Introduction: Ethical Issues in Nephrology

The coronavirus disease 2019 pandemic has brought discussion of ethical issues in medicine to the front pages of newspapers and to kitchen tables. A patient may be denied access to intensive care treatment or dialysis if another patient is deemed more likely to benefit from the limited resource. Prioritization decisions around access to vaccination have been accepted by the general population, meaning some still do not know when their turn will come. It has become clear that individual choices we make affect the lives of others in our communities. It also is clear that some people and some countries are “more equal than others” as George Orwell would put it¹ given the huge inequities in access to vaccinations across the globe. This fact raises the question of what exactly the human right to health means in the face of these inequities? Race and poverty have emerged as major modulators of risk of infection and for severe disease. How have we as global and medical communities allowed structural violence to take root so strongly in our communities? Clinicians worldwide have valiantly risen to the task of trying to provide the best care, for many in higher-income settings, under unprecedented circumstances; for many in lower-income settings, under relatively familiar circumstances; in all circumstances, often with a heavy heart, carrying patients home in one's mind, wondering if one could have done more? Rapid research and advances in technology also have taken center stage during this pandemic, with the consequences of decisions regarding inclusion, exclusion, safety, and study design having to be considered in exceptionally short order. Many of these ethical dilemmas highlighted by the pandemic are not new, but it is now imperative to discuss and acknowledge these to find a common way forward.

Why ethics in nephrology? We are familiar with the four principles of biomedical ethics, outlined by Beauchamp and Childress,² taught in medical school and repeated periodically during our training: autonomy, beneficence, nonmaleficence, and justice. We all strive to be ethical in our clinical practice and our interactions with patients and colleagues. We all likely achieve a reasonable standard of ethical practice. Ethics, however, is not merely a checklist of these four principles to be ticked off, and it extends well beyond these four principles. In life there are some absolute rights and absolute wrongs, some issues are black or white, but mostly there are varying shades of grey that intersect in the tapestry of our everyday professional and personal lives and we must make hard choices.

In this issue of Seminars of Nephrology we highlight some of the shades of grey as they relate to kidney care. Tucker describes the deep-rooted social and structural factors, many of which still are present today, which impact risk of kidney disease. These factors must be urgently addressed not only to improve kidney health, but also to achieve social justice. Shekhani and Lanewala describe ethical dilemmas posed by daily choices that must be made at the bedside in contexts where social and structural factors contribute to the demand for dialysis care but at the same time limit access to this care. Oberoi and Forman elaborate on the meaning of human right to health and the obligation that states have to progressively realize this to the fullest extent for their citizens. Within the context of progressive realization of the right to health, Luyckx and Moosa discuss the necessity for fair and transparent priority setting as a means to achieve this goal. Given that not all therapies are available to everyone in many places, the true meaning of patient autonomy can be debated. Martin and Muller discuss this point and defend the obligation to ensure that all patients are fully informed. Ducharlet et al discuss the reality of moral distress experienced by clinicians at the bedside when tough choices are imposed by the health system, and Parsons et al discuss the duty of doctors when challenges arise in an individual patient's care. The breadth of ethics implications of research in nephrology is discussed by Nichol et al, including considerations that arise during implementation research, research in pandemics, and so forth. Ho and Caals end with a discussion of the ethical considerations that arise around the use of emerging technologies and artificial intelligence in nephrology, which are highly promising tools but require good governance and oversight. As testament to the contextual nature of ethics and the need to discuss and debate to find acceptable solutions to ethical questions and dilemmas, most authors use case examples to illustrate their points. This was not planned, but cases run as a thread throughout the issue. Many cases will resonate with the reader. It is our hope that these provide food for thought and fruitful discussion as we all strive to become better clinicians, better researchers, and better people.