The Evolving Ethics of Dialysis in the United States

Abstract

Throughout the history of dialysis, four bioethical principles -beneficence, nonmaleficence, autonomy and justice -have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations.

New Intravenous Calcimimetic Agents: New Options, New Problems. An Example on How Clinical, Economical and Ethical Considerations Affect Choice of Treatment

“…The ethical discussion of the clinical indications follows the four principles of principlist ethics (beneficence, non-maleficence, autonomy and justice) [46][47][48].…”

What Should We Learn From Early Hemodialysis Allocation About How We Should Be Using ECMO?

“…In the 1930s and 1940s, HD for acute renal failure was to be complimented with dietary treatment. 10 It is unlikely that early "protonephrologists" envisioned treating end-stage renal disease (ESRD) with HD, as is currently done, but once repeated vascular access was developed in 1960, 11 HD became a feasible maintenance therapy. This breakthrough led to the establishment of the first outpatient dialysis center, the Seattle Artificial Kidney Center (now the Northwest Kidney Centers), in 1962.…”

“…12 HD use in treating chronic disease ballooned when Medicare funding for dialysis began in 1972. 11 As of 2015, 468 000 patients were maintained on chronic HD. 13 At the Seattle Artificial Kidney Center, ethics committees helped determine how to allocate limited HD resources.…”

Dialysis Payment Model Reform: Managing Conflicts Between Profits and Patient Goals of Care Decision Making

“…Nephrologists have professional responsibilities and ethical duties to their patients, must maintain their primary role as patient advocate, and must practice in a manner consistent with available evidence and established guidelines without being unduly influenced by the costs of care. 18,19 In contrast, dialysis corporations, while responsible for providing high-quality care, also have fiduciary responsibilities to shareholders (if for profit) or boards (if not for profit) that might overwhelm other ethical obligations.…”