy goal, but cannot do so without incurring some moral costs. At the outset, you believed that achieving your goal was worth no more than a given moral cost. And suppose that, time having passed, you have wrought only harm and injustice, without advancing your cause. You can now reflect on whether to continue. Your goal is within reach. What's more, you believe you can achieve it by incurring—from this point (...) forward—no more cost than it warranted at the outset. If you now succeed, the total cost will exceed the upper bound marked at the beginning. But the additional cost from this point is below that upper bound. And the good you will achieve is undiminished. How do the moral costs you have already inflicted bear upon your decision now? (shrink)

Many find it reasonable to take our past actions into account when making choices for the future. In this paper, I address two important issues regarding taking past investments into account in prudential deliberation. The first is the charge that doing so commits the fallacy of honoring sunk costs. I argue that while it is indeed irrational to care about sunk costs, past investments are not sunk costs when we can change their teleological significance, roughly their contribution (...) to our excellence as temporally extended, reasons-responsive, and goal-directed agents. I suggest some general principles for evaluating such significance. Second, it’s a live issue whether we should care about the fate of our past projects, even if we can now affect it. I reject Dale Dorsey’s recent answer, and argue that the puzzle he addresses turns out to be merely apparent, if we take seriously the fact that we are temporally extended. (shrink)

The problem of moral sunk costs pervades decision-making with respect to war. In the terms of just war theory, it may seem that incurring a large moral cost results in permissiveness: if a just goal may be reached at a small cost beyond that which was deemed proportionate at the outset of war, how can it be reasonable to require cessation? On this view, moral costs already expended could have major implications for the ethics of conflict termination. (...) Discussion of sunk costs in moral theorizing about war has settled into four camps: Quota, Prospect, Addition, and Discount. In this paper, I offer a mathematical model that articulates each of these views. The purpose of the mathematisation is threefold. First, to unify the sunk costs problem. Second, to show that these views differ in the nature of their justifications: some are justified qualitatively and others quantitatively. Third, to clarify the differential force of qualitative and quantitative critiques of these four views. (shrink)

If you are more likely to continue a course of action in virtue of having previously invested in that course of action, then you tend to honor sunk costs. It is widely thought both that (i) individuals often do give some weight to sunk costs in their decision-making and that (ii) it is irrational for them to do so. In this paper I attempt to cast doubt on the conventional wisdom about sunk costs, understood as the conjunction (...) of these two claims. (shrink)

This project tackles the problem of analyzing a specific form of reasoning called ‘sunk costs’ in economics and ‘argument from waste’ in argumentation theory. The project is to build a normative structure representing the form of the argument, and then to apply this normative structure to actual cases in which the sunk costs argument has been used. The method is partly structural and partly empirical. The empirical part is carried out through the analysis of case studies of the (...) sunk costs argument found in business decision-making, as well as other areas like medical decision-making and everyday conversational argumentation. The structural part is carried out by using existing methods and techniques from argumentation theory, like argumentation schemes. The project has three especially significant findings. First, the sunk costs argument is not always fallacious, and in many cases it can be seen to be a rational precommitment strategy. Second, a formal model of argumentation, called practical reasoning, can be constructed that helps a rational critic to judge which sunk costs arguments are fallacious and which are not. Third, this formal model represents an alternative model of rationality to the cost-benefit model based on Bayesian calculation of probabilities. This alternative model is called the argumentation model, and it is based on interpersonal reasoning in dialogue as the model of rational thinking. This model in turn is based on the underlying notion of commitment in dialogue. (shrink)

-/- This chapter evaluates the ethical issues that using cost-effectiveness considerations to set animal health priorities might present, and its conclusions are cautiously optimistic. While using cost-effectiveness calculations in animal health is not without ethical pitfalls, these calculations offer a pathway toward more rigorous priority-setting efforts that allow money spent on animal well-being to do more good. Although assessing quality of life for animals may be more challenging than in humans, implementing prioritization based on cost-effectiveness is less (...) ethically fraught. (shrink)

