As pressures increase to contain growing healthcare expenditures, there is currently a prominent rise in the shift of healthcare costs to patients in the form of deductibles, co-pays, and co-insurance. Rising co-payments are part of a larger picture of increasing overall out-of-pocket healthcare expenditures. From 1990 to 2000, per capita out-of-pocket payments for healthcare reached $707 in the United States, and doubled in several European countries with universal health insurance, reaching $396 in Denmark, $290 in Germany, and $466 in Italy in 2000.The authors thank Dan Brock, Nir Eyal, Alex Rajczi, and Dave Wendler for their invaluable criticism of the manuscript. This study was funded by the National Institutes of Health. The National Institutes of Health was not involved in the design of this study. SAH was partially supported by a grant from the University Hospitals of Geneva. This work was conducted while Dr. Hurst was a fellow in the Department of Clinical Bioethics at the National Institutes of Health. The views expressed here are the authors' own and do not reflect the position of the National Institutes of Health, the Public Health Service, the Department of Health and Human Services, or the University Hospitals of Geneva.