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CHAT has its limits. It is a three-hour exercise. However, the real world problems of healthcare rationing and priority-setting are too complex for a three-hour exercise. What is needed, as a supplement, are sustained processes of rational democratic deliberation that can address the challenges to healthcare justice posed by costly emerging medical technologies, such as these targeted cancer therapies., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Clinicians must inevitably make therapeutic decisions under nonideal conditions. They practice in circumstances that involve incomplete evidence. They deliver care in health care systems that are complex and poorly coordinated. Each of the patients that they take care of is unique while research offers evidence regarding relatively homogeneous populations of patients. Under these circumstances, many parties-medical scientists, reviewing agencies, insurers, and accountable care organizations-can and should contribute to optimizing the development, approval, funding, and prescription of therapies-particularly expensive and marginally beneficial therapies. In aggregate, they should aspire to achieve a pattern of fair, cost-effective therapeutic decisions to ensure a sustainable health care system. Here we offer some suggestions regarding decisions that physicians might pursue to facilitate fair and cost-effective patient care., (© 2017 American Medical Association. All Rights Reserved.)

As healthcare reform evolves, nurse practitioners (NP) will play key roles in improving health outcomes of diverse populations. According to the Institute of Medicine (IOM) 2011 report, The Future of Nursing: Leading Change Advancing Health, nurses should be change advocates by caring for populations within complex healthcare systems. The IOM reports asserts, "advanced practice registered nurses (APRNs) should be able to practice to the fullest extent of their education and training" (IOM, 2011, s8). However, existing barriers in the healthcare arena limit APRN practice. This article will discuss some of these barriers and provide suggestions for possible ways to decrease the barriers.

Personalized medicine has been presented in public and professional contexts in excessively optimistic tones. In the area of cancer what has become clear is the extraordinary heterogeneity and resilience of tumors in the face of numerous targeted therapies. This is the problem of cancer drug resistance. I summarize this problem in the first part of this essay. I then place this problem in the context of the larger political economic problem of escalating health care costs in both the EU and the US. In turn, that needs to be placed within an ethical context: How should we fairly distribute access to needed health care for an enormous range of health care needs when we have only limited resources (money) to meet virtually unlimited health care needs (cancer and everything else)? This is the problem of health care rationing. It is inescapable as a moral problem and requires a just resolution. Ultimately that resolution must be forged through a process of rational democratic deliberation.

It's not only necessary, but possible, if the public can be educated.