It is evident that particularly for the rich, dying is an un-American activity! This accounts in part for Americans’ spending twice as much per capita on health care as the British do. The British reluctantly accept two facts of life. First, they are all suffering from a terminal, sexually transmitted disease called life. Second, with death inevitable and resources finite, health care rationing is inevitable. Rationing involves depriving patients of care from which they could benefit and which they wish to consume. The British are much more vigorous than Americans are in “drawing the line,” as Henry Aaron, William Schwartz, and Melissa Cox show in Can We Say No? But even with Americans’ higher levels of health spending, rationing in the United States is also inevitable. Victor Fuchs articulated the explicit and implicit criteria that determine who will die and who will live, and in what degree of pain and discomfort, three decades ago.1 Because of affluence and political chicanery common to all governments assaulted by the inevitability of rationing, Americans (despite the Oregon experiment and other policies) have lost their focus on rationing, but this new book might destroy these illusions. Can We Say No? is a follow-up study of Aaron and Schwartz’s 1984 book, The Painful Prescription.2 Both books analyze the workings of the United Kingdom’s National Health Service (NHS) as seen through American eyes. Then and now the authors show that the British spend less on health care and consequently provide less care for their citizens. They also show that in the twenty-first century, the NHS is changing rapidly, largely because of the Blair government’s massive increases in public investment since 2000. Despite this growth in funding, the relative gaps in provision remain large and have increased since the 1984 book. So while the funding of care for patients with chronic renal failure in the NHS has given elderly patients increased access to dialysis, provision in this and other specialist areas remains inferior to that in the United States. The authors examine relative provision in a number of other areas—including hemophilia, stem cell transplantation, hip replacement, cardiac revascularization, and intensive care— which affect the relative quality and length of life of patients in the two countries. In all of these areas, although the United Kingdom is providing absolutely more care than in 1984, the gap between British frugality and American generosity is widening. An interesting issue explored by the authors is how, given an evidence base of clinical effectiveness, U.K. clinicians accept and explain their frugality. The authors report that NHS physicians believe that they are always doing what is appropriate for patients even though their treatment choices might result in shorter, lower-quality lives than achieved for similar patients in the United States. Of particular interest to U.S. readers is the issue of waiting times. One method of rationing health care in the NHS is to treat emergencies promptly if relatively frugally and to ration resources for elective care by making patients wait. The political pressures created by waiting lists and waiting times is one of the primary causes of the Blair reforms, which will double NHS spending in a decade and drive the share of gross domestic product (GDP) spent on the NHS to the European average of 8–9 percent. However, increases in funding take time to translate into service provision, B o o k R e v i e w s