The history of hemodialysis sheds light on the ethical use of limited medical resources

As medical research continues to generate new technologies and drugs for a wide variety of uses, many questions arise regarding how such resources should be used and who should have access to them. These questions are especially pertinent as society strives to address rising healthcare costs and consider responsible distribution of limited healthcare dollars. A paper appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN) addresses these questions, using the history of hemodialysis as a guide.

To shed light on this issue, Catherine Butler, MD (University of Washington) and her colleagues consider the history of hemodialysis, examining how in 1962 a committee of lay people 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 the focus shifted to providing dialysis for all who needed it. This lessened the ethical stress of how to fairly distribute resources, but created new questions such as the balance of longevity and quality of life and how to understand and respect patient preferences "The first formal method of medical ethics grew up with the technology and set a precedent for many future medical resources," said Dr. Butler.

By studying the history of the development and dissemination of dialysis, the investigators found that the 4 principles forming the basis of clinical ethics—beneficience, nonmaleficence, autonomy, and justice—are emphasized to varying degrees over time. "Through the history of hemodialysis, the 4 bioethical principles are weighed differently as forces of technologic innovation, resource limitation, and social values change," said Dr. Butler. Because of this variability, creating sustainable ethical solutions may require considering and addressing all 4 ethical principles as fully as possible. "The themes explored in the history of dialysis are common and recurring among newly developed medical technologies, so may serve as a template for future discussion in parallel fields," Dr. Butler added.

As an example, the researchers highlight Medicare's recently announced 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.