Stressful ethical issues in uremia therapy: Long Island College Hospital Conference, 30 May 2008, Brooklyn, New York, USA
2010; Elsevier BV; Volume: 78; Linguagem: Inglês
10.1038/ki.2010.190
ISSN1523-1755
Autores Tópico(s)Palliative Care and End-of-Life Issues
ResumoThe objectives of this review are to introduce and explore the following representative ethical problems generated by modern renal replacement therapy: (1) reviewing the historical origin of medical ethics with specific reference to nephrology; (2) recognizing the complex stresses surrounding assignment of a deceased donor renal transplant to a geriatric patient while young patients continue waiting for a donor kidney; and (3) appreciating the concept of futility and support for a uremic patient opting for death rather than further uremia therapy as the best in choice in coping with renal failure. The objectives of this review are to introduce and explore the following representative ethical problems generated by modern renal replacement therapy: (1) reviewing the historical origin of medical ethics with specific reference to nephrology; (2) recognizing the complex stresses surrounding assignment of a deceased donor renal transplant to a geriatric patient while young patients continue waiting for a donor kidney; and (3) appreciating the concept of futility and support for a uremic patient opting for death rather than further uremia therapy as the best in choice in coping with renal failure. Medical ethics existed thousands of years before there was a specialty named nephrology. The wonderment and stress engendered by selecting patients for life extension by dialysis demark the beginning of the current era of attention to the ethics of practice. At an organizational meeting of the International Congress (Society) of Nephrology in 1960, at Eaux d'Evian, a resort on Lake Geneva, 20 invited clinicians and scientists presented papers on renal physiology, the newly discovered mesangial cell, and on a variety of glomerular lesions, but were unprepared for reports detailing survival on chronic dialysis and after kidney transplantation.1.Richet G. A brief history of the International Society of Nephrology.Kidney Int. 1989; 36: 938-940Abstract Full Text PDF PubMed Scopus (3) Google Scholar Attendees recognized the need for a new specialty they called nephrology. However, no studies recounted the emotional toll imposed on 'kidney doctors' selecting those permitted life on renal replacement therapy. Nephrology was established in the United States at the Third International Congress of Nephrology in Washington, DC, in 1966, sponsored by the Renal Section of the American Heart Association, followed in 1967 by the founding of the American Society of Nephrology. US Public Health Service-funded dialysis units during 1960–62 facilitated exceptional growth of nephrology, as well as an expanding population of uremic patients seeking treatment. To date (mid-2008), of the body's vital organ systems, only renal function can be replaced over the long term by either a bionic device or a solid organ transplant. Our newly established 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. It is true that although an ethical code binding physician's conduct did not begin with Kolff's invention of a practical artificial kidney, it was the burden of a fair allocation of life-saving treatment with Kolff's device that forced the adoption of a transparent standard for a nephrologist's life or death decisions.2.Friedman E.A. Kolff's contributions provoked the birth of ethics in nephrology.Artific Organs. 1998; 13: 46-51Google Scholar Geriatric patients with advanced kidney disease provoked two ethical questions generated by two realities: (1) The 33 million Americans aged 65 years or older in 2003 will, by the year 2030, increase to 70 million.3.Coresh J. Astor B.C. Greene T. et al.Prevalence of chronic kidney disease and decreased kidney function in the adult US population. Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Scopus (2301) Google Scholar (2) More than 1 million Americans over the age of 65 years currently have advanced kidney disease, and provision for their expensive care has been incomplete and lack any organized overall plan. Extrarenal geriatric comorbidity forces the decision of whether to commence costly uremia therapy.4.Hansberry M.R. Whittier W.L. Drause W. The elderly patient with chronic kidney disease.Adv Chronic Kidney Dis. 2005; 12: 71-77Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar During China's Zhou Dynasty, the fact that a doctor's conduct must relate to patient's attitudes was taught in seven Chinese medical schools between 770 and 221 BC, linking doctor's fees to patient benefit, introducing the concept of an ethical standard in medicine.5.Benfu L. Medical Ethics. Peking Union Medical College and Beijing Medical University Press, Beijing1996: 41-42Google Scholar Physicians were