 The dilemma created by the cost-effectiveness strategy, or more generally a utilitarian approach, may be argued to reflect the perennial conflict in distributive justice between “fair chances” and “best outcomes”. Although there are diehard utilitarians like Stein, most philosophers are drawn to the view that we must in light of these problems find compromise positions in which cost efficiency is moderated by some countervailing principle of fairness. Although the debate is about how to construct a social policy of health care allocation—which potentially affects everyone, so that everyone’s interests need to be taken into account—this does not mean that the three presumptions mentioned above are rejected. No participant in this debate would argue that costs do not matter, that effective use of resources is irrelevant, or that health care outcomes are wholly subjective and incommensurable. Instead, we need to make allocation decision-making more complex by taking account of egalitarian “side constraints” that might modify our CEA results.