I read with interest the article on the treatment of a severely anemic, acutely bleeding Jehovah's Witness who refused blood transfusion [1]. His survival was a remarkable accomplishment. It was also an object lesson in the careful application of physiologic and pharmacologic principles. One is reminded that much can be done by the medical profession even if the patient's requests run counter to "common sense" and standard therapies.

The case raises many questions about preservation of personal choice in the medical setting and the medical cost of personal preference. Ought there to be limits on use of economic and human resources connected with requests (demands) for nonstandard treatment? This patient had a life-threatening illness that normally would have been handled quite differently, with greater safety, much less time, and enormous savings in terms of dollars and caregivers' time and energy.

Physicians increasingly are taking responsibility for their part in generating health care costs because of the urgent need to provide better services for more people at less expense. If we are ever to have a successful health care system for all, it is imperative that the patients (consumers) also begin to take responsibility for not unduly raising the stakes or "raiding the commons" [2, 3]. The personal choices in this case involved both refusal of accepted therapy and acceptance (or demand) of high-cost, intensive, high-technological care. Perhaps the restrictions inherent in a fixed global health care budget will be incompatible with this kind of self-determination.

There are many ways of making undue demands on joint resources, involving everything from self-neglect, poor health habits, over-reliance on alternative therapies, and refusal of the best available treatment. In each instance, the health care system eventually has to deal with more severe illness requiring higher expenditures.

Finding solutions to these problems will not be easy. Maybe it would be possible to tie choices of fully competent patients to individual financial responsibility for excess costs incurred. Currently, it is the health care providers, insurers, or "the commons" that bear the added expense.