Editor's note: One of the most interesting aspects of this job is that the contributors never fail to surprise me. When I submit what I consider a straightforward case, I commonly receive quite complex and circuitous answers. Conversely, cases that could be treated in a variety of ways may come back with a consensus. Responses in this case lived up to my unexpected expectations. Health care costs in the United States are skyrocketing. Health care providers now grapple with economic decisions that in years past would have been inconceivable. We also face the stark realization that health care in this country is now rationed. Not everyone gets it. In the opinion of this editor, as we attempt to deal with health care costs in the future, harder decisions will have to be made. If a patient develops cancer after years of smoking or cirrhosis after years of abusing alcohol, who should be responsible for the costs of treatment? Does secondhand smoke play a role in the genesis of head and neck cancers? Should a patient's home life alter treatment plans? Should economics be considered? Who will make the decisions? The answers are complex. What I thought would be long and conflicting thoughts from the experts turned out to be short and to the point–another surprise.