In the WebSurf task, humans forage for videos paying costs in terms of wait times on a time-limited task. A variant of the task in which demands during the wait time were manipulated revealed the role of attention in susceptibility to sunk costs. Consistent with parallel tasks in rodents, previous studies have found that humans preferred shorter delays, but waited longer for more preferred videos, suggesting that they were treating the delays economically. In an Amazon Mechanical Turk sample, we (...) replicated these predicted economic behaviors for a majority of participants. In the lab, participants showed susceptibility to sunk costs in this task, basing their decisions in part on time they have already waited, which we also observed in the subset of the mTurk sample that behaved economically. In another version of the task, we added an attention check to the wait phase of the delay. While that attention check further increased the proportion of subjects with predicted economic behaviors, it also removed the susceptibility to sunk costs. These findings have important implications for understanding how cognitive processes, such as the deployment of attention, are key to driving re-evaluation and susceptibility to sunk costs. (shrink)

It is widely recognized that prioritizing health care resources by their relative cost-effectiveness can result in lower priority for the treatment of disabled persons than otherwise similar non-disabled persons. I distinguish six different ways in which this discrimination against the disabled can occur. I then spell out and evaluate the following moral objections to this discrimination, most of which capture an aspect of its unethical character: it implies that disabled persons' lives are of lesser value than those of non-disabled (...) persons; it constitutes “double jeopardy” or violates Frances Kamm's non-linkage principle; it conflicts with equality of opportunity; it conflicts with fairness, which requires ignoring (some/most) differential impacts of treatment; it wrongly gives lower priority to disabled persons for equally effective treatment; it conflicts with giving all persons an equal chance to reach their full potential; and, it is in conflict with giving priority to the worse off. (shrink)

Cost-effectiveness analysis (CEA) is an analytical tool in health economics. One of the most important objections to it is that its use can lead to unjust discrimination against people with disabilities. This chapter evaluates this objection. It begins by clarifying its nature, then it examines some alleged forms of discrimination. It argues that they are either not cases of unjust discrimination, or they are based on misunderstandings of CEA. However, the chapter does point out that there is one case (...) in which the use of CEA may disadvantage people with disabilities. It goes on to consider several proposals for explaining the wrongness of discrimination but argues that none of them accommodates this case. It concludes that the case should not be thought as a matter of unjust discrimination; rather, it should be thought of as raising an issue for justice in the allocation of health-care resources. (shrink)

This paper argues that cost-effectiveness analysis in the healthcare sector introduces a discrimination risk that has thus far been underappreciated and outlines some approaches one can take toward this. It is argued that appropriate standards used in cost-effectiveness analysis in the healthcare sector fail to always fully determine an optimal option, which entails that cost-effectiveness analysis often leaves decision makers with large sets of permissible options. Larger sets of permissible options increase the role of decision makers’ biases, (...) whims, and prejudices, which means that the discrimination risk increases. Two ways of mitigating this are identified: tinkering with standards used in the cost-effectiveness analysis and outlining anti-discrimination guidelines for decision makers. (shrink)

Cost effectiveness analysis is a tool for evaluating the aggregate benefits of medical treatments, health care services, and public health programs. Its opponents often claim that its use leads to unfair discrimination against people with disabilities. My aim in this paper is to clarify the conditions under which this might be so. I present some ways in which the use of cost effectiveness analysis can lead to discrimination and suggest why these forms of discrimination may be unfair. I (...) also discuss some proposals for avoiding discrimination without rejecting cost effectiveness analysis altogether. I argue that none of these proposals is ultimately convincing. I describe a different approach to the problem and conclude by answering the question in the title. (shrink)

Cost-effectiveness analysis suggests that a society should allocate its health care budget in order to achieve the greatest total health for its budget. However, in ‘rescue’ cases, where an individual’s life is in immediate peril, reasoning in terms of cost-effectiveness can appear inhumane. Hence considerations of cost-effectiveness and of rescue appear to be in tension. However, by attending to the division of labour in medical decision making it is possible to see how cost-effectiveness analysis and rescue-style (...) reasoning are commonly combined in an ethically acceptable fashion. (shrink)

Cognitive Science, Volume 45, Issue 11, November 2021.

