In poorly designed pay-for-performance schemes in which case mix adjustments are not adequate, self-interest could lead nephrologists toward cherry picking dialysis patients. Cherry picking, however, is morally problematic. First, it may manifest itself as a subtle form of covert rationing which threatens to undermine patient trust. Second, it involves shifting the burden of caring for sicker (and less financially attractive) patients to other nephrologists and dialysis units that do not practice cherry picking, creating injustices in the health care system. Finally, it treats patients as mere means through which nephrologists achieve reimbursement instead of as persons possessing dignity and deserving of respect.