In America, we spend an enormous amount of money on patients who are very near death and occasionally on patients who (for all practical purposes) are already dead. In the Medicare program alone, we spend almost one out of every three dollars on elderly patients who are in the last year of their lives; as much as one out of every ten Medicare dollars is spent on elderly patients within the last 40 days of their lives. In some highly publicized cases, families have been forced to sue hospitals to disconnect artificial life support systems from loved ones who had become little more than human vegetables. These facts are surprising only if we view health care dollars as primarily belonging to patients and if we view patients and their families as the primary customers of hospitals. They are not surprising once we acknowledge that most health care dollars are transferred from bureaucracy to bureaucracy, far out of reach of patients and their families.

Unlike in the United States, cancer patients in Britain are spared not only the high cost of death but also the agony of painful therapies. Terminally ill cancer patients in Britain are often sent to hospices, where they are given heroin injections to ease their pain. The British solution seems sensible, but with one caveat. In Britain, as in America, the money is controlled by bureaucracies, not by patients and families. So itís not clear whether the choice of a hospice over continued treatment reflects family preferences or bureaucratic rationing. Cancer patients with the potential to be cured are much better off in the American health care system.