Distributive Justice: Methods
of Distribution, Redistribution,
and the Role of Time in Allocating
Intensive Care Resources
M. Cathleen Kaveny
In the United States, the proportion of the gross domestic product that is consumed by health care currently hovers around 14 percent. Although the United States conceivably could provide every person living within its borders with the full range of potentially beneficial health care, we seem to have reached a consensus not to exceed current levels of spending in this area. Consequently, the health care financing and delivery system has increasingly focused upon reducing costs and providing cost-efficient care. Many hospitals have closed; those that remain in operation have downsized in order to enter into affiliations with other facilities that reduce duplication of services in a given area and achieve economies of scale. Managed care has placed increased emphasis on the need to provide medical services in the least intense setting possible, including, if possible, discharge to home care.
A particularly attractive target for cost-cutting measures is the intensive care unit (ICU). First, the ICU is extremely expensive. Second, it is not self-evidently cost-effective, at least in some cases. Third, it has come to symbolize the excesses of late-twentieth-century industrial-world medicine, as well as its more dehumanizing elements. Intensive care will provide many patients with the life support that enables them to survive an acute illness or injury and return to a relatively acceptable level of functioning. To them, it doubtless appears nothing short of a miracle. But for other patients, intensive care will not even enable them to survive long past discharge from the hospital, if even that long. For them, intensive care arguably counts as a harm. Not only does it fail to save their lives, but it also imposes intrusions, distractions, and isolation that prevent them and their families from coming to terms with the waning of their earthly lives.
Assuming that the number of available intensive care beds continues to shrink as health care restructuring continues, how should we allocate those that are available in cases