Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Perspective
  • Published:

Ethical challenges in nephrology: a call for action

Nature Reviews Nephrology volume 16, pages 603–613 (2020)Cite this article

Subjects

Abstract

The American Society of Nephrology, the European Renal Association–European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges — equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest — with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Optimizing the utility of treatment outcomes in kidney failure can exacerbate health inequalities.
Fig. 2: Navigating pathways for treatment of kidney failure requires shared decision-making.

Similar content being viewed by others

References

  1. Jha, V. et al. Chronic kidney disease: global dimension and perspectives. Lancet 382, 260–272 (2013).

    Article  PubMed  Google Scholar 

  2. Liyanage, T. et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet 385, 1975–1982 (2015).

    Article  PubMed  Google Scholar 

  3. Parker, J. C. Cherry picking in ESRD: an ethical challenge in the era of pay for performance. Semin. Dial. 24, 5–8 (2011).

    Article  PubMed  Google Scholar 

  4. Rodriguez, R. A. Dialysis for undocumented immigrants in the United States. Adv. Chronic Kidney Dis. 22, 60–65 (2015).

    Article  PubMed  Google Scholar 

  5. Saunders, M. R., Lee, H., Maene, C., Schuble, T. & Cagney, K. A. Proximity does not equal access: racial disparities in access to high quality dialysis facilities. J. Racial Ethn. Health Disparities. 1, 291–299 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  6. White, S. L., Chadban, S. J., Jan, S., Chapman, J. R. & Cass, A. How can we achieve global equity in provision of renal replacement therapy? Bull. World Health Organ. 86, 229–237 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  7. Kahrass, H., Strech, D. & Mertz, M. The full spectrum of clinical ethical issues in kidney failure. Findings of a systematic qualitative review. PLoS One 3, e0149357 (2016).

    Article  CAS  Google Scholar 

  8. Jha, V. et al. Ethical issues in dialysis therapy. Lancet 389, 1851–1856 (2017).

    Article  PubMed  Google Scholar 

  9. Davison, S. N. & Holley, J. L. Ethical issues in the care of vulnerable chronic kidney disease patients: the elderly, cognitively impaired, and those from different cultural backgrounds. Adv. Chronic Kidney Dis. 15, 177–185 (2008).

    Article  PubMed  Google Scholar 

  10. Davison, S. N. The ethics of end-of-life care for patients with ESRD. Clin. J. Am. Soc. Nephrol. 7, 2049–2057 (2012).

    Article  PubMed  Google Scholar 

  11. Brennan, F. & Brown, M. An ethical approach to dialysis — an alliance of nephrology, palliative medicine and ethics. Q. J. Med. 106, 397–400 (2013).

    CAS  Google Scholar 

  12. Muthalagappan, S., Johansson, L., Kong, W. M. & Brown, E. A. Dialysis or conservative care for frail older patients: ethics of shared decision-making. Nephrol. Dial. Transplant. 28, 2717–2722 (2013).

    Article  PubMed  Google Scholar 

  13. Ozar, D. T. et al. Nephrologists’ professional ethics in dialysis practices. Clin. J. Am. Soc. Nephrol. 8, 840–844 (2013).

    Article  PubMed  Google Scholar 

  14. Etheredge, H. & Paget, G. Ethics and rationing access to dialysis in resource-limited settings: the consequences of refusing a renal transplant in the South African state sector. Dev. World Bioeth. 15, 233–240 (2015).

    Article  PubMed  Google Scholar 

  15. Shooter, M. & Watson, A. The ethics of withholding and withdrawing dialysis therapy in infants. Pediatr. Nephrol. 14, 347–351 (2000).

    Article  CAS  PubMed  Google Scholar 

  16. Lantos, J. D. & Warady, B. A. The evolving ethics of infant dialysis. Pediatr. Nephrol. 28, 1943–1947 (2013).

    Article  PubMed  Google Scholar 

  17. Fauriel, I. et al. Decisions concerning potentially life-sustaining treatments in paediatric nephrology: a multicentre study in French-speaking countries. Nephrol. Dial. Transplant. 19, 1252–1257 (2004).

    Article  PubMed  Google Scholar 

  18. Maurizi, J. B., Moreaud, O., Palacin, P., Truche, A. S. & Zaoui, P. Ethics consultation unit in nephrology (UCEN): review of 10 years of operation in the Grenoble area. Nephrol. Ther. 9, 222–227 (2013).

