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Journal of Long-Term Effects of Medical Implants
Abstract of "Stressful Ethical Issues in Therapy of Kidney Failure"
Eli A. Friedman
Division of Nephrology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203
Our newly established, federally funded academic nephrology service, in 1963, continuously debated the ethical correlates of making life-death decisions allowing patients to receive kidney transplantation, maintenance hemodialysis, or peritoneal dialysis. Fair allocation of lifesaving treatment for kidney failure demanded a transparent standard in nephrologists' life-or-death decisions. Forced rationing of dialysis changed thinking about accessibility of health care in the United States underscoring dilemmas in modern bioethics. Congress, in 1972, amended the Social Security Act to reimburse long-term hemodialysis, and later included peritoneal dialysis, home hemodialysis, and kidney transplantation under Medicare. In January 2009, 78,250 patients are wait-listed for a deceased donor kidney, of whom more than 7000 who die each year would have survived had a donor kidney been available. Strategies to expand the donor poolpublic relations campaigns and driver's license designation of willingness to donatedid not increase deceased organ donor consents. Purchasing kidneys from compensated donors, a highly controversial and evocative issue, evolved from an unmentionable practice performed secretly in developing (poor) countries to an openly debated topic at major medical congresses. Clearly viewed as illegal and unethical by governments, the voluntary sale of purchased donor kidneys accounts for thousands of black market transplants including an estimated one-quarter of all kidney transplants performed globally. Legalizing kidney purchases relies on the key premise that individuals control their body parts, even when inducing risk of life. Because of its ethical complexity, the profound issue of whether marketing body parts should be an option for physician, patient, or government is unlikely to yield a simple answer. Failed efforts to control vital aspects of human behavior by legislation, including prostitution and consumption of alcohol, teach us that a mixture of wisdom and broad education will be needed to construct an equitable system to regulate who, under which circumstances, may "legally" and "ethically" supply a kidney to whom.
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