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This book provides a comprehensive review of ethical issues in clinical nephrology. With the advent of dialysis and kidney transplantation midway through the 20 Century, clinical nephrology was one of the first areas of medicine to deal with complex ethical issues such as rationing of health care and discontinuation of life-sustaining therapy. In the first section of the book this historical perspective is reviewed, followed by a consideration of legal issues. Specific ethical issues in nephrology are discussed in detail in the next section. These include problems in the allocation of chronic dialysis and in termination of that treatment. Also reviewed are issues in kidney transplantation, such as proposals for enhanced acquisition of kidneys, including a number of controversial proposals such as payment to donors and xenotransplantation; and equity in allocation of the supply of kidneys. Other chapters consider ethical issues in genetics; special problems in the care of children with kidney disease; and broad societal issues such as allocation of national resources for expensive therapies and economic issues in clinical practice. In the final part of the book ethical issues in the care of patients with kidney disease are discussed from an Asian and African perspective.
- Sales Rank: #5189206 in Books
- Published on: 2001-04-12
- Original language: English
- Number of items: 1
- Dimensions: 9.30" h x .80" w x 6.60" l, 1.30 pounds
- Binding: Hardcover
- 288 pages
From The New England Journal of Medicine
Before the availability of renal-replacement therapies, people with end-stage renal disease faced certain death, and their care generated few ethical questions. This hopeless situation changed dramatically after the introduction of transplantation and dialysis in the 1950s and 1960s. Patients who would previously have died from renal failure could now be saved. But with technical success came a multitude of new ethical questions, several of which continue to plague us today. Ethics and the Kidney reviews many of these difficult ethical problems in nephrology and the groundbreaking attempts to resolve them. As noted in the preface, these efforts have yielded valuable lessons and precedents for many other medical disciplines.
The book was edited and partially written by Norman Levinsky, an esteemed academic nephrologist who has made important contributions to the field of medical ethics and chaired an Institute of Medicine committee on the Medicare end-stage renal disease program. Most of the other authors are also well-known experts with extensive experience in their fields.
The book has four sections, the first of which begins with a historical review of dialysis in the United States. This is important background information, although the discussion is somewhat repetitive. It is here that the reader first encounters the vexing issue of how to allocate scarce lifesaving resources, a theme that recurs frequently throughout the book. The second chapter gives an overview of general medical ethics. Although it is clearly relevant, the chapter is much too long and does not explain how the many concepts presented apply to the care of patients with end-stage renal disease. This discussion is followed by a useful review of key legal issues in nephrology, although the section on the procurement and allocation of organs is incomplete and poorly referenced.
The second section of the book deals with specific ethical issues in the care of patients with kidney disease. It begins with two chapters that ask whether, given limited resources, there are any legitimate reasons for withholding dialysis from patients with renal failure. The possibilities considered include age, coexisting conditions, diminished mental status, and noncompliance. The discussions are provocative and the authors of the two chapters reach somewhat different conclusions. The next chapter offers useful guidelines for providing high-quality end-of-life care to patients on dialysis; however, there is no illustrative case that shows how to apply the guidelines, and the suggestions for conflict resolution -- an extremely important issue -- are not specific enough to be very helpful.
The book then turns to ethical issues in the acquisition and allocation of kidneys for transplantation, including the selling of organs, unrelated living donors, and xenotransplantation. These chapters are enlightening, but there are some notable omissions and deficiencies. The discussion of unrelated living donors, especially altruistic strangers, is too brief, and the ethical issues surrounding living related donors and minors are not mentioned at all. The review of proposals for increasing the supply of cadaveric kidneys is also limited; although there are lengthy discussions of the selling of organs and the use of organs from prisoners, there is little or no mention of mandated choice (which would require all adults to decide whether they wish to donate their organs after death) or the many ethical issues raised by the use of organs from marginal donors and those removed from cadavers after their hearts have stopped beating. The operation of several actual plans for allocation is described, but there is not enough discussion of racial inequities in access to transplantation or of which factors are appropriate (and inappropriate) to consider when distributing organs.
The next chapter raises important questions generated by the dramatic advances in medical genetics but provides few specific answers. The authors begin with an almost incomprehensible definition of health and propose a ``new interactive counseling model,'' the essential elements of which do not seem new at all. And they argue unconvincingly that people have an obligation to know their genetic makeup. The concluding chapter of this section is a lucid discussion of special ethical issues that arise in the care of children with renal disease, including the difficult problem of informed consent.
The third section of the book deals with societal and economic issues and contains two well written and intriguing essays. The first argues that eventually the United States will be forced to limit the use of dialysis because of its high cost, and the second provides a sobering reminder of the real dangers of the industrialization of nephrology.
In the last section of the book, the reader is treated to a fascinating insider's account of medicine and nephrology in Japan, China, India, and Africa. Important cultural features of these societies are discussed. For example, in Japan, individual autonomy in medical decision making is not valued as highly as it is in the Western world; in China, the kidney is considered to be the most important organ in the body, and many people turn first to traditional (herbal) medicine; and in both countries, the concept of brain death is not widely accepted. Ethical problems raised by the lack of resources are discussed, and physicians from India, a country famous for the selling of organs, offer their perspective on this practice. Because of population migration and the importance of understanding cultural influences when caring for patients, these chapters should be of practical as well as academic interest to physicians from all parts of the world.