This article considers some different views of fairness and whether they conflict with the use of a version of Cost Effectiveness Analysis (CEA) that calls for maximizing health benefits per dollar spent. Among the concerns addressed are whether this version of CEA ignores the concerns of the worst off and inappropriately aggregates small benefits to many people. I critically examine the views of Daniel Hausman and Peter Singer who defend this version of CEA and Eric Nord among others who (...) criticize it. I come to focus in particular on the use of CEA in allocating scarce resources to the disabled. (shrink)

Many clinicians believe that allowing costs to influence clinical decisions is unethical. They are mistaken in this belief, because it cannot be ethical to ignore the adverse consequences upon others of the decisions you make, which is what 'costs' represent. There are, however, some important ethical issues in deciding what costs to count, and how to count them. But these dilemmas are equally strong with respect to what benefits to count and how to count them, some of which expose ethically (...) untenable assumptions about such widely-used clinical criteria as survival rates. One of the advantages of systematic cost-effectiveness analysis is that it exposes these hidden assumptions, and requires explicit judgements to be made about which ethical position is appropriate in a particular policy context. This should have the important incidental benefit of improving the accountability of policy-makers to the community they are serving. (shrink)

AimTo examine the relative cost-effectiveness of predictive genetic tests for familial breast and ovarian cancer provided by Genetic Services of Western Australia.MethodsThe relative cost-effectiveness was assessed using a decision analytic model.ResultsThe cost and outcomes of genetic testing was compared in first-degree relatives of known BRCA1/2 mutation-carriers who have a 50% risk of carrying the mutated gene (intervention group) to individuals with the same a priori risk but who do not undergo a genetic test (control subjects).Since genetic testing (...) enables the restriction of intensive surveillance to individuals with an identified BRCA1/2 gene mutation, net savings in the period observed (age 25-70) were $980-$1008 per woman in the ovarian intervention group and $1681-$1795 per woman in the breast intervention group, and delayed the onset of breast cancer (6mths BRCA1, 3mths BRCA2).Compared to control subjects undergoing population surveillance, it was estimated the onset of breast cancer could be delayed at a total net cost of $3055 (5.1yrs) to $3389 (3.2yrs) for women in the breast intervention group with BRCA1/2 mutations. Since population surveillance is not currently recommended for ovarian cancer, control subjects undergoing no surveillance were compared with the intervention group. The onset of ovarian cancer was delayed at a net cost of $1630 (3.5yrs) to $2509 (1.2years) for women with BRCA1/2 mutations.ConclusionsTesting allows targeted high-level surveillance for gene mutation carriers, which ensures the cost-effective use of resources and reduces cancer-related morbidity if clinical recommendations for intervention are adopted. (shrink)

Many ethical theorists believe that a given distribution of healthcare is morally justified only if (1) it is cost-effective and (2) it does not discriminate against older adults and disabled people. However, if (3) cost-effectiveness involves maximizing the number of quality-adjusted life-years (QALYs) added by a given unit of healthcare resource, or cost, it seems the pursuit of cost-effectiveness will inevitably discriminate against older adults and disabled patients. I show why this trilemma is harder to escape (...) than some theorists think. We cannot avoid it by using age- or disability-weighted QALY scores, for example. I then explain why there is no sense of “discrimination” on which discrimination isbothunjust, and thus something healthcare rationing must avoid,andsomething cost-effective healthcare rationing inevitably involves. I go on to argue that many of the reasons we have for not favoring rationing that maximizes QALYs outside the healthcare context apply in healthcare as well. Thus, claim (1) above is dubious. (shrink)

Ratio Juris, Volume 35, Issue 1, Page 21-29, March 2022.

Cost‐effectiveness analysis (CEA) raises questions that are too important to be left to policy analysts and economists. Those who utilize CEA should acknowledge its inherent value system and adapt it to a more ethical usage.

