The ubiquity of multiple-choice questions (MCQs) results from their efficiency and hence reliability. Cognitive knowledge assessed by MCQ predicts and correlates well with overall competence and performance but examinees and examiners alike frequently perceive MCQ-based testing as 'unfair'. Fairness is akin to defensibility and is an increasingly important concept in testing. It is dependent on psychometric adequacy, diligence of construction, attention to consequential validity and appropriate standard setting. There is a wealth of evidence that extended matching questions are the fairest format but MCQs should always be combined with practical assessments, as written testing emphasizes learning from written sources.