Current medical practice is enormously expensive, often without clear long-term benefits. A few examples:

*End-of-life care at New York University averaged $105,000 per patient in the last two years of life, without evident improvement in mortality rates. Costs at other centers were nearly as high, also without evident benefits.

*Studies document that providing intensive care to infants born at 22-23 weeks resulted in more than 1,700 extra days in intensive care, with fewer than 20 percent of the infants surviving -- only 3 percent without profound impairment. Costs per day were approximately $3,400.

*New cancer drugs cost up to $100,000 for a single course of treatment and may prolong life only a few months. Among new treatments, monthly costs are $8,800 per month for Avistatin; $10,000 per month for Erbitux; and $30,000 per month for Folotyn. Used only for late-stage cases, these drugs are taken only for a few months.

These cases and countless others raise an uncomfortable but necessary question: How much medical care can society afford?

As former Colorado Gov. Richard Lamm has written "everything we do prevents us from doing something else we also care about." What do we, as individuals or as a society, care about? Or rather, what should we care about? We all care about health care for ourselves. Many are in favor of universal health care. But we will not be able to continue our current coverage, let alone afford universal health coverage, without some constraints on costs and choice.

Among many reasons for the rising cost of care: Medicine and society overly respect the concept of autonomy and are reluctant ever to say "no" to requests for care from those who have health insurance. In recent debates about health care reform, potential constraints and choices were rarely discussed in a rational, non-alarmist fashion.

The failure to discuss the concept of constraint or rationing is all the more puzzling, because many things within the current system are already rationed. We ration care for all those without medical insurance, even though they tend to enter the system when their condition worsens and care becomes more expensive.