But, he says, no-one is prepared to face up to this reality, and rather like the Charles Dickens character Oliver, doctors and patients simply clamour for more and bemoan the perpetual state of health service underfunding.
"A health service in 'political denial' stunts the development of socially agreed rationing principles that are openly discussed and accountably applied," contends Professor Maynard. And it promotes an irresolvable tug of war between the providers who advocate "more" and parsimonious politicians who want more for less, he says. This conflict allows the agenda to be dominated by self-interest and policies that are not rooted in evidence.
In the midst of the "ubiquitous cacophony" about lack of money, existing resources are not used properly, he says. Variations in practice and differences in death rates between practitioners have been known about for decades but have not been resolved by NHS management. Many routine interventions in health care are demonstrably not cost effective, and national guidance fails to take into consideration local needs, he adds.
The economic perspective is to maximise health improvements using limited resources by targeting them at activities that are cost effective and produce the greatest health gain for all. And concludes Professor Maynard, "it has a strong claim for use, probably with equity weighting, in a world of scant resources."
Journal of Medical Ethics