We don't need an organ market to cure conventional dialysis

By Bill Peckham

This organ market issue was not one I imagined covering when I started this blog but looking through just the 50+ DSEN posts categorized "Transplant" it turns out that we've written a number of relevant posts (and there are probably others since my post categorizing is inconsistent). So what is it about DSEN that attracts people who don't think paying for kidneys is a good idea? And can I tie that in to why I think Postrel misappropriated Halcomb's views?

I think it is because DSEN authors have all experienced unconventional, healthier doses of dialysis. We understand that renal transplants cure conventional dialysis. That is how Postrel and others have presented the case for an organ market, as compared to conventional dialysis. The cost savings are compared to conventional dialysis. Transplant's increased sense of well being is as compared to conventional dialysis. The mortality advantage is as compared to conventional dialysis. It is not a cure for Chronic Kidney Disease, it's just another treatment for CKD; its a cure for conventional dialysis.

The problem as Postrel sees it is how do we improve the lives of the 80,000 people waiting for a kidney who either face or are languishing on conventional dialysis? Oh and save Medicare money. Of course the first thing we at DSEN all say is hey! What about the hundreds of thousands of additional people who don't want to languish on conventional dialysis? Why just try to help a small subset of the population? And why save Medicare money on just a small subset of the CKD5 Medicare population?

The next thing we at DSEN all say is wait - before you change the ethical structure of organ transplant to cure 80,000 people of conventional dialysis stop and consider other cures. I know that daily nocturnal hemodialysis is a very good method of renal replacement. All here at DSEN know that there are other ways to cure the problem of conventional incenter dialysis. Routinely offering every other day dialysis incenter, especially in combination with longer runs, would cure some of what is wrong with conventional dialysis. And higher doses of dialysis would save some of the hospitalization costs Medicare incurs when beneficiaries replace their renal function with nine hours of dialysis a week.

I can point to things Halcomb wrote that suggests he would share DSEN's point of view' and to Halcomb's October 2006 Nephrology News & Issues interview (PDF available to IHD members) subtitled NxStage machine leads to attitude change for one patient. I think anyone who has experienced an unconventional, healthier dose of dialysis would be against an organ market because of their dialysis experience.

There are libertarians on dialysis too but based on his dialysis experience I believe Halcomb would have known that the choice isn't between transplant/languish and die. His experience with unconventional dialysis is why Halcomb matters in this debate. He matters because he had experience with an unconventional, healthier doses of dialysis - Postrel using a quote from before this experience to bolster her case is not fair.

I and everyone who writes at DSEN support the idea of curing conventional dialysis. We can cure conventional dialysis for hundreds of thousands of people by changing what the term refers to. Speaking for myself I think conventional dialysis should be nocturnal dialysis at home, with the frequency worked out between the dialyzor and doctor. Three hour runs, three days a week should be offered only as a last resort, an appropriate use of today's conventional dialysis would be as palliative care for someone transitioning to hospice. As has been written and adopted as DSEN's position, optimal dialysis and transplant are complimentary forms of renal replacement. And both are cures for today's conventional dialysis. I don't see the need for the organ market solution.

Comments

[Peter Laird, MD]

I believe that the entire position of those that favor a market based approach to renal transplant is in part based on the predication that there is no other alternative to transplant if you wish to thrive with renal disease. To admit to the well established fact that people can and do indeed live well on dialysis if at high enough dose takes away their chief reason for seeking such a radical solution.

This is further a completely American discussion in many ways since we kill our dialysis patients at a rate 2.5 times higher than other developed nations due to under dosage of the first renal gift of life. Thus, people that tell the truth of optimal dialysis do weaken their position. That is why I believe we do not see those searching for a market based transplant system even readily acknowledging the several studies showing equal survival with daily dialysis to cadaveric transplant.

In my opinion, anyone that must hide the element of truth about optimal dialysis to the point that it is never mentioned as another alternative to renal transplant ultimately will lose their flawed quest to supplant current transplant ethics. That is if truth can still prevail in current politically correct world we live in today.

DSEN is not in opposition of any treatment options that will ethically promote and maintain the life of a CKD5 patient, yet we do wonder at what cost some are prepared to go. Staying within the ethical bounds of true informed consent should be the first priority at all times. It is my opinion that those such as Satel and Postrel violate the longstanding ethical heritage of informing those that they advise of all options and alternative treatments. I have yet to see this in any of their writings to date.

[Lynn Roberts]

I have been reading this blog for over a year now. I enjoy the information shared here.
I was shocked to read the article and discussions. I do not like it when authors use terms like "you will die without a transplant", whether it is implied or stated.
Yes, I may be simple and naive. But I live with a dialysis patient, my husband.
I totally agree that transplant is another venue to follow. You can live and function on diaylsis. Our story is long, and includes my husband, niece, and step-mother. They all 3 are on dialysis. Everyone cannot have a transplant, everyone does not want a transplant, which can come with it's own set of problems.
Keep informing the public. You are doing a wonderful job!

[Mark]

What most people don't know is that organ procurement organizations and tissue banks can make up to $2 million off a donated whole body.

This is a $20 billion a year business in the United States. If we were talking about copper and Bolivia, the issues would be crystal clear. The current system is unjust and immoral.

If you live in a state that has adopted the 2006 Uniform Anatomical Gift Act, it is presumed that you are an organ donor until they can find evidence of a contrary position. This includes hooking you up to life support systems even if you have an Advanced Healthcare Directive that says otherwise. They can keep your body alive until they can talk to your family to find out what your true intentions were.

Under this new Act, you have the right to refuse to participate in an organ harvesting procedure, but you must register your desire with a known organ registry. There is only one organ registry in operation that allows you to record your preferences, including allowing for the contingency that just compensation might become legal at some future date.

Check out www.DoNotTransplant.com to learn more about your rights under the law