Despite its shortcomings, this book is a valuable contribution that summarizes many of the difficult ethical questions facing nephrology today. Although it provides few definitive answers, it should be required reading for fellows in nephrology, who need to understand the ethical as well as the medical aspects of their profession. It may also provide valuable information and perspective for experienced nephrologists and policy makers. Finally, because the relevance of the issues discussed (e.g., the allocation of limited lifesaving resources, end-of-life care, and the industrialization of medicine) extends far beyond the domain of nephrology, this book should also be of interest to physicians in other fields and to all students of biomedical ethics.
Aaron Spital, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Review
"This excellent multiauthored book gives a comprehensive account of the many ethical issues that have surrounded the management of end-stage renal disease...a book every nephrologist and kidney transplant surgeon should read."--The Lancet2001
"...a slim volume that provides a broad overview of almost every ethical issue that nephrologists encounter."--American Journal of Kidney DiseaseMarch 2002
About the Author
Norman Levinsky is at Boston University Medical Center.
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2 of 2 people found the following review helpful.
An important legacy from a giant in nephrology
By M. Galishoff
And in the third millenium of the new era there arose among us a group of men and woman who have come to be known as "medical ethicists." Well meaning and well educated, they wrestled with the toughest issues in medicine: autonomy, paternalism, futility, euthanasia, death with dignity, allocation of resources, quality of life issues and the like.
As economic pressures on the health care industry grew the influence of the ethicists likewise grew. The ethicists then retired to their ivory tower to ask questions and attempt to find meaningful answers. In time, their ranks were swelled by people of influence whose agenda and purpose was less noble. In time, the work of the ethicists was used to create a new world medical order ...
History may one day read this way. As a Nephrologist I shudder at the thought of the principles of Hippocrates and Maimanodies, which bound the duty of the physician to the patient, with a system which binds the duty of the physician to the government or 3rd party payor.
The reason that we find this prospect abhorrent is that our generation was raised with a strong Judeo-Christian tradition supported by the principles of individual liberty embodied in the revolution of the enlightenment.
However, before the first shots were fired in the Revolution, our founding fathers and their collegues in Europe worked to change the hearts and minds of the people of the world with the most powerful tool they had: the pen.
The younger generation of physicians are being asked to adopt a view that may even be something other than post-modern. Wesley Smith refers to this as a "Culture of Death" wherein the very meaning of life, liberty, soul, health, quality of life, are redefined to suit the new medical "ethics" of cost effectiveness, medical rationing, withdrawing care, with-holding care etc.
The dialysis population of the United States is represented by some of the poorest, uneducated and disenfranchised patients in the health care system. This is especially true of dialysis patients in the deep rural Southeast where I live and work. The cost of a year of hemodialysis has become the "standard" upon which all other diagnostic and theraputic items are compared in terms of cost-effectiveness. Decreasing the annual cost of care of dialysis patients lowers the bar for us all. Beware. Everyone should beware and take notice.
Increasingly, sick, elderly, complicated patients are seen as a burden to society. As Wesley Smith points out, creating a "heirarchy of Human life" is a recurring theme in our history. In the last century, the Eugenics movement, represented by "Die Freigabe der Vernichtung lebensunwertten Leben" (Permission to Destroy Life Unworthy of Life"), was believed to be the philosophical basis upon which Hitler formed his Eugenics program and Holocaust. This work was written by a famous law professor, Karl Binding, and a physician and "humanitarian", Alfred Hoche. It is an example of medical "ethics" gone bad. It is sobering to remember that physicians participated, administered and executed each and every part of Hitler's "Eugenic's Program" and "Final Solution."
Today, the Eugenicists are called Social Darwinists by their critics. The roles of Binding and Hoche, long dead and forgotten, are being played on the stage of this tragedy by another group of well-meaning philosophers and ethicists. History repeats itself.
Thankfully we have works like that of Norman Levinsky and Eli Freidman ("Legal and Ethical Concerns in Treating Kidney Failure Case Study Workbook"). As the first generation of nephrologists ages and retires they retire with them an important part of medical history. These physicians well remember the days before 1972 when only a fortunate few had access to life saving dialysis.
Patients were presented before "tribunals" composed of laymen, clergy, hospital administrators and doctors. They had to choose who was worthy of dialysis and who was not. A white 35 year old banker, father of two would receive treatment whereas a Black woman living in rural South had a snow ball's chance in Hades of receiving dialysis.
These older Nephrologists witnessed everyday what we rarely witness today: the pain, stench and suffering of a patient dying of uremia. The crys and stench rarely reach the top of the ivory tower where the great grandchildren of Binder and Hoche play their roles.
Levinsky's book should be a must read for every physician caring for sick patients. The issues raised are practical, everyday issues that go the heart and soul of the survival of the traditional medical ethics we have taken for granted. It is written with a balanced perspective. There is no political agenda. This is an academic work that combines experience, philosophy, law and ethics. The subject matter is comprehensive and I was impressed with the sections dealing with issues outside the USA.
There are no cookbook answers. Only the same old questions which will plague those who follow us well into the next millenium. Levinsky's book gives good food for thought as we try to help our patients, be their doctors and advocates. It gives us something to work with other than our own bias and preferences.
These great men witnessed something that my generation would find unthinkable. Physicians in need of a moral and ethical compass should look to such men for guidance. They won't be with us much longer.
Every Nephrologist and Transplant Surgeon should have this book on their shelf with the binder clearly cracked and worn from use.
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