self-governing, as evident in the teaching of Bian Que,6.Bocong L. On Bianque and the School of Bianque. Shanxi Science and Technology Press, Xian1990Google Scholar who urged that medicine be withheld from individuals who (1)expressed unreasonable arrogance and indulgence,(2)appreciated wealth more than life,(3)were unable to keep body and soul together,(4)suffered from an interlocking Yin and Yang,(5)were too weak to take prescribed medicines, or(6)favored sorcery over medicine. Indian culture, both the Caraka-Samhita (approximately 500 BCE) and Susruta Samhita (approximately 300 AD), alludes to earlier works dating to 2000 BCE that describe the foundation of a natural healing, Ayurveda Caraka Samhita expounded, 'He who practices medicine out of compassion for all creatures rather than for gain or for gratification of the senses surpasses all. No benefactor, moral or material, compares to the physician who by severing the noose of death in the form of fierce diseases, brings back to life those being dragged towards death's abode, because there is no other gift greater than the gift of life. He who practices medicine while holding compassion for all creatures as the highest religion is a man who has fulfilled his mission. He obtains supreme happiness.'7Girindranath M. History of Indian Medicine - 3 Vols.in: Containing Notices, Biographical and Bibliographical, of the Ayurvedic Physicians and their Works on Medicine - From the Earliest Ages to the Present Time8121506603 Munshiram Manoharlal Publishers Pvt. Ltd., 2003Google Scholar Hippocrates, a Greek physician in about 400 BCE, proposed ethics-based constraints on physician behavior.8.Chadwick J. Mann W.N. Hippocratic writings. Penguin Books Ltd, London, WC2R 0RL1950Google Scholar His credo is repeated to this day as many medical students graduate as 'The Hippocratic Oath', which proclaims, 'I will follow that system of regimes which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.' Contemporary physicians in practice offer conflicting interpretations of this oath, as some defend their treatment decisions arguing, 'I have an ethical obligation never to cause the death of a patient,' provoking the rejoinder in others that 'My ethical obligation is to relieve pain and suffering even if the patient dies.' Physicians' behavior under the realities and temptations of practice is imprecisely defined by the Oath of Hippocrates,9.Miles S.H. The Hippocratic Oath and the Ethics of Medicine. Oxford University Press, University of Oxford, Oxford, UK2003Google Scholar the 'rules' of which require physicians to (1)honor their medical instructors and their offspring,(2)teach medicine only to those bound by the Oath,(3)practice medicine for the benefit of patients. Do no harm,(4)prescribe neither deadly medicine nor substance to produce abortion,(5)abstain from mischief and corruption, and(6)maintain doctor–patient confidentiality. China led further development of medical ethics starting with the Han Dynasty (206 BCE–24 AD). Confucianism emphasized patient care and benevolence (loving people), believing that the purpose of medicine was to save lives, an ultimate expression of love.10.Simiao Sun Essential Prescriptions Worth a Thousand Gold in Hua Fan's History of Late Han Dynasty: Records of Crafts. 476. People's Health Press, Beijing1982Google Scholar Zhong Zhang Jin (author of Shang Han Lun, the earliest systematic herbal text) stipulated that Confucians could love people, provided they grasped medical theories attentively.11Yimo Zhou Famous Physicians' Addresses on Medical Ethics. Hunan Science and Technology Press, Changsha1983: 212Google Scholar Diagnoses must be rigorous and painstaking to avoid doing harm. Benevolence demanded a duty to respect patients as an ultimate expression of humanity. Demanding money or sex for care was proscribed. Furthermore, no patient's treatment was to be influenced on the basis of status, wealth, appearance, age, race, or mental ability. Amplifying Confucianism, Tianchen Li, a Ming Dynasty (1368–1644 AD) physician, suggested, 'We should treat patients as our mothers.12.Shuming Liang Essence of Chinese Culture. Xuelin Press, Shanghai1987: 69Google Scholar' Confucius believed that everyone had a conscience, an inborn sense of right and wrong, which, in physicians, governs a medical doctor's purported four senses: (1)Pity: Compassion and love for the patient.(2)Shame: The doctor would feel shame if he ever(a)put his interests ahead of his patient(b)diagnosed without all four physical examination methods(c)abused medicines, or(d)deceived a patient.(3)Respect.