[New ethical issues around dialysis. To dialyze or not to dialyze, that is not the question].

Although a physician's first ethical duty is to master the relevant techniques, it is not enough for kidney specialists to know the major principles of dialysis and apply them to all patients with kidney failure. Historically a truly ethical promise, dialysis revolutionized the management of chronic kidney disease by sparing life for the time needed to wait for renal transplantation. Constrained by a supply considerably lower than demand, the nephrologists of that time selected patients, treating only the young and relatively healthy. These decisions were probably made jointly with others. Ethical reflections about patient selection at that time thus took place in a different setting, where the supply of dialysis was limited. Today, in a different context, dialysis has not always kept its ethical promises. It is widely available, and its practical contraindications are rare. Nonetheless, we can sometimes doubt its pertinence, as the population on chronic dialysis becomes increasingly elderly and increasingly ill, with comorbidities that contraindicate transplantation. Might dialysis become harmful? Used ill-advisedly, it can hinder the quality of life. There are increasingly more situations in which we may doubt its salutary effects and conclude that it is not always adequate to fulfill the real objective of medicine: providing care, without necessarily curing. We must avoid ethical blindness about this technique. Let us use it well by looking for different types of use for it. To dialyze or not to dialyze, that is not the question. What matters is our mission of care - beyond the quantity of life we must improve its quality, especially at its end. To succeed in providing this care is not to know to how begin, limit, space out or shorten sessions. It requires instead that professionals working in nephrology be trained in palliative care for it is their job to provide care to the very end to these very sick patients, outside of palliative care units, which do not seem to have been created for them or adapted to their needs.