Until recently, American society was uncritically committed to prolonging the
life of all citizens. Insurance payments influenced physicians through direct
financial incentives and through the indirect incentive of societal approbation.
Insurance companies, as powerful representatives of society, clearly approved
of the prolongation of life with advanced life-support technologies. The insurers
ratified the life-at-any-cost mentality that physicians were adopting in the
1960s and 1970s. This is not surprising because the dominant insurers of this
period—Blue Cross and Blue Shield— were controlled by physicians and
This mentality lead to striking increases in the cost of medical care. Employers,
who buy most health insurance, and government, which pays for Medicare and
Medicaid, became concerned with resource allocation. Resources expended on
supporting the life of a patient are not available for other objectives, such as
education or preventive medical care. [Murphy DJ, Matchar DB. Life-sustaining
therapy: a model for appropriate use.
JAMA. 1990;264:2103–2108.] The
enactment of the Medicare prospective payment system is one manifestation
of this concern. Implicit in the prospective payment system is a repudiation of
the life-at-all-cost signal sent by the previous cost-based reimbursement
system. [Veatch RM. Justice and the economics of terminal illness.
Hastings Cent Rep. 1988;18:34.]
Societal interests have become more complicated as antiabortion forces have
sought legislation that demands that the state favor life under all
circumstances. Although intended to limit abortions, such statutory
presumptions can also be read as limiting termination of life-support decisions.
This is at issue in the Cruzan decision by the Missouri Supreme Court. The
court held that its refusal of an order to terminate life support for an
incompetent person was mandated by a pro-life statutory provision in the
state’s antiabortion law.