(4)Right and Wrong: Do not damage the patient's interests. Confucian physicians practiced self-cultivation through self-examination, self-criticism, and self-restriction. Confucius proposed that instead of trying to set up a universal code of behavioral guidelines, each person should subject themselves to self-examination.13.Zhang D. Cheng Z. Medicine is a Human Art: The Basic Principles of Professional Ethics in Chinese Medicine. Medical History Research Center, Beijing Medical University, Garrison, NY2000Google Scholar From Hippocrates on, guides to ethical medical practice venerated human life, today termed benevolence. Mencius observed, 'In medicine, benevolence means causing no harm to patients.'14.Wu J.S. Mencius.in: McGreal I.P. Great Thinkers of the Eastern World. HarperCollins, New York1995: 3-6Google Scholar Modern concerns about the ethical treatment of 'patients' were a key concern of the Nuremberg Military Tribunal, which punished (by death) sadistic unscientific 'research' by Nazi Germany during World War II, devising the Nuremberg Code in 1947.15Nuremberg Code Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law No. 10. Nuremberg U.S. G.P.O, Washington, D.C.October 1946–April 1949Google Scholar Derivative efforts to define ethical conduct in medical investigation and practice at a conference in Geneva (1948)16Declaration of Geneva Adopted by the General Assembly of World Medical Association at Geneva Switzerland. September 1948Google Scholar produced the Declaration of Helsinki (1964) of the World Medical Association, which has been subsequently updated several times.17Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects Adopted by the 18th WMA General Assembly Helsinki, FinlandJune 1964Google Scholar29th WMA General Assembly, Tokyo, JapanOctober 1975Google Scholar35th WMA General Assembly, Venice, ItalyOctober 1983Google Scholar41st WMA General Assembly, Hong KongSeptember 1989Google Scholar48th WMA General Assembly, Somerset West, Republic of South AfricaOctober 1996Google Scholar52nd WMA General Assembly, Edinburgh, ScotlandOctober 2000Google Scholar Perhaps the single most important resource governing both the practice of medicine and the conduct of research involving human subjects is The Belmont Report (1979),18The Belmont Report Ethical Principles and Guidelines for the Protection of Human Subjects of Research. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Ethical Principles and Guidelines for Research Involving Human Subjects.April 18, 1979Google Scholar, 19.Lemaire F. Patient care versus research: does clinical research provide individual benefit to patients enrolled in trials?.Curr Opin Crit Care. 2004; 10: 565-569Crossref PubMed Scopus (15) Google Scholar defining (1)boundaries between practice and research,(2)basic ethical principles:(a)respect for persons,(b)beneficence,(c)justice,(3)applications:(a)informed consent,(b)assessment of risk and benefits,(c)selection of subjects. Discovery and research may instantaneously change 'proper' medical practice, as in introduction of vaccination for smallpox.20.Lombard M. Pastoret P.P. Moulin A.M. A brief history of vaccines and vaccination.Rev Sci Tech. 2007; 26: 29-48Crossref PubMed Scopus (116) Google Scholar Similarly, Scribner's 1960 report that irreversible fatal renal failure was a treatable disorder21.Scriber B.H. Buri R. Caner J.E. et al.The treatment of chronic uremia by means of intermittent hemodialysis: a preliminary report.Trans Am Soc Artif Intern Organs. 1960; 10-11: 114-122Google Scholar stimulated denial, incredulity, and finally acceptance of a new standard of medical practice. Lacking equipment, trained staff, and any funding, the renal community suddenly confronted patients on the brink of death because of uremia who wanted to continue living. Unanticipated was the reality that a year of twice-weekly maintenance hemodialysis, as originally designed by Scribner's Seattle team, required more than $10,000, not including doctors' fees (more than $80,000 in 2008 dollars). Life Magazine and other national news sources enthusiastically reported the success of 'chronic dialysis,' raising demand for the life-sustaining regimen beyond the capacity of Scribner's small hospital unit. Throughout the 1960s, forced by inadequate resources to refuse treatment for a growing number of patients in kidney failure, the Seattle team established the now infamous anonymous panel of volunteer community members, functioning as termed by Life Magazine as the 'Who Shall Live Committee.' Struggling with the enervating chore of screening applicants to select those most 'deserving' of life-sustaining treatment, the Committee set criteria for acceptance to chronic dialysis, including an age range of 18–45 years.22.Darrah J.B. Moment in history. The Committee.ASAIO Trans. 