In addition to affecting how much health is generated overall, alternative approaches to estimating cost-effectiveness thresholds can also notably impact the distribution of health outcomes.  Use of aspirational thresholds, and seeking to provide the “best” possible interventions judged by their impact on individuals’ health, may lead to the concentration of health gains amongst relatively few, especially if these interventions are high cost.  Determining what would represent “fair” (i.e. equitable) distributions of health outcomes relies upon social value judgements, upon which there can be reasonable disagreement.    The paper demonstrates why policymakers should carefully consider the distribution of health outcomes, and underpinning social value judgements, as well as whose values matter.  The role of fair process is highlighted.