Dr. Caplan [1] presents for our serious consideration a recent Swedish approach to setting priorities for health care resources. Dr. Caplan suggests that adopting the simple ethical principles of this Swedish approach would provide an "enormous boon to health policy," that is, an orderly approach to reform of the U.S. health care system.

Dr. Caplan's recommendation has two disabling flaws. The first concerns the centrality of the value of solidarity. Put aside for the moment that the use of this language in Europe—and Canada—may be a device to paper over cultural and moral pluralism in a misguided nostalgia for cultures in which everyone is essentially alike. Solidarity is not a fundamental U.S. value. The United States consists of a far more pluralistic, contentious, regional, even neighborhood people and culture than Sweden—or any other country, for that matter. As a consequence, there can be found in the United States serious, thoughtful advocates of divergent views of the obligations of society to its vulnerable members and about the priority that should be given to controlling health care costs. We cannot simply import consensus about health care; if U.S. history is a reliable guide, we may never be able to achieve it, short of a national emergency. Proposals that we look to other countries' responses, as if we could simply import them here, are therefore unrealistic. We must build consensus, which is hard work [2].

Second, we do not have a health care system to reform, because we do not have a health care system. We are nonsystematic, perhaps even antisystematic, in the manner in which we provide health care and nearly every other basic social service [3]. The failure to appreciate this fact explains far better the failure of the Clinton health care legislation than anything having to do with rationing. Dr. Caplan's continuing attachment to the misconception that we have a system in the first place shows how deeply ingrained this failure is.