I recently did an informal, unscientific survey consisting of two questions: "Do you want the best available health care? How much would you be willing to pay for it?" Everyone answered "Yes" to the first question. But interestingly, no one could answer the second question at all. No one could put a price tag on their own health care.

Here is the ugly truth: Everyone wants the best possible medical care, at whatever cost ... as long as someone else is picking up most of the tab. Now, I don't fault people for wanting the best. But I wonder if people have any idea what "the best" actually costs.

For example, some 350,000 knee replacements were performed in the United States last year, at a typical cost of $30,000. Do the math; we spent over $10 billion for a single operation in one year.

Or consider the appendectomy. Thirty years ago, if you showed up at the hospital complaining of right lower abdominal pain, fever and nausea, you might expect a brief consultation with a surgeon followed by a half-hour surgery and a week's recovery. Today, a patient presenting similar symptoms can expect to receive an abdominal CT scan, or at the very least an ultrasound exam to confirm the diagnosis. The surgery is likely to be done laparoscopically.

These sophisticated imaging and operative techniques, which didn't exist 30 years ago, have no doubt reduced the number of unnecessary surgeries, and shortened the recovery time. But they have also driven up the cost of a case of appendicitis. My point is that, while people will always want "the best" medical care, the definition of "the best" has undergone a revolutionary, technologically driven expansion.

First-rate medical care appears to be in danger of pricing itself out of the market.

An obvious way to decrease the cost of medical care is to use less of it. There are persuasive arguments to be made for promoting efforts at preventive care. After all, adopting a more healthy lifestyle would surely reduce the incidence of heart disease, diabetes, hypertension, obesity and many cancers. But as H.L. Mencken shrewdly observed, "One of the chief objects of medicine is to save us from the natural consequences of our vices and follies."

Human nature changes slowly, if at all. Forty-five years after the Surgeon General's Report made clear the hazards of tobacco, more than 40 million Americans still smoke. We are inundated with diet and exercise programs, yet the obesity rate increases year by year. No one can seriously claim that this is due to a lack of information.

It's not that people don't get it; they just don't want to hear it. I am therefore skeptical that an increased emphasis on preventive care will drastically lower health care costs any time soon.

There is another way to reduce the utilization of medical care: rationing. The "R word" is virtually taboo in the current discussion. It leads to politicians muttering darkly about "death panels" and "pulling the plug on Grandma."But what is the alternative?

If you oppose rationing and are intellectually honest, then you must necessarily favor unlimited access to medical care for every citizen, no matter what the cost. Anything else is simply rationing by another name.

America faces a growing public demand for an increasingly expensive commodity, and a simultaneous demand that it be kept "affordable." These two demands are ultimately irreconcilable.

I offer no simple solution, but I know this: The debate will go nowhere until the policymakers, the health care industry and the public at large decide to deal honestly with this massive contradiction.

Dr. William Foster is an anesthesiologist and has practiced in Salt Lake County for the past 17 years. He lives in Sandy with his wife and son.