1987; 33: 791-793PubMed Google Scholar Scribner's team was further strained when a uremic 16-year-old high school student with lupus nephritis was rejected because of age – meaning certain death. Dr Albert 'Les' Babb, the Seattle team's chief engineer, solved the problem by designing a small and portable dialysis system termed the mini-monster permitting her dialysis at home, thereby originating 'home dialysis' in July 1964. Babb's accomplishment, listed as one of the 'Ten Wonders of Biomedical Engineering' by the Biomedical Engineering Society in 1990, gained entry into the National Academy of Engineering, the National Academy of Sciences,' and the Institute of Medicine. Ethical stress gave rise to a new device and a novel location for its application, resulting in salvage of life. Ethical allocation of dialysis required nephrologists, hospital administrators, academic deans, and legislators to fairly triage insufficient life-saving resources. Rationing of dialysis (and other high-cost regimens) sparked changed thinking about accessibility of health care in the United States,23Childress J. Who Shall Live When Not All Can Live.Soundings. 1970; 53 (Reprinted: Intervention and Reflection: Basic Issues in Medical Ethics, pp 497–505. Edited by Ronald Munson Belmont California: Wadsworth Publishing Company, 1983): 339-355Google Scholar underscoring dilemmas in modern bioethics.24.Blagg C.R. The early years of chronic dialysis: the Seattle contribution.Am J Nephrol. 1999; 19: 350-354Crossref PubMed Scopus (17) Google Scholar Alber Jonsen, professor of biomedical history and ethics at the University of Washington, aptly concluded that the 'Committee' forced open 'a new era for the ethics of medicine,' as the health-care profession confronted 'an issue that the traditional ethics of medicine had not previously faced and for which it had no ready response.'25.Jonsen A.R. The New Medicine and the Old Ethics. Harvard University Press, Cambridge, Massachusetts1990Google Scholar A demonstration of hemodialysis before the Ways and Means Committee of the Congress's House of Representatives resulted in the establishment of dialysis treatment for renal failure as a national legislative priority.26.Kidney Failure and the Federal Government Rettig Richard A. Levinsky Norman G. Committee for the Study of the End Stage Renal Disease Program. Division of Health Care Services. Institute of Medicine. National Academy Press, Washington, DC1991Google Scholar The United States Congress, in 1972, amended the Social Security Act disability criteria reimbursing long-term dialysis.27Section 2991 of the Social Security Act Amendments. 30 October 1972Google Scholar As home hemodialysis grew in acceptance, Medicare, in 1978, together with related state legislation, increased deductibles and copayments, allowing reimbursement for home hemodialysis supplies. These actions affirmed the principle that America's health care was not restricted to the rich and privileged by any 'profile.'28.Jonsen A.R. The Birth of Bioethics.Special Supplement, Hastings Center Report. 1993; 23: S1Crossref PubMed Scopus (53) Google Scholar Looking backward, Scribner remarked that 'When the US Congress enacted legislation in 1972 which made all patients with end-stage kidney disease eligible for Medicare, they set a precedent that led to Medicare funding of many of the very expensive technology-based treatments such as coronary bypass open heart surgery, and bone marrow transplantation.' The ethical basis for universal dialysis in kidney failure became the foundation for 'fair' organ allocation in kidney transplantation29.Friedman E.A. Najarian J. Starzl T. et al.Ethical aspects in renal transplantation. Discussions on ethics in transplantation.Kidney Internat. 1983; 23: S90-S93Google Scholar and in other forms of modern high technology medicine. Derivative concerns in paying for kidney transplants today relate to the issue of whether access to the donor kidney pool should apply if the patient is very old, a noncitizen, or human immunodeficiency virus positive. Initiating and or continuing treatment in a nonadherent, hostile, and even combative patient suffering end-stage renal disease (ESRD) is a vexing recurrent problem.30.Kutner N.G. Improving compliance in dialysis patients: Does anything work?.Semin Dialy. 2001; 14: 324-327Crossref PubMed Google Scholar Confrontational patients who threaten staff and/or other patients challenge the viability of an ESRD program, forcing resolution by resorting to courts. A landmark case in Jackson, Mississippi, established the point when on 21 December 1987, in Civil Action No. 086-079 (B), in the United States District Court, Southern District of Mississippi, Judge William H. Barbour ruled that Dr John Bower, Director of Nephrology at the University Medical Center, had to continue dialysis of Michael Brown after a 10-year record of misconduct and staff abuse. Brown overtly injected narcotic drugs, missed dialysis treatments, and verbally abused dialysis staff. Brown died in a motor vehicle accident after a police chase at 100 miles/h. The reason why Bower was forbidden to transfer Brown and the subsequent stress of court-enforced retention of the patient are depicted in Bower's 'Rest of the Story,31Bower J. Friedman E.A. Brown versus Bower—The Rest of the Story in Legal and Ethical Issues in Treating Kidney