Ethics and the Kidney - Hardcover

Hardcover

ISBN 10: 0192631594 ISBN 13: 9780192631596

Publisher: Oxford University Press, 2001

Synopsis

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.

About this title

About the Author

Norman Levinsky is at Boston University Medical Center.

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.

About this edition

• Publisher: Oxford University Press
• Publication date: 2001
• ISBN 10: 0192631594
• ISBN 13: 9780192631596
• Binding: Hardcover
• Language: English
• Number of pages: 286
• Editor: Levinsky Norman G.