Abstract

Critical care as a discipline has become so expensive that some have proposed extensive limitations on the amount of money devoted to it by society. In this paper that issue is examined with respect to pediatric and neonatal intensive care. Initially, a case is presented which includes many of the ethical and economic issues. The neonatal population at present has a tolerable median cost, with a distinctly higher average cost created by many special cases such as the one described with very high costs. The pediatric population is served by an intensive care system costing approximately one billion dollars. This contrasts with the adult costs which are markedly higher and yet do not meet the total preceived need. Different theories of justice would concede differing allocations to individuals and to the problem of critical care as a whole based on their view of the obligations of societal membership. The authors argue that in fact critical care might be analyzed from the view-point of economics more effectively by breaking down the cost allocations for different components for that care, and argue that labor is the major cost in its provision. They then argue that that labor component may be a necessary and affordable cost for a post industrial society. It may be that libertarians, Rawlsians, and utilitarians could accept such an allocation of resources. Further, it is argued that triage is not an appropriate approach to limiting expenses, and that other methodologies such as cost effectiveness are the only appropriate ones to invoke in pediatric critical care. Recognition of the economic realities present in a given case may be the key to clinicians' demonstrated reluctance to participate in the gatekeeper role through the use of triage.