Diminishing resources seem to be forcing rationing of medical services. Rationing the public health care system means that there needs to be ethical discussion on justice. Several years before resource allocation could impact on the levels of morbidity and mortality, economic problems created numerous methods of regulating medical and nursing services. In clinical practice, regularisation means a reduction of the possibility to decide autonomously and therefore requires specific ethical discussion. The different methods of regularisation from standards and quality control to (...) managed care are discussed with respect to their influence on medical thinking and decision making. Formalised decisions in severe disease can also be a field for regularisation, for example guidelines on the termination of life sustaining treatment (vs. Do-Not-Attempt-Resuscitation Orders). The debate on futility is discussed as a part of the economic discussion, with special regard to the impact of the macroeconomic situation on ”peripheral” medical decisions, which very often are made unconsciously, as shown by a new German study. It is impossible to discuss the influence of macroeconomy, different attempts at regularisation and the individual decision of the doctor without reflecting on their principle interdependency. Ethical reflection in this field cannot be sectioned into an economic, medical decision-making and futility sections. (shrink)