Only in recent years have developmental psychologists begun advocating and exploring dual-process theories and their applicability to cognitive development. In this paper, a dual-process model of developments in two processing systems—an “analytic” and an “experiential” system—is discussed. We emphasise the importance of “metacognitive intercession” and developments in this ability to override experiential processing. In each of two studies of sunk cost decisions, age-related developments in normative decisions were observed, as were declines in the use of a “waste not” (...) heuristic. In the second study, children and adolescents were presented with arguments for normative and non-normative sunk cost decisions. Following argument evaluation, participants were re-presented the original problems and a set of novel, transfer problems. Results indicated that post-argument improvements were most apparent during adolescence. Age-related improvements were most noticeable on the transfer problems. In general, the findings suggest that the ability to metacognitively intercede (i.e., reflect on arguments; inhibit experientially produced responses) emerges towards middle adolescence. However, even by the end of adolescence, in the absence of significant contextual cues and motivation, this ability is infrequently utilised. (shrink)

(1981). Cost‐effectiveness Analysis as a Method of Assessing ‘A’ level Performance in Different Educational Establishments. Educational Studies: Vol. 7, No. 2, pp. 95-103.

In my article above, I cite an earlier article by Frances Kamm, ‘Deciding Whom to Help, Health-Adjusted Life Years, and Disabilities’, in Public Health, Ethics, and Equity, eds. S. Anand, F. Peters, and A. Sen circulated as a working paper of the Center for Population Studies, Harvard University). However, I failed to correctly identify her position on one view that she took up in that article, and also failed to cite a proposal she developed in that article similar to one (...) I took up in my paper. (shrink)

Risk is the probability that within a certain time some expected negative event will take place. In medicine risk can be related to a decision or to some intrinsic factors which are associated with the probability of the occurrence of a disease. Decisions can be necessary in the individual life with respect to the question of visiting a physician or performing a certain diagnostic or therapeutic procedure. The introduction of new pharmaceutical or technical products into medical use are another set (...) of decisions which can generate certain risks. Intrinsic or inherent risk factors are a set of variables or signs and symptoms which indicate the presence of a certain probability that some disease or event, e.g., arteriosclerosis or sudden infant death syndrome, may occur. Risk is always related to judgement. In a decision process cost, effectiveness and profit can be used to estimate the magnitude of the risk to be taken. In a similar way the problems in connection with an inherent risk are primarily related to the recognition of the magnitude of risk and to the possibility of prophylactic measures.In our own area of research, the sudden infant death syndrome (SIDS) is an event where only risk factors can be observed. We point at two facts in this context: Highly complex patterns of symptoms like behaviour can better be classified by intuitive Gestalt perception. A medical procedure like induction of labour can itself become a risk factor. (shrink)

The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA’s provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue that the ACA is neither (...) uniformly hostile nor uniformly friendly to efforts to set priorities in ways that promote cost and quality. Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the health care system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy). Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry. (shrink)

Germany has just started a public debate on priority-setting, rationing and cost-effectiveness due to the cost explosion within the German health care system. To date, the costs for German health care run at 11,6 % of its Gross Domestic Product (GDP, 278,3 billion €) that represents a significant increase from the 5,9 % levels present in 1970. In response, the German Parliament has enacted several major and minor legal reforms over the last three decades for the sake of (...) cost containment and maintaining stability of the health care system. The Statutory Health Insurance—SHI (Gesetzliche Krankenversicherung—GKV) is based on the fundamental principle of solidarity and provides an ethical and legal framework for implementing equity, comprehensiveness and setting the principles and rules for financing and providing health care services and benefits. Within the SHI system, several major actors can be identified: the Federal Ministry of Health, the 16 state ministries of health, the Federal Joint Committee (G-BA), the physicians (with their associations) and the hospitals (with their organizations) on the provider side, and the sickness funds with their associations on the purchasers’ side. This article reviews the structure and complexities of the German health care system with its major players and participants. The focus will be put on relevant ethical, legal and economic aspects for prioritization, rationalization, rationing and cost-effectiveness of medical benefits and services. In conclusion, this article pleads for open discussion on the challenging subject of priority-setting instead of accepting the implicit and non-transparent rationing of medical services that currently occurs at many different levels within the health care system, as it stands today. (shrink)