This paper systematically reviews the literature on how to reduce nutrient emissions to the Baltic Sea cost-effectively and considerations for allocating these costs fairly among countries. The literature shows conclusively that the reduction targets of the Baltic Sea Action Plan (BSAP) could be achieved at considerably lower cost, if countries would cooperate to implement the least costly abatement plan. Focusing on phosphorus abatement could be prudent as the often recommended measures—wastewater treatment and wetlands—abate nitrogen too. An implication of our review is that the potential for restoring the Baltic Sea to good health is undermined by an abatement strategy that is more costly than necessary and likely to be perceived as unfair by several countries. Neither the BSAP nor the cost-effective solution meet the surveyed criteria for fairness, implying a need for side-payments.