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    « NxStage wonkery on the Freedom Cruise | Main | Dialysis & CKD Blog Report 1/14 »

    January 13, 2010

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    Peter Laird, MD

    Bill, she is simply following suit with population based ethics as we have discussed in prior threads. Unfortunately, this is simply a sign of the changing ethics that in the long run shall place all chronic renal replacement patients at great risk when we compare our expenditures compared to the average patient.

    http://www.billpeckham.com/from_the_sharp_end_of_the/2009/08/the-new-medical-ethics-population-based-outcomes.html

    Over time, with pressure placed on the physicians to stay with in the average utilization when compared to their peers, with the outliers constantly counseled, the average drops dramatically. However, without a concomitant decrease in fixed expenditures of the various renal replacement therapies, this gap is likely to increase making the inevitable difficult decisions that are likely to come.

    When these hard decisions are made, in my opinion, fellow CKD patient, Dr. Sally Satel is likely to be their champion on why it is needed. The doors of fiscal responsibility and social duty shall march forth as the solution by reducing and ending renal replacement therapies for those too expensive to continue. This is the inevitable end of their philosophy and ethics when the population over rides the ethical concerns of the individual.

    Lifepactx2

    Bill Peckham's point: Fox and Swasey's work precedes Sally Satel's insights into organ transplantation is gladly taken. Nowhere does she seem to be holding her scholarly qualifications higher or better grounded than theirs-, her angle to the theme is that of a patient who came through the system and is now empowered to call for change.
    Also unfounded is his view of her pointing to a "moral imperative" when it comes to financial incentives in organ transplantation. All she is advocating for is to include as equal the option of incentives of a monetary value in the arsenal of upping the number of living donations.
    Being successfully on dialysis as Bill has been for many more years than most patients allows him to view that treatment and future betterment's of it as an answer to transplants.
    Sally Satel also contends that gains in transplants to a level that eliminates the backlog of wait-listed patients could be used to revert to an altruistic-only system.
    In the end her critique of Fox & Swasey's latest book is not so much an expose of philosophical differences but a persistent effort on her side to move the discussion out of the theoretical realm and into an actionable mode.
    The activist-patient, employed by a republican-leaning think tank saying: we can-we must-and now!

    Somerville

    Sally Satel is a dialysis patient and understands the reality. Fox and Swazey are just bioethicists, and have recently announced that they are leaving the field of dialysis bioethics to go home and sulk about the fact that dialysis patients are for some incomprehensible reason not willing to accept their professional wisdom and die as they should rather than buy their way of out a slow death on dialysis.

    What bioethicists ignore is the fact that allowing patients to buy their way out of dialysis by purchasing a transplant from a volunteer benefits BOTH the individual and the community, according to John Rawls' famous 'difference' principle of justice. This is the case because the rich who can afford to buy an organ benefit the poor who can't afford to, because the poor move up one on the tansplant list for every rich person who inducts an extra kidney into the pool of organs available for transplant by a monetary inducement. It is a win-win outcome, with the poor organ donor gaining the money he demands for the sale; the organ recipient saving his life; and the whole population of the community becoming healthier. It is only irrational notions of the 'sacredness' of the body which prevent a rational, supervised, kidney market from being introduced.

    Bill Peckham

    Sommerville, long time no read - can't say I missed you though. Satel never was on dialysis she had a preemptive transplant.

    As readers of DSEN know "'sacredness' of the body" has nothing to do with Peter's or my concern about creating an organ market for kidneys.

    Concern about the donor is a factor and if the proponents of a kidney market advocated as hard for lifetime followup - study - of donor outcomes, their arguments would not seem so self centered.

    Somerville

    I still think the ultimate reason for objections to the voluntary sale of kidneys is some covert assumption that the sacredness of the body must not be violated, as though what was sacred about humans was not their moral autonomy but the fleshy substrate of that autonomy. I say this because the data simply don't support the theory that living donation is harmful, or that lack of medical follow-up for living donors is a serious problem. Look at the extensive studies by Ingela Fehrman-Ekholm, et al, "Kidney Donors Live Longer" (1997) 64 Transplantation 976 and Fehrman-Ekholm, et al, "No Evidence of Accelerated Loss of Kidney Function in Living Kidney Donors" (2001) 72 Transplantation 444. The donors followed more than 30 years in Fehrman-Ekholm's study had one medical follow-up two months after donation, and after that there were "no regular check-ups." Even if you assume that check-ups are required, in a Third-World country like the Philippines an appointment with a nephrologist costs about $10, so for the $4000 payment the donors there receive, follow-ups should be affordable.

    But the logic of the objection collapses when we consider that in Kantian morality, which characterizes the basis of much Western thinking about morals, what we respect about other humans is their autonomous will, not their bodies. Thus if a person decides that for him, selling his kidney is worthwhile, we disrespect him and treat him immorally if we deny him that freedom. Motorcycle racing and other sports which our culture permits are more dangerous than donating a kidney, and these exercises of autonomy are much less important than the third-world donor rescuing himself from dire and perhaps lethal poverty by selling a kidney. So forbidding organ sales simply makes no sense, and thus it must rely on some covert, irrational, emotional aversion to the imagery of organ sales.

    I suspect that a lot of the objection to kidney sales also represents the manifestation of an unexamined hatred and loathing for sick persons among the healthy majority, and this comes out strongly in the articles by the main opponent of organ sales, Nancy Scheper-Hughes, who has characterized the sale of kidneys are due solely to a "commodity fetishism" among wealthy dialysis patients who simply want the best organs rather than the cadaver organs they could otherwise easily access. (N. Scheper-Hughes, "Rotten Trade" (2003) 2 Journal of Human Rights 197, 198) She regrets that to dialysis patients on the verge of dying without a transplant, "the ancient prescription for virtue in suffering and grace in dying can only appear patently absurd." (Ibid., 200) There is no need for CKD5 patients to join forces with people like this.

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