ASN Kidney Week will return to Philadelphia, PA, in 2023, from November 1st (Early Programs) through November 5th (Annual Meeting). Philadelphia is known as the City of Brotherly Love because its name combines two Greek words: phileo, which means love, and adelphos, which means brother (1). William Penn, the city's founder, wanted to establish a place of religious tolerance where people would not be persecuted for their beliefs. He also hoped to live in peace with the region's indigenous population.
In medicine, no matter our affiliations or titles, we all benefit from a shared, common goal: the health of the patient.
In thinking about the City of Brotherly Love, I'm struck that we are living through a divisive time, failing to agree on much of anything and demonizing differing views. Everywhere you look, one group or position is pitted against another, particularly in politics. People dig in their heels and will not even listen to other approaches. We have really hit an all-time high—or, from my perspective, an all-time low—with what can only be described as tribalism.
As ASN returns to Philadelphia and (in many ways) the birthplace of the United States of America, I must ask: Are we still united? I am not so sure. That may sound like an unpatriotic opinion, especially in July when the country celebrates its 247th birthday. However, our current state of politics has me feeling that way.
Stubbornly taking sides is an age-old phenomenon. As a transplant nephrologist, I am well aware of people taking sides, healthy debates about care and ethics, and identity politics. Is a transplant nephrologist a transplanter or a nephrologist? My answer to that question is “Yes!” I like having a clear identity, and I'm fundamentally a consensus builder. As a transplant nephrologist, however, I have gotten used to living with multiple perspectives and simultaneous identities. Through this experience, I have become comfortable hearing different perspectives and, when possible, finding common ground.
Not everyone feels this way. Some colleges and universities try to shield students from hearing ideas that differ from their own and that they may find discomforting. Although a frequent practice, not all academic institutions approach differences of perspective this way. Robert Zimmer, president of the University of Chicago from 2006 to 2021, passed away in May. During his tenure, he put into place “Chicago Principles,” guidelines for upholding the idea that “concerns about civility and mutual respect can never be used as a justification for closing off discussion of ideas” (2). Perhaps my years at the University of Chicago have helped me get used to hearing different perspectives, as much as I may disagree with some of them.
In medicine, no matter our affiliations or titles, we all benefit from a shared, common goal: the health of the patient. That is a huge advantage in having us consider different approaches and being able to reach agreement or accept a plan. And in nephrology—whether private practitioner, academic clinician, researcher, educator, general nephrologist, transplant nephrologist, or other kind of nephrology subspecialist—we too have a common, shared goal. This reality was nicely articulated in the We're United 4 Kidney Health campaign that used surveys, focus groups, and a consensus-building process to identify four priorities: intervene earlier, transform transplant, accelerate innovation, and achieve equity (3).
Working toward such a shared goal is one way to unite. Another approach is to unite in opposition to a shared enemy. David M. Oshinsky won the 2006 Pulitzer Prize in History for his book, Polio: An American Story. The Crusade That Mobilized the Nation Against the 20th Century's Most Feared Disease (4). He tells the story of how the public, led by a patient organization that became the March of Dimes; politicians, especially former President Franklin D. Roosevelt, who was diagnosed with polio in 1921; and scientists, most notably Jonas E. Salk, MD; Albert B. Sabin, MD; and Isabel M. Morgan, PhD, worked together to find a cure.
To take it a step further, an old proverb states, “amicus meus, inimicus inimici mei” (“my friend, the enemy of my enemy”). Although the origin of this proverb is debated, I'm struck by how many cultures have used it (or a close variation) throughout history.
With the story of polio and this proverb in mind, you may be thinking that is exactly what we did during the COVID-19 pandemic. Didn't we stick together against a shared enemy—severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—particularly for the first year of the pandemic? I believe we reverted to opposing camps during the second year of the pandemic due to the difficulty in balancing personal freedoms and public health. Too many people unnecessarily lost their lives because they did not accept the science behind the vaccine.
