Abstract The future of critical care medicine will be shaped not only by the evidence-validated foundations of science, but also by innovations based on unproven and, in many cases, untested concepts and thoughtful visions of scientists and clinicians familiar with the complex problems actually faced in clinical practice. Clinical investigations and trials often lag behind collective experience and impressions, in a well-intentioned and necessary quest to determine the fallacy or validity of ongoing practice. Progress made in this way can be painfully slow, and imperfect theory may prove difficult to challenge. On occasion, an innovative paradigm shift fostered by a novel approach can reorient the forces of academic investigation toward generating an evidence base upon which such concepts and interpretations can find scientific justification. This discussion presents a selected set of ideas to improve the future practice of critical care - each having a defensible rationale, but unconfirmed validity.