The efficient production and distribution of resources has long been a central feature of the debate on a national policy on health care. The issue of rationing, or limiting the use of potentially beneficial resources, has emerged relatively recently. Nowhere is rationing of greater concern than in the intensive care unit (ICU), the high citadel of technology. In the ICU, highly trained nurses care for critically ill patients using a wide range of life-saving technologies. The vital signs of the patients are constantly monitored. Often there is a ratio of one nurse to patient for the most severely ill. Many have argued that in terms of increased rates of survival and improved quality of life, investment in ICU services is inefficient. While some patients clearly will benefit form the life-support interventions of the ICU and return to normal life, the chance that many patients in chronically poor health will survive is at best only marginally improved by ICU intervention. In Rationing of Medical Care for the Critically Ill physicians, administrators, economists, lawyers, politicians, philosophers, ethicists and third-party payers have been brought together to shed light on this critical subject of health care rationing and what the alternatives might be for tomorrow. In this volume, one of the two major issues discussed was whether cost containment and efficiency can obviate the need for a policy restricting costly but beneficial life-sustaining care in the ICU. Or will the United States move to a system like Great Britain's where costly but beneficial services are limited at a societal level by implicit rationing by physicians? The second major issue, dealing with the allocation ofservices, asked whether physicians must act as society's gatekeepers in distributing medical services or remain the patients agent as called for by the Hippocratic Oath. Who, other than the physician and patient, should be brought into the process of deciding whether to limit beneficial services?
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