History of Hemodialysis Could Help Guide Ethical Use of Medical Resources

Ongoing advances in technology and drug discovery continue to transform numerous aspects of health, but making such breakthroughs available to all who may benefit from them is often not possible, especially in the early days of their use. Furthermore, as society strives to address rising healthcare costs and consider responsible distribution of limited healthcare dollars, many questions arise regarding the most appropriate use of expensive tests and therapies.

A new paper in the Clinical Journal of the American Society of Nephrology addresses such questions, using the history of the development and dissemination of maintenance dialysis as a guide (Butler CA, et al. Clin J Am Soc Nephrol. doi: 10.2215/CJN.04780515 [published online February 11, 2016]).

“The medical research community is feverishly developing new technologies and drugs offering a plethora of treatment options; however, the existence of these treatments does not direct how and for whom they should be used,” said lead author Catherine Butler, MD, of the University of Washington. “Increasingly, medical practitioners, lawmakers, and laypeople take part in debate about this complex distribution. This discourse is best coordinated by participants understanding a common structure of ethical evaluation.”

Butler noted that because the themes explored in the history of dialysis are common and recurring among newly developed medical technologies, they may serve as a template for future discussion in parallel fields. As an example, the researchers highlight Medicare’s recently announced National Quality Strategy, which seeks to build a healthcare delivery system that’s better, smarter, and healthier. It includes 3 aims—better care for the individual, better health for populations, and reduced healthcare costs—that can only be reached by addressing multiple, and sometimes conflicting, values.

In their Ethics Series paper that considers the history of hemodialysis, Butler and her colleagues trace the ethical conundrums that arose at various times during the adoption and distribution of dialysis. “The first formal method of medical ethics grew up with the technology and set a precedent for many future medical resources,” Butler said.

Hemodialysis was conceived in the 1940s, but it wasn’t until 1960, when the Quinton–Scribner shunt (designed by Wayne Quinton and Belding Scribner, MD) allowed repeated vascular access, that maintenance dialysis became feasible. In 1962, a committee of laypeople in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. Later, as technology advanced, dialysis was funded under an amendment to the Social Security Act in 1972, and patients with end stage renal disease were entitled to receive Medicare benefits. With this change, the focus shifted to providing dialysis for all who needed it, which lessened the ethical stress of how to fairly distribute resources but created new questions such as how to balance longevity and quality of life and how to understand and respect patient preferences. Also, with funding available through Medicare, a growing number of older patients with comorbidities began dialysis, and utilization grew to the point that Dr. Scribner suggested the need for a “deselection committee” because the criteria for starting dialysis had become so liberal.

Butler’s team found that the 4 principles forming the basis of clinical ethics—beneficence, nonmaleficence, autonomy, and justice—are emphasized to varying degrees over time. In the early days, the survival benefit offered by dialysis provided a strong argument for beneficence in initiating treatment, but it later became clear that the toll of treatment on quality of life sometimes outweighed the benefit, highlighting a role for the concept of nonmaleficence. Also clear is that a well informed and autonomous person is in the best position to consider whether initiating maintenance dialysis will support his or her own values and preferences. Therefore, clinicians must ensure that patients receive adequate information and work together with patients to establish appropriate and individualized treatment plans. Finally, the authors note that recent scrutiny of healthcare spending has put a focus on the just allocation of limited Medicare funds, and the utility of dialysis is not simply being compared among kidney failure patients but also in the context of payments for coronary stent placement, supporting cancer research, or instituting preventive health programs.

“Through the history of hemodialysis, the 4 bioethical principles are weighed differently as forces of technologic innovation, resource limitation, and social values change,” said Butler. Because of this variability, creating sustainable ethical solutions may require considering and addressing all 4 ethical principles as fully as possible.

“I found the article very thorough and, to the best of my knowledge, very accurate. It is certainly one of the best expositions of one of the early bioethical dilemmas,” said Albert Jonsen, PhD, emeritus professor of Ethics in Medicine at the University of Washington’s School of Medicine. He noted that he and the late Dr. Scribner once talked about how commercial dialysis had become, and Dr. Scribner noted that he had often been asked why he didn’t patent the shunt. “He said he had never given it a thought, then went on to say that he deplored the formation of so many dialysis centers to exploit patients for whom dialysis was of marginal value,” said Dr. Jonsen. “He concluded that he had never made a penny from the shunt or from such profit-making dialysis centers: to do so would be profoundly unethical.”

Govind Persad, PhD, a junior faculty fellow in ethics at Georgetown University, added that it may be useful to bring nonclinical components into the discussion. “The article makes the welcome and important point that, at the level of health policy, dialysis must be compared to alternative medical interventions. I would add that dialysis also must be compared to non-medical interventions,” he said. “One promising avenue for further research is considering what approach—whether the 4 principles or something else—is best for making these kinds of comparisons.” He noted that administrators and policymakers, such as those tasked with implementing Medicare’s National Quality Strategy, “frequently employ cost-effectiveness analysis and cost-benefit analysis, but proposals for alternative approaches would be welcome.”

Co-authors include Rajnish Mehrotra, MD, MS, Mark Tonelli, MD, MA, and Daniel Lam, MD.

Disclosures: Daniel Lam receives some salary support from the Northwest Kidney Centers as their Palliative Care Medical Advisor.

The article, titled “The evolving ethics of dialysis in the United States: A principlist bioethics approach,” is available at http://cjasn.asnjournals.org/content/early/2016/02/10/CJN.04780515.abstract.