Balancing personal freedoms and public health is nothing new. We have speed limits, seat belt laws, and motorcycle helmet laws, to name a few. However, the pandemic helped fuel this division between personal freedoms and public health, causing it to take on other dimensions and reach a crisis point, especially when we consider the current debate over reproductive health in the United States.
In Roe v. Wade, a 1973 case before the U.S. Supreme Court, Roe argued that the Texas antiabortion law violated an individual's right to liberty under the 14th Amendment to the U.S. Constitution. Roe further argued that the Texas law infringed on rights to marital, familial, and sexual privacy guaranteed by the Bill of Rights and that the right to an abortion is absolute. Roe sided with personal freedoms.
By contrast, Wade argued that states have an interest in safeguarding health, maintaining medical standards, and protecting prenatal life. According to Wade, a fetus is a person protected by the 14th Amendment, and protecting prenatal life from the time of conception is a compelling state interest. Wade argued for the public health of the unborn fetus.
In the Supreme Court's decision on Roe v. Wade, Justice Harry Blackmun, who drafted the majority opinion, wrote that the court held a woman's right to an abortion was implicit in the right to privacy protected under the 14th Amendment. Nearly 50 years later in 2022, the Supreme Court reversed itself in Dobbs v. Jackson Women's Health Organization, stating that the Constitution does not confer a right to abortion and returned to individual states the power to regulate any aspect of abortion not protected by federal law.
Since the Dobbs v. Jackson ruling, we have witnessed turmoil, unrest, and chaos, as well as even more divisiveness. Some states are upholding the right to abortions, whereas others are restricting access after 6–22 weeks of pregnancy. A few states may be considering bans for women to travel to a different state for an abortion, and Idaho is the first state to make it illegal to help a minor cross state lines to get an abortion without parental consent. In May 2023, the only five women in the 46-member South Carolina Senate formed a coalition that fought unsuccessfully against the 6-week ban on abortions in that state (5). The five senators include three Republicans, one Democrat, and one Independent, which gives me hope—despite the ultimate result in this case—that we can work together across political divides to address important challenges. For now, the law is on hold, however, until the state Supreme Court can review the case.
The issue of reproductive health has become even more complicated with conflicting rulings over the abortion drug mifepristone. In April 2023, U.S. District Court Judge Matthew J. Kacsmaryk, a federal judge in Texas, ruled in Alliance for Hippocratic Medicine et al v. the U.S. Food and Drug Administration (FDA) et al to suspend the FDA's 23-year-old approval of mifepristone. On the same day as Judge Kacsmaryk's ruling—illustrating how divided the United States is—Judge Thomas O. Rice of the U.S. District Court of Eastern Washington state ordered U.S. authorities not to make any changes that would restrict access to mifepristone.
As a member of the Council of Medical Specialty Societies (CMSS), ASN condemned Judge Kacsmaryk's ruling and raised concerns over how it undermines the FDA (Table 1). A “coalition of 50 specialty societies representing more than 800,000 physicians across the house of medicine,” CMSS “works to catalyze improvement through convening, collaborating, and collective action” (6). In addition to ASN, CMSS includes the American College of Physicians, American College of Surgeons, and American College of Obstetricians and Gynecologists.
CMSS response to Judge Kacsmaryk's ruling
The Biden Administration took Judge Kacsmaryk's ruling to the Fifth Circuit Court, which blocked the part of the ruling that overturned the 2000 FDA approval but also restricted mifepristone's use from 10 weeks to 7 weeks of pregnancy. The administration then appealed the ruling to the Supreme Court, which blocked the lower court's ruling but has returned the case to the Fifth Circuit Court. The future of access to mifepristone is unclear. The only matter that is clear is that this situation is very fluid. Whatever recent rulings apply to mifepristone are unlikely to be the end of this story, and the Supreme Court's decision in Dobbs last year raises the possibility that each state will have the ability to regulate mifepristone individually in the future.
