In an era characterized by intensive efforts to reform healthcare, rising costs have become the most scrutinized component of debate—receiving abundant, but negative attention from society-at-large, the business sector, as well as Federal and State Governments. A specific cost area under study is renal replacement therapy (also called dialysis, artificial kidney treatment, and End Stage Renal Disease or ESRD). It has merited disproportionate attention because it is an expensive therapy and has been funded by Medicare, a third party payer under increasing financial pressures, for more than 3 decades. As a group, renal replacement therapies have experienced a 57% increase in expenditures from 1999 through 2004, thereby absorbing approximately 7% of Medicare’s total budget every year. Debate has been vocal, inquiring whether these figures may represent excessive costs for a program that treats a single disease. However, there are other reasons why the ESRD program has become a potential cost-cutting paradigm. The demographic under the umbrella of chronic dialysis is getting older, in fact the fastest growing segment is comprised of persons 75-years-of-age and older, and that cohort has been burdened by multiple debilitating comorbid conditions. As an example, kidney failure complicated by heart disease eventuates in the highest per capita costs throughout the entire program. Future budgetary considerations directed at cost cutting, especially efforts directed at Medicare, will foster an intense debate, one layered with substantive ethical ramifications. A contingent discussion will accompany this debate—one engaging the future rationing of medical care in the U.S.A.. Limiting geriatric renal failure patients’ access to ESRD solely based on their age, applying a social value criterion, would be unjust. However, would an empiric focus on the medical benefit these individuals realize from dialysis be a more prudent manner in which to evaluate ESRD in the elderly? A number of well-designed recent studies have demonstrated that dialysis initiates a serious decline in functional status for this age group. These studies were followed by others demonstrating that the presence of ESRD accompanied by concurrent comorbidities (ischemic heart disease, dementia, peripheral vascular disease) in international geriatric/ESRD cohorts led to survivals on dialysis that were not significantly better than conservative strategies without renal replacement therapy. Cost cutting in medicine per se can represent either stewardship or unjust social value criteria. The present era may offer an opportunity to carefully consider medical benefit as an ethical way in which to approach excessive costs for healthcare.