High-technology medicine and the old: the dialysis example.

High-technology medicine, which is often expensive, and most often very useful for old people, whose numbers are rapidly increasing, is presenting huge moral problems for physicians. There are now pressures to make physicians salaried employees rather than professionals, and this will decrease or obliterate their efficiency as advocates for patients. Advocacy is a previously non-described duty, which is an important ethical principle for physicians, in addition to the four universally recognized principles: beneficence, non-maleficence, respect for autonomy, and justice. Not-so-subtle economic pressure by managed care, government, administrators, and politicians, is already in force. If physicians, by advocating expensive treatment for many, irritate those with economic power, they may violently retaliate. Chronic dialysis illustrates well the dilemma of high-technology medicine because acceptance numbers are accurate and widely known, most patients are old, the treatment is rationed everywhere by age, and, as patients die if excluded, it can be used to analyse reactions to an ongoing age rationing. Post-modern bioethics and moral philosophy appears helpless and, in some regards, irrelevant in elucidating and solving the concrete moral conflict posed by high-technology medicine and the old. Administrators and politicians wish physicians to be society's economic gatekeepers; however, this is incompatible with classical ethical concepts of the profession of physicians. Physicians and their professional organizations had better realize this in order to map out defensive strategies so that physicians, as a profession, do not disappear.