From early Greece, physicians have been committed to curative treatment
whenever possible. Physicians have always used whatever technology was
available. The Hippocratic Oath’s proscription of cutting for stone was based on
the operation’s uniform failure rate, not an aversion to technology. As
anesthesia and antisepsis made surgery safer and much more effective in the
late 1800s, modern hospitals and technology- based medicine were born.
Physicians embraced life- support technologies as they became available in the
1950s and 1960s. Although originally intended to support metabolism while the
patient recovered from a specific pathology, patient demands and insurance
incentives soon made life support an end as well as a means.
Physicians made money by billing for patient visits and for doing procedures on
patients in the hospital. Although physicians have financial interests in life-
support decisions, their interests are not as great as those of hospitals. The
physicians’ stakes are as much emotional as financial. Physicians are torn
between the urge to help specific identified patients avoid unnecessary
suffering and a traditional reluctance to talk to patients about death and dying.
Until diagnosis-related groups (DRGs) were introduced in the 1980s, physicians
were rewarded by hospitals for keeping patients on life support as long as
possible because the hospitals were paid based on the number of days the
patient was hospitalized. Now irrespective of their personal feelings, physicians
are under pressure from hospitals, managed care providers, and the federal
government to save money by denying and terminating life support. This
pressure is directed at all patients, not just those who are clearly terminally ill.