Luyckx Valerie A, Martin Dominique E, Moosa Mohammed Rafique, Bello Aminu K, Bellorin-Font Ezequiel, Chan Tak Mao, Claure-Del Granado Rolando, Douthat Walter, Eiam-Ong Somchai, Eke Felicia U, Goh Bak Leong, Jha Vivekanand, Kendal Evie, Liew Adrian, Mengistu Yewondwossen Tadesse, Muller Elmi, Okpechi Ikechi G, Rondeau Eric, Sahay Manisha, Trask Michele, Vachharajani Tushar
Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland.
Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Kidney Int Suppl (2011). 2020 Mar;10(1):e72-e77. doi: 10.1016/j.kisu.2019.11.003. Epub 2020 Feb 19.
Ethical issues relating to end-stage kidney disease (ESKD) care are increasingly being discussed by clinicians and ethicists but are still infrequently considered at a policy level or in the education and training of health care professionals. In most lower-income countries, access to kidney replacement therapies such as dialysis is not universal, leading to overt or implicit rationing of resources and potential exclusion from care of those who are unable to sustain out-of-pocket payments. These circumstances create significant inequities in access to ESKD care within and between countries and impose emotional and moral burdens on patients, families, and health care workers involved in decision-making and provision of care. End-of-life decision-making in the context of ESKD care in all countries may also create ethical dilemmas for policy makers, professionals, patients, and their families. This review outlines several ethical implications of the complex challenges that arise in the management of ESKD care around the world. We argue that more work is required to develop the ethics of ESKD care, so as to provide ethical guidance in decision-making and education and training for professionals that will support ethical practice in delivery of ESKD care. We briefly review steps that may be required to accomplish this goal, discussing potential barriers and strategies for success.
临床医生和伦理学家越来越多地讨论与终末期肾病（ESKD）护理相关的伦理问题，但在政策层面或医疗保健专业人员的教育与培训中，这些问题仍很少被考虑。在大多数低收入国家，透析等肾脏替代疗法的可及性并不普遍，导致资源的公开或隐性配给，以及那些无力承担自付费用的患者可能被排除在护理之外。这些情况在国家内部和国家之间造成了获得ESKD护理的严重不平等，并给参与决策和提供护理的患者、家庭及医护人员带来情感和道德负担。在所有国家，ESKD护理背景下的临终决策也可能给政策制定者、专业人员、患者及其家庭带来伦理困境。本综述概述了全球ESKD护理管理中出现的复杂挑战的若干伦理影响。我们认为，需要开展更多工作来发展ESKD护理伦理，以便在决策以及为专业人员提供教育和培训方面提供伦理指导，从而支持ESKD护理提供中的伦理实践。我们简要回顾实现这一目标可能需要采取的步骤，讨论潜在障碍和成功策略。
