Imagine someone took you into the woods with three other people: a young child of no particular distinguishing characteristics, a middle-aged drunkard with a family, and a 75-year-old Nobel Prize winner. The person then told you that you had to kill one of the three, and that, if you did not do so, he would go back and kill your child. How would you choose?

The child has more quality-adjusted life years at stake, multiple lives depend (not very well) on the drunkard, and the Nobel Prize winner has made huge contributions to society but may not have much longer to contribute. But there is a better choice:

Shoot the person who gave you the choice. Then your child is safe, and the rest of you can all go home.

Think about this when someone claims that reform of the U.S. health care system must involve rationing care, as Dan Brock did in his post here.

The United States spends 16 percent of gross domestic product on its health care. If our financing and payment system were more like that of other countries, we could be providing the same basket of services, to all our citizens, for around 12 percent to 13 percent of G.D.P.

The most fundamental ethical conflict in the U.S. medical system isn’t which care to provide. It is between the interests of sick people and of all those who make money from the health care system. Some of the latter deserve their current incomes. But some of the incomes in our current system provide no social value at all; and others are surely much higher than they need to be. If we ignore the option of reducing the payments for care, including unnecessary overhead, then we are allowing all the people who make those incomes to tell us, essentially, “shoot the patients but keep us whole.”

Dr. Brock’s analysis ignores this dimension, accepts the current distribution of power and income in the system, assumes it is inviolate, and moves on to identify which patients to hurt. I don’t see how that is wise or ethical.

There are situations in which discussions of relative merits of services are highly appropriate. It is necessary in triage situations. It has to be done to define benefit packages: which benefits we will promise to each other and, even more important, which services we will force some people to subsidize.

But the logic of these applications is less important than the misleading implications of the common claim that ethical honesty requires that reformers admit that national health insurance requires rationing.

The extremely high costs in the U.S. are not due to overutilization. Compared to other countries, they are clearly due much more to high prices and excessive overhead.

Can we in the U. S. reach a point where “rationing,” as Professor Brock has in mind, may be the best way to control costs? Yes, and if we do I will be extremely happy (and I should live so long). As it is, lecturing the public that it must accept rationing is a recipe for political failure, and bad policy as well.

Joseph White, Ph.D., is Chair of Political Science, Luxenberg Family Professor of Public Policy, and Director of the Center for Policy Studies at Case Western Reserve University. His most recent book is False Alarm: Why the Greatest Threat to Social Security and Medicare is the Campaign to “Save” Them. joseph.white@case.edu; 216-514-8337.

Dan Brock Replies

Joseph White is, of course, correct that high prices for drugs and other health care services, together with great and costly administrative inefficiencies, are primary causes of our very high level of health care spending. And, he might have added, spending substantially more of our G.D.P. on health care than any other developed country has not bought Americans better health. I do not believe, and nowhere said, that “the current distribution of power and income” in the system should remain inviolate, and I will gladly join him in supporting proposals to overturn them.

So why argue, as I did, that rationing is ubiquitous, desirable, rational, and ethical, especially when it continues to be the third rail of health policy reform? While I would much prefer a single payer system that could fundamentally change the “current distribution of power and income” in the system that both Prof. White and I lament, no alternative that would do so is on the current reform agenda.

It is widely believed in political and policy circles, rightly or wrongly, that the American people do not want and would not accept such fundamental reforms. “Would you want the government running your health care?” remains a potent charge, however, false and misleading.

Because it is widely believed that most Americans are generally satisfied with the care they get, reform proposals all leave the employer-based insurance system largely in place. Because one lesson commonly drawn from the failed Clinton health reform effort of 1993 is that the drug and insurance companies will defeat any proposal that they see as too contrary to their interests, reforms being considered do not take on these groups head on.

Current reform proposals are limited by judgments of what is politically possible, but in no small part also by trying to avoid the charge that they will lead to rationing. So we pay a price in what reforms are deemed feasible by avoiding the third rail of rationing.

There is reasonable disagreement about whether acknowledging and supporting rationing is counterproductive from a political and policy perspective. Prof. White and others, like Jim Sabin in his blog, may be right that it is. Perhaps we should continue to pretend that we don’t and won’t ration health care to blunt attacks on reform and rationing.

But any reformed health care system will and should continue to ration care, and we should not let opponents of reform get away with attacking reforms on the grounds that they would lead to rationing; a reformed system will only ration in different places and in different ways than we do now. My hope, like that of Peter Singer in his recent piece in The New York Times Magazine, is that if the public better understands that rationing is already commonplace in all health care systems, and that it would be irrational and unethical not to ration care, then the charge of rationing may come over time to lose some of its political force.