Dialysis: a case study in medical ethics

When I was a medical student, I had a renal small-group leader who had practiced in the time before dialysis. He talked about what it was like to use this new technology. “It was life-changing, literally,” he said. “And hard work. We had to manually filter patients’ blood to keep them alive long enough to be dialyzed.”

This reminded me of Seattle’s “god squad,” a case which was a crucial mover in the American bioethics movement. Dialysis was very limited in the 1960s; demand exceeded supply. In Seattle, one hospital created a selection committee composed of laypeople, including housewives, a reverend, and local community leaders, who sat around a table and checked off certain names and not others, making life and death decisions.

The selection committee chose dialysis candidates based on not only their medical history (so who would most gain the most years of life from receiving dialysis) but also social factors like financial stability, church attendance, standing in the community. The rationale for choosing a married churchgoer with kids over a convicted felon seems implicit: choose the person who has the better compliance and is more likely to contribute to society. And to a certain extent, it is satisfying. If you have been good, you get good treatment.

But when this treatment comes at the expense of “bad” people, we must question if being “bad” means that you don’t deserve the same medical treatment as others. Are all poor people “bad?” All felons? People who dropped out of high school? Drug addicts? Sex workers? The uninsured?

This goes back to the basic principle that everyone, regardless of who they are or what they’ve done, must receive the same level of medical treatment. Many people cannot control the financial situation that they’re in, what neighborhood they’re born in, or whether they get physically or mentally sick. But the dominant groups in society may see these people as undesirables, unfit. As the Seattle case shows, if we do not have a medically sound system for evaluating patients, a eugenics-like situation based on ugly social biases is a very real possibility.

Although dialysis is much more widespread now, there are still ethical dilemmas that basically determine whether someone lives or dies (and how they choose to live or die). This is a moving paper about the emotional turmoil that dialysis may cause to doctors. How do you present dialysis to a patient who will eventually die of end-stage renal disease? What is the benefit of keeping someone alive on dialysis if they don’t have a certain quality of life? What if the patient’s wishes and the family’s wishes are not the same?

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