Institutional Guidelines for the
Appropriate Use of Critical Care
Concerns about cost and the use of health care for individuals that have a very poor quality of life have led to increased reflection on the need to limit treatment. However, such reflection usually involves implicit assumptions about the nature of medicine that need to be questioned. It is assumed that medicine is grounded in value-neutral science, and that any intrusion of socioeconomic values into medical decision making involves violation of its integrity and of the ethical norms of the medical profession. When institutions and other health care providers come to exercise authority over matters that are thought to be physicians' prerogative, the language of externally imposed limits on medicine is used. I challenge these assumptions and call for a more radical reflection on the relations among medical science, economics, and ethics. I argue that we should move beyond the question of limits, and directly consider how the values and available resources of health care institutions direct the way the norms of medicine are constructed. I this seek to shift the focus of discussion from the microethical issues of the physician-patient relation and the macroehical issues of broad social and political policy, in order to bring into view the interethics of health care institutions.
From the 1950s through most of the 1970s, it was assumed that one should not ask about limits on health care (Rodwin 1993; Morreim 1995). In the United States, most people obtained treatment in a fee-for-service, indemnity-based system that insulated them and their physicians from costs. Insurance reimbursed on a “cost-plus” basis, and then passed on costs in the form of increased premiums (Goodman and Musgrave 1992). Additionally, physicians worked with an understanding of professional ethics, and of the fiduciary relation in particular, which called for doing whatever was in the patient s interest, no matter how marginal the benefit. As a result of the economic structure and the conceptualization of ethical norms, costs rose exponentially.