Taking the Tradition Seriously
Mark J. Cherry
To place the hope of one's health in the hands of the doctor is the act of
an irrational animal.
—Saint Basil, “Ascetical Works: The Long Rules”
In the United States, nearly one out of every seven dollars is spent on some form of health care; in 1998, this amounted to approximately 13.6 percent of the gross domestic product (GDP), or $4,178 per capita. By way of comparison, health care in Canada, Germany, Belgium, and Austria in 1998 respectively represented 9.5, 10.6, 8.8, and 8.2 percent of each country's GDP, or approximately $2,312, $2,424, $2,081, and $1,968 per capita (OECD 2000).1 Of such expenditures, critical care medicine accounts for approximately 15 to 20 percent of all hospital expenses, which in turn amounts to 38 percent of all U.S. health care expenditures (ATS Board of Directors Position Statement 1997). In 1994, intensive care unit (ICU) costs amounted to approximately 1 percent of GDP (roughly $64 billion) (Chalfin, Cohen, and Lambrinos 1995). This increasingly significant investment of personal and social resources into high-technology medicine is driven by very real concerns to ameliorate the physiological collapse brought on by age, accident, injury, and disease.
Critical care medicine provides a heuristic example of the desire to make available an optimal level of care for all who require it, where “optimal” means the highest available standard of care. Technologically sophisticated critical care was developed medically to maintain compromised patients requiring extensive and advanced support of respiration, support of two or more organ systems, and assistance with chronic impairment of one or more organ systems along with intervention for acute reversible failure of additional organ system(s). ICUs focus on two primary categories of patients: (1) those with a high risk of imminent death (e.g., critically ill patients with respiratory failure or heart failure) and (2) those who are potentially at high risk of imminent death (e.g., those admitted for supervision of a high-risk procedure, such as management of cardiac arrhythmias) (Taboada, essay in this volume).
Given its expense, high-technology critical care is primarily a feature of affluent industrial-world societies. Even among affluent nations, however, budgetary retrenchments in