[Rationalizing versus rationing in the practice of clinical nutrition; fourth Jesús Culebras lecture].

The current economic situation is the reason for this conference that will be split in two main areas: first, we will focus on general concepts on rationalizing versus rationing in health care, and secondly, on rationing in the practice of clinical nutrition. According to the Spanish Royal Academy of the Language, to rationalize is to organize the production or the work in a manner such the yields are increased or the costs are reduced with the least effort. However, to ration is the action and effect of rationing or limiting the consumption of something to prevent negative consequences. In Europe, the percentage of the Gross National Product dedicated to health care progressively decreases whereas the costs of health care are ever increasing. From the economic viewpoint, this would be the main reason why the health care authorities have no other option but rationing. Until what extent the ethical principle of justice is compatible with rationing? Ethically, it seems that in order to accept rationing, not only a fair distribution of the limited resources should be achieved, but also a rational use of them. If we accept that limiting the health care allowances is necessary, we should then answer some questions: is it ethical not to limit? Who decides what is medically necessary? How is it decided? With no coherent answers to these questions it is ethically difficult to accept rationing from a healthcare viewpoint. When dealing with rationing in the practice of clinical nutrition, we should focus on how rationing impacts on hyponutrition, and more particularly on disease-related hyponutrition, since this is the focus of Clinical Nutrition. Given its importance and its implications, in several countries, including Spain, actions integrated in the European Union strategy "Together for health: a Strategic Approach for the EU 2008-2013", are being performed aimed at taking decisions for preventing and managing hyponutrition. However, restrictions persist with the imperative necessity of using all the tools available to prevent hyponutrition in patients at risk, to early detect malnourished patients or patients at risk for hyponutrition, and to establish the most appropriate actions.