The physician who is entrusted with a large quantity of resources for the treatment of ARF/MOSF has a social responsibility for optimizing the treatment, auditing the outcome, and where possible, preventing the illness. Best treatment includes not only modern techniques but also efficient organization and leadership of the ICU team. Audit is an individual responsibility, may be fruitfully pursued on a multicenter basis, and is a cost-containment discipline. Audit of the St. Thomas' Hospital ARF program has resulted in a predictive scoring formula. This is used to illustrate a cost-effective analysis related to disease severity. Prevention of ARF/MOSF is a challenge to emergency services. There may also be a considerable opportunity to prevent ARF in high-risk surgical patients. A randomized study carried out at St. George's Hospital illustrates the health gains which could result.