    Article  Google Scholar 

  19. Redman, B. K., Hill, M. N. & Fry, S. T. Ethical conflicts reported by certified nephrology nurses (CNNs) practicing in dialysis settings. Anna J. 24, 23–34 (1997).

    CAS  PubMed  Google Scholar 

  20. Akbar, S. & Moss, A. H. The ethics of offering dialysis for AKI to the older patient: time to re-evaluate? Clin. J. Am. Soc. Nephrol. 9, 1652–1656 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Butler, C. R., Mehrotra, R., Tonelli, M. R. & Lam, D. Y. The evolving ethics of dialysis in the United States: a principlist bioethics approach. Clin. J. Am. Soc. Nephrol. 11, 704–709 (2016).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Luyckx, V. A., Miljeteig, I., Ejigu, A. M. & Moosa, M. R. Ethical challenges in the provision of dialysis in resource-constrained environments. Semin. Nephrol. 37, 273–286 (2017).

    Article  PubMed  Google Scholar 

  23. Hirsch, D. J., West, M. L., Cohen, A. D. & Jindal, K. K. Ethical and moral issues in nephrology: experience with not offering dialysis to patients with a poor prognosis. Am. J. Kidney Dis. 23, 463–466 (1994).

    Article  CAS  PubMed  Google Scholar 

  24. Rabetoy, C. P. & Bair, B. C. Nephrology nurses’ perspectives on difficult ethical issues and practice guideline for shared decision making. Nephrol. Nurs. J. 34, 599–607 (2007).

    PubMed  Google Scholar 

  25. Reese, P. P., Boudville, N. & Garg, A. X. Living kidney donation: outcomes, ethics, and uncertainty. Lancet 385, 2003–2013 (2015).

    Article  PubMed  Google Scholar 

  26. Gordon, E. J. Informed consent for living donation: a review of key empirical studies, ethical challenges and future research. Am. J. Transpl. 12, 2273–2280 (2012).

    Article  CAS  Google Scholar 

  27. Maizlin, Z. V., Barnard, S. A., Gourlay, W. A. & Brown, J. A. Economic and ethical impact of extrarenal findings on potential living kidney donor assessment with computed tomography angiography. Transplant. Int. 20, 338–342 (2007).

    Article  Google Scholar 

  28. Wiles, K. S. et al. Pre-pregnancy counselling for women with chronic kidney disease: a retrospective analysis of nine years’ experience. BMC Nephrol. 16, 28 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  29. Davison, S. N. Ethical considerations regarding pregnancy in chronic kidney disease. Adv. Chronic Kidney Dis. 14, 206–211 (2007).

    Article  PubMed  Google Scholar 

  30. Whitehead, M. The concepts and principles of equity and health. Health Promot. Int. 6, 217–228 (1991).

    Article  Google Scholar 

  31. Harris, D. C. et al. Increasing access to integrated ESKD care as part of universal health coverage. Kidney Int. 95, S1–S33 (2019).

    Article  PubMed  Google Scholar 

  32. Ducharlet, K. et al. Moral distress in nephrology: perceived barriers to ethical clinical care. Am. J. Kidney Dis. https://doi.org/10.1053/j.ajkd.2019.09.018 (2019).

    Article  PubMed  Google Scholar 

  33. Austin, W. Moral distress and the contemporary plight of health professionals. HEC Forum 24, 27–38 (2012).

    Article  PubMed  Google Scholar 

  34. Anderson, K. et al. If you can’t comply with dialysis, how do you expect me to trust you with transplantation? Australian nephrologists’ views on indigenous Australians’ ‘non-compliance’and their suitability for kidney transplantation. Int. J. Equity Health 11, 21 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  35. Stewart, D. E. et al. Measuring and monitoring equity in access to deceased donor kidney transplantation. Am. J. Transplant. 18, 1924–1935 (2018).

    Article  CAS  PubMed  Google Scholar 

  36. Patzer, R. E. et al. Variation in dialysis facility referral for kidney transplantation among patients with end-stage renal disease in Georgia. JAMA 314, 582–589 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Singer, P., McKie, J., Kuhse, H. & Richardson, J. Double jeopardy and the use of QALYs in health care allocation. J. Med. Ethics 21, 144–150 (1995).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Ramos, H. C. & McCauley, J. Ethical issues in organ transplantation. In Contemporary Kidney Transplantation. Organ and Tissue Transplantation (eds Ramirez, C. & McCauley, J.) 343–353 (Springer, 2018)

  39. Shaikh, M. et al. Utilization, costs, and outcomes for patients receiving publicly funded hemodialysis in India. Kidney Int. 94, 440–445 (2018).