Failure. Case Study Manual. Kluwer, Dordrecht, The Netherlands2000Google Scholar recounting a senior nephrologist's unsuccessful plea that the Court help a renal program seeking relief from a vindictive and hurtful patient. No reports find geriatric ESRD patients less adherent to their regimen than younger adults. Indeed, the opposite may be true, although no report rates nonadherence by age cohorts. Although elderly ESRD patients gain added life through dialysis, and show better psychosocial adjustment to dialysis than younger patients, limitations in physical function characteristic of chronic dialysis patients, such as arthritis and peripheral motor neuropathy, increase with patient age.32.Loghman-Adham M. Medication noncompliance in patients with chronic disease issues in dialysis and transplantation.Am J Manag Care. 2003; 9: 155-171PubMed Google Scholar Poor adherence by geriatric ESRD patients has been attributed to 'too' frequent drug dosing, inadequate grasp of treatment benefits, poor patient–physician communication, lack of motivation, poor socioeconomic background, and lack of family and social support.33.Koveh K. Kimmel P.L. Compliance in hemodialysis patients: multidimensional measures in search of a gold standard.Am J Kidney Dis. 2001; 37: 244-266Abstract Full Text PDF PubMed Scopus (140) Google Scholar No evidence-based strategy has been established to improve regimen adherence by dialysis and transplant patients, such as simplifying the treatment regimen, establishing partnership with the patient, and increasing education and feedback. Table 1 lists issues examined in an Ethics Case Manual devoted to ESRD.34.Friedman E.A. Legal and Ethical Issues in Treating Kidney Failure. Case Study Manual. Kluwer, Dordrecht, The Netherlands2000Crossref Google Scholar To illustrate the complexity of conjoined legal and ethical stresses while demonstrating the extent of controversy and the absence of a single truth, two cases are presented. Application of medical ethics is far removed from evidence-based science. Reaching and acting on an 'answer' may engender annoyance at best and outrage at worst.Table 1Ethical stresses in nephrologyPatient selection for/exclusion from long-term renal replacement therapya.How old is too old for renal replacement therapy?b.Should young people be selected before old people for kidney therapy?c.Should 'important' people (Politicians (President), Clergy (Pope), Affluent (Billionaire contributor to hospital)) be placed ahead of ordinary people in allotting renal replacement therapy?d.Are multiple deceased organ transplants ethical while a wait list exists?73.Piccoli G.B. Soragna G. Putaggio S. et al.How many organs should one patient receive? The ethics of transplantation in the medical school.Transplant Proc. 2004; 36: 444-445Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholare.Must noncitizens be treated when therapy is scarce or expensive?f.Are women to be assigned treatment on an equal basis as are men?g.Is it reasonable to take race and religion into account when determining who shall be treated?h.Is HIV infection a reasonable exclusion criterion?i.Does absent insurance coverage and being poor mean denial of therapy?j.Should prisoners be excluded from renal replacement therapy?Who decides not to start life-sustaining dialysis in ESRD?a.Patientb.Familyc.Futilityd.FinancialHow should the medical staff cope with patient noncompliance,74.Willaims M.E. Kitsen J. The involuntarily discharged dialysis patient: conflict (of interest) with providers.Advances in Chron Kidney Dis. 2005; 12: 107-112Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar hostility, or criminality?a.Withdraw renal replacement therapy with death an obvious consequenceb.Consultation (psychiatry, social service, administration family, clergy, friends)c.Role of Ethics CommitteeIs it OK to instill commodification (buying and selling) of kidney transplants?75.Piccoli G.B. Putaggio S. Soragna G. et al.Kidney vending: opinions of the medical school students on this controversial issue.Transplant Proc. 2004; 36: 446-447Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholara.Payment to deceased donor familiesb.Concealed payment to donorc.Open marketing of kidneys legallyd.Open marketing of kidneys concealedAbbreviations: ESRD, end-stage renal disease; HIV, human immunodeficiency virus. Open table in a new tab Abbreviations: ESRD, end-stage renal disease; HIV, human immunodeficiency virus. An 83-year-old married accountant undergoing hemodialysis was a six-antigen 'perfect match' for a deceased donor kidney shipped from Memphis, Tennessee, to Brooklyn on a Sunday morning. Working as a fiscal consultant, with no known extrarenal complications of his polycystic kidney disease, the accountant fully adhered to instructions as an independent, functional person, actively volunteering in the local chapter of a kidney patient support group. An alternative