The growth of intensive care medicine has paralleled the growth of hospitals as businesses. Hospitals have evolved from “physicians’ workshops” to independent agents in medical care delivery. It is hospitals, rather than physicians, that bear the financial impact of termination of life-support decisions. Most legal challenges to termination of life-support decisions have been brought by hospitals rather than physicians.
The most controversial issue in critical care medicine is the extent to which financial concerns have driven hospital attitudes on termination of life-support decisions. Until the prospective payment system was put in place, termination of life support also meant the termination of a substantial income stream from the patient’s insurer. Although it would be unfair to see reimbursement considerations as controlling, it is clear that they have had an impact on ethical decision making. It is likely that the technological imperative was greatly strengthened by its profitability. [Powerly KE, Smith E. The impact of DRGs on medical care workers and their clients. Hastings Cent Rep. 1989;19:16.] The troubling question now is the extent to which prospective payment systems lead to the denial of necessary medical care. [Dougherty CJ. Ethical perspectives on cost containment. Hastings Cent Rep. 1989;19:5.]