The recent perspective by Mann and colleagues [1] describing the critical care of a Jehovah's Witness suggests that the patient's preference resulted in an excessive intensive care unit stay and cost. The authors failed to mention the price tag of this exercise in the application of alternative, less effective technology. The normal length of stay for a similar patient is 8 days with a reimbursement of $6879, according to the 1992 DRG Handbook. The complication of Pseudomonas aeruginosa pneumonia increases the length of stay to 13 days and the reimbursement to $14 429. Outlier status is achieved by 28 and 36 days, respectively. The cost for the 41 days of intensive care with mechanical ventilation and a total hospital stay of 58 days for the patient described is likely to have exceeded $150 000 using conservative estimates.

I would suggest that, in addition to the ethical principles of beneficence and autonomy mentioned by the authors, a third ethical principle is raised, that of social justice. Should society be compelled to use precious resources in an inefficient fashion because of patient choice? The authors do an admirable job of discussing the physiology, cost, uncertain efficacy, and risks for each individual intervention but fail to acknowledge their apparent misuse of resources that might be better used for prenatal care or vaccination programs.

Society would do well to reevaluate its approach to patients who, by choice, refuse the standard of care in a given situation but are willing to submit themselves to expensive, risky, technological interventions that put themselves, the physician, and the hospital in jeopardy.