potential recipient, a 23-year-old medical student on dialysis since 3 months had an incomplete three-antigen match to the donor. The transplant coordinator thought it unethical to 'waste' the kidney on an old person when society would benefit from facilitating the medical career of the student. The student's wife previously advised his nephrologist that she is concerned over her husband's growing sense of depression and futility threatening his continued attendance at medical school. The mean wait for a deceased donor kidney in New York City exceeds 9 years (in 2008). Individuals seeking a kidney transplant face greater mortality on dialysis than after a deceased donor kidney transplant. Denying a dialysis patient a donor kidney, in fact, is a form of death sentence (for the duration of shortened survival on dialysis). Defense of the 'too old' for a deceased donor kidney position requires that an upper age limit that is not 'too old' be established.35.Oniscu G.C. Brown H. Forsythe J.L. How old is old for transplantation?.Am J Transplant. 2004; 4: 2067-2074Crossref PubMed Scopus (112) Google Scholar If not 84 years, then 74 years? Or 64? What if the choice is between a 'young' 74-year-old and an 'old' 64-year-old patient? Question upon question arises from almost any method of organ allocation. One recurrent issue raised by some geriatric patients able to afford the cost is whether a purchased kidney might truncate their death-defying delay while 'suspended' on dialysis. Continued growth of the ESRD population, with only a marginal increase in the number of deceased donor kidneys, has progressively lengthened the waiting time for a deceased donor transplant. As estimated by the United States Department of Health and Human Services, in May 2008, as this is written, 80,130 patients were waitlisted for a deceased donor kidney by the U.S. Organ Procurement and Transplant Network (http://www.optn.org/latestData/rptData.asp).36Organ Procurement and Transplant Network Website. 8 May, 2008www.optn.orgGoogle Scholar An estimated cohort of at least 3000 who die each year on the waitlist would have survived had a donor kidney been available.37US Department of Health & Human Services 200 Independence Avenue, S.W. Washington, DC 20201August 2005http://www.organdonor.govGoogle Scholar Geriatric ESRD patients are especially vulnerable for protracted waits because of what many legislators and transplant teams view as the rational priority of providing a scarce commodity (solid organ transplants) to those likely to attain the longest benefit (younger patients). Strategies to expand the donor pool – public relations campaigns and Drivers' license designation of willingness to donate – have not raised deceased organ donor consents. The number of US deceased donor kidney transplants has been relatively static over the past decade, despite intensive public relations programs such as celebrity endorsements, National Kidney Foundation efforts, and State Drivers License advance permission. According to the United Network for Organ Sharing,38United Network for Organ Sharing (UNOS) website. September 2005www.unos.orgGoogle Scholar whereas kidney transplants performed between 1988 (8873) and 2004 (16,004) increased by 80.3%, deceased organ transplants in the same interval increased by only 32.5% (from 7061 to 9357). Because of this shortage of donor kidneys, acceptance of previously termed 'marginal' kidneys now called 'expanded criteria donors' from geriatric,39.Remuzzi G. Cravedi P. Perna A. et al.Long term outcomes of renal transplantation from older donors.N Engl J Med. 2006; 354: 343-352Crossref PubMed Scopus (413) Google Scholar hypertensive, and even proteinuric donors increased progressively.40.Baskin-Bey E.S. Kremers W. Stegall M.D. et al.United Network for Organ Sharing's expanded criteria donors: is stratification useful?.Clin Transplant. 2005; 19: 406-412Crossref PubMed Scopus (39) Google Scholar Purchasing kidneys from compensated donors, a highly controversial and evocative issue, gradually evolved from being an unmentionable practice performed secretly in developing (poor) countries to an openly debated topic at the American Society of Nephrology and the American Transplantation Society. Clearly illegal in most nations, and viewed as unethical by professional medical organizations, the voluntary sale of purchased donor kidneys now accounts for thousands of black market transplants amounting to an estimated one-quarter of all kidney transplants performed globally. Legalizing kidney purchase relies on the key premise that individuals control their body parts even when inducing risk of life. Selling a human organ in the United States has been proscribed for over 20 years. As starkly stated in the National Organ Transplant Act, 'It shall be unlawful for any person to knowingly acquire, receive, or otherwise tra
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