In addition to concerns over how Judge Kacsmaryk's ruling undermines FDA's authority, sets a terrible precedent for the future of patient-physician relationships, and increases the likelihood of further divisiveness, nephrologists have a personal stake in the outcome of access to reproductive care, including mifepristone. Full access to reproductive health services in nephrology is often a matter of kidney health and sometimes a matter of life and death (7). This is also an equity issue, with individuals who are socially disadvantaged and minoritized having both an increased risk of kidney diseases as well as reduced access to reproductive care (8).
For our patients with reduced kidney function, pregnancy can further diminish their kidney health as well as be associated with pre-term deliveries. Furthermore, for all women, even healthy women who do not have access to reproductive services, illegal abortions performed by individuals who are not medically trained have been associated with acute kidney failure, septicemia, and death (9).
As nephrologists, we have a vested interest in full reproductive health services, including but not limited to pre-pregnancy counseling, contraception, and prenatal care, as well as surgical and medical abortions. For our patients with kidney diseases—no matter what state in which they live—there is no choice between personal freedoms or public health. This issue is a matter of both kidney health and survival. Can we at least agree upon that?
Supporting FDA's role in safeguarding patients, I urge the Supreme Court to act swiftly to reverse Judge Kacsmaryk's decision. I also recognize that we live in divisive times. In my book group comprised of female pediatric pulmonologists, general pediatricians, psychiatrists, a pediatric ER physician, a primary care physician, a pediatric intensivist, a nurse, an ethicist, and me—a nephrologist—we differ on assessments and interpretations of the books we read as well as many of the most controversial issues of the day. We all agree, however, on the need to reverse Judge Kacsmaryk's decision.
The ASN membership is much larger and more diverse—with many opinions on this issue—than is my book group. Do you all agree with my perspective on this case? I think you should, but whether you do or not, I am always open to dialogue.
References
- 1.↑
Satullo C; The Encyclopedia of Greater Philadelphia. City of Brotherly Love. https://philadelphiaencyclopedia.org/themes/city-of-brotherly-love/
- 2.↑
Roberts S. Robert J. Zimmer, who promoted free speech on campus, dies at 75. The New York Times, May 24, 2023. https://www.nytimes.com/2023/05/24/us/robert-zimmer-dead.html
- 3.↑
American Society of Nephrology. American Society of Nephrology launches “We're United 4 Kidney Health” to help foster a world without kidney diseases. September 29, 2021. https://www.asn-online.org/about/press/releases/ASN_PR_20210929_press_release_templ.pdf
- 4.↑
The Pulitzer Prizes. The 2006 Pulitzer Prize winner in history. https://www.pulitzer.org/winners/david-m-oshinsky
- 5.↑
Pollard J. South Carolina ready to renew abortion ban around 6 weeks of pregnancy after Senate vote. The Associated Press, May 24, 2023. https://apnews.com/article/abortion-ban-south-carolina-legislature-b191cb6a7d0987ee723cd437e2e0f80e
- 7.↑
Morgan JC, et al. Navigating the Dobbs versus Jackson America for patients with CKD and kidney transplants. J Am Soc Nephrol 2023; 34:201–204. doi: 10.1681/ASN.0000000000000049
- 8.↑
Kattah AG, Butler CR. The nephrologist's role in supporting people with CKD and unplanned pregnancy post-Dobbs. J Am Soc Nephrol 2023; 34:530–532. doi: 10.1681/ASN.0000000000000081
- 9.↑
Ingelfinger JR. A remembrance of life before Roe v. Wade. N Engl J Med 2018; 379:708–709. doi: 10.1056/NEJMp1809150
- 10.
Council of Medical Specialty Societies. Position statement: CMSS warns that mifepristone ruling threatens all FDA-approved drugs. April 13, 2023. https://cmss.org/position-statement-cmss-warns-that-mifepristone-ruling-threatens-all-fda-approved-drugs/