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Society's Interests

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. This ratified the life-at-any-cost mentality that physicians were adopting in the 1960s and 1970s.

In conflict with this interest is the problem of resource allocation. Resources expended on supporting the life of a patient are not available for other objectives, such as education or preventive medical care.[61] 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.[62]

Societal interests have become more complicated as antiabortion forces have sought legislation that demands that the state favor life under all circumstances. While 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 prolife statutory provision in the state's antiabortion law.

[61]Murphy DJ; Matchar DB: Life-sustaining therapy: A model for appropriate use. JAMA 1990; 264:2103-8.

[62]Veatch RM: Justice and the economics of terminal illness. Hast Cent Rep 1988; 18(4):34.

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