    Article  PubMed  Google Scholar 

  40. Germain, M. J., Davison, S. N. & Moss, A. H. When enough is enough: the nephrologist’s responsibility in ordering dialysis treatments. Am. J. Kidney Dis. 58, 135–143 (2011).

    Article  PubMed  Google Scholar 

  41. Hoang, V. L., Green, T. & Bonner, A. Informal caregivers’ experiences of caring for people receiving dialysis: a mixed-methods systematic review. J. Ren. Care 44, 82–95 (2018).

    Article  PubMed  Google Scholar 

  42. Rodrigue, J. R. et al. Spouse caregivers of kidney transplant patients: quality of life and psychosocial outcomes. Prog. Transpl. 20, 335–342 (2010).

    Article  Google Scholar 

  43. Sawinski, D. & Foley, D. P. Personalizing the kidney transplant decision: who doesn’t benefit from a kidney transplant? Clin. J. Am. Soc. Nephrol. 15, 279–281 (2020).

    Article  PubMed  Google Scholar 

  44. Thorsteinsdottir, B., Swetz, K. M. & Tilburt, J. C. Dialysis in the frail elderly — a current ethical problem, an impending ethical crisis. J. Gen. Intern. Med. 28, 1511–1516 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  45. Shih, C. J. et al. The impact of dialysis therapy on older patients with advanced chronic kidney disease: a nationwide population-based study. BMC Med. 12, 169 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  46. Rutecki, G. W., Cugino, A., Jurjoura, D., Kilner, J. F. & Whittier, F. C. Nephrologists’ subjective attitudes towards end-of-life issues and the conduct of terminal care. Clin. Nephrol. 48, 173–180 (1997).

    CAS  PubMed  Google Scholar 

  47. Ladin, K. & Smith, A. K. Active medical management for patients with advanced kidney disease. JAMA Intern. Med. 179, 313–315 (2019).

    Article  PubMed  Google Scholar 

  48. Boulware, L. E., Wang, V. & Powe, N. R. Improving access to kidney transplantation: business as usual or new ways of doing business? JAMA 322, 931–933 (2019).

    Article  PubMed  Google Scholar 

  49. Van Biesen, W., Vanholder, R., Ernandez, T., Drewniak, D. & Luyckx, V. Caring for migrants and refugees with end-stage kidney disease in Europe. Am. J. Kidney Dis. 71, 701–709 (2018).

    Article  PubMed  Google Scholar 

  50. Luyckx, V. A., Bello, A. K., & Naicker, S. Developing nephrology programs in low resource settings. In Chronic Kidney Disease in Disadvantaged Populations (eds Garcia-Garcia, G., Agodoa, L. Y., & Norris, K. C.) 273–289 (Academic Press, 2017).

  51. Tong, A. et al. Research priority setting in kidney disease: a systematic review. Am. J. Kidney Dis. 65, 674–683 (2015).

    Article  PubMed  Google Scholar 

  52. Vanholder, R. et al. Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat. Rev. Nephrol. 13, 393 (2017).

    Article  PubMed  Google Scholar 

  53. Van Der Tol, A., Lameire, N., Morton, R. L., Van Biesen, W. & Vanholder, R. An international analysis of dialysis services reimbursement. Clin. J. Am. Soc. Nephrol. 14, 84–93 (2019).

    Article  PubMed  Google Scholar 

  54. Dusseux, E. et al. A simple clinical tool to inform the decision-making process to refer elderly incident dialysis patients for kidney transplant evaluation. Kidney Int. 88, 121–129 (2015).

    Article  PubMed  Google Scholar 

  55. Osman, M. A. et al. Global nephrology workforce: gaps and opportunities toward a sustainable kidney care system. Kidney Int. Suppl. 8, 52–63 (2018).

    Article  Google Scholar 

  56. Makoul, G. & Clayman, M. L. An integrative model of shared decision making in medical encounters. Patient Educ. Couns. 60, 301–312 (2006).

    Article  PubMed  Google Scholar 

  57. