Book Review
Ethical Problems in Dialysis and Transplantation
N Engl J Med 1993; 328:1204-1205April 22, 1993
- Article
Ethical Problems in Dialysis and Transplantation
(Developments in Nephrology. Vol. 33.) Edited by Carl M. Kjellstrand and John B. Dossetor. 235 pp., illustrated. Boston, Kluwer Academic, 1992. $108.50. ISBN: 0-7923-1625-8In 1960, kidney doctors lost their innocence. Prioritizing, rationing, and exclusion, before 1960, were words alien to the lexicon of renal medicine. Before that year, except for patients treated by Alwall in Lund, Sweden, and Merrill in Boston, who applied hemodialysis to acute renal failure, the diagnosis of uremia meant death in days or weeks. Proposals for repetitive hemodialysis in patients with uremia were termed “unethical” and “cruel” and were considered needlessly stressful for patient and family in protracting the inevitable. I recall being taught the use of magnesium sulfate and chloral hydrate injections to mute agonal uremic seizures. Physicians committed to the study of the kidney conducted repetitive, unproductive explorations of sodium, potassium, and chloride transport in the rat nephron. Awards from the National Institutes of Health mainly supported exploration of where and how the rodent nephron secreted uric acid, how diuretics blocked canine sodium reabsorption, and ion transport in the toad bladder. Dominant renal physicians evinced minimal interest in two-legged subjects with failing kidneys. Physiologists owned the kidney and its diseases.
Then, in 1960, Scribner startled an unprepared renal community by demonstrating that tenuous though seemingly unlimited prolongation of life might be made possible by “chronic hemodialysis.” That same year, Starzl added corticosteroids to azathioprine, devising a standard for effective immunosuppression in transplant recipients for the next 20 years. Now that kidney doctors had something to contribute to the extension of life, there was reason to accept Hamburger's suggestion of “nephrology” as the name for their emerging specialty. Scribner's dialysis team in Seattle recognized that the power to forestall death in cases of renal failure raised troublesome issues of who would be treated and under what circumstances. Never before in the practice of medicine had the physician's decision on treatment so clearly been converted into a choice of life or death, as governed by policy, resources, and long-term budgets.
Evaluating patients with renal failure became a horrible slow-motion water ballet with dying people clutching for an insufficient number of lifeboats. Nephrologists were subject to discordant pressures from patients, institutions, and society, each with a distinct agenda. Given limits on the number of patients who might be “accepted” for hemodialysis supported by grants and philanthropy, it became evident that rules were necessary to “allot the slots” equitably. Deliberations on these guidelines were, in fact, the start of bioethics, as we now term the subspecialty. For the first decade of dialytic therapy, nephrologists striving for fairness organized committees, established boards, and otherwise stumbled through an era when all rich people and some poor people found that there was life after the onset of uremia.
When Medicare solved the problem of financial resources for maintenance hemodialysis in 1972 by enacting universal entitlement, derivative dilemmas were created. Pithy questions faced by nephrologists no longer restricted by concern about costs included the issues of futility and treatment withdrawal. For example, whether or not to initiate dialytic therapy in a 95-year-old nursing home resident without a family is often a subjective determination based on the physician's religious beliefs, upbringing, or past experience. Discontinuing dialysis in an unresponsive patient with metastatic cancer, AIDS, or profound depression is an equally vexing decision.
In their superb book, Ethical Problems in Dialysis and Transplantation, Kjellstrand and Dossetor provide what amounts to a study guide on these and other ethical problems faced to a greater or lesser extent by all physicians. In 18 chapters written by 16 contributors, the book includes a virtual listing of the vital problems of resource allocation when demand far exceeds supply. Starting with the disturbing question “Even though everyone rations and selects, does that make such selection just?” and proceeding through an examination of “Theories of Justice,” “Selection and Commercialization,” “Profit,” and “Stopping Treatment,” Kjellstrand and Dossetor raise the profound and vexing subjects that dominate discussions on rounds and in morning reports.
I have found that ethicists tend to be verbose and hard to understand. Engelhardt, in the opening chapter on “The Search for a Universal System of Ethics,” exemplifies these traits. I was unable, for instance, to understand sentences such as “Somewhat like empirical science which does not require a metaphysical agreement, only the interest in empirically resolving intersubjectively certain disputes concerning phenomenal reality, this approach to morality provides a practice open and available for moral strangers without presupposing any metaphysical assumptions or content-full moral premises” and “Instead, the moral discourse that develops around considerations of limited solidarity or social insurance can come closer for general secular ethics to accounting for political structures with general secular warrant: in creating health care entitlements, societies are endorsing one among many other possible responses to losses at the natural and social lotteries.”
Once the reader is past this murky sea, however, the writing is generally concise, direct, and stimulating. Atsumi's insight into Japanese patterns of dialysis (no home hemodialysis) and kidney transplantation (nearly no cadaver-donor transplants) provides a rare opportunity to understand differences between the United States and other rich nations. Wing's lucid summary of how the United Kingdom came to be willing to permit its older uremic patients to die without treatment should give pause to the geriatric reader who sees only benefit in the British system of health care. Kjellstrand's brilliant essay on stopping dialysis includes practical suggestions on how to minimize the anguish of family and physician. He notes that families wish “for more openness and truthfulness” on the part of doctors and that “no long-term psychological harm seems to have come to relatives and family because of their involvement in the decision.”
In our complex everyday attempts to juggle services and costs, futility and rationing, miracles and failures, I urge a beneficial pause to read through Kjellstrand and Dossetor's small book. These original thinkers force each of us to ask what is right and what is wrong in the way we practice medicine. There is no doubt that the questions will get tougher as lungs, pancreases, and other organs prove beneficial when transplanted, not even counting the enormously expensive implantable bionic hearts, lungs, and other 21st-century realities. I intend to use Ethical Problems in Dialysis and Transplantation as a course book for renal fellows and senior medical students in elective courses. There is no reservation to my endorsement of this book as an invaluable, constructive tool to aid all who worry about what really happened when Scribner let the healing genie out of the bottle.
Eli A. Friedman, M.D.
State University of New York Health Science Center at Brooklyn, Brooklyn, NY 11203- Citing Articles (29)
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L Fontana. (1997) Ethanol induces the expression of α1(I) procollagen mRNA in a co-culture system containing a liver stellate cell-line and freshly isolated hepatocytes. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease 1362:2-3, 135-144
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P Greenwel. (1997) Accelerated development of liver fibrosis in CCl4-treated rats by the weekly induction of acute phase response episodes: Upregulation of α1(I) procollagen and tissue inhibitor of metalloproteinase-1 mRNAs. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease 1361:2, 177-184
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CrossRef29
Norifumi Kawada, Machiko Uoya, Shuichi Seki, Tetsuo Kuroki, Kenzo Kobayashi. (1997) Regulation by cAMP of STAT1 Activation in Hepatic Stellate Cells. Biochemical and Biophysical Research Communications 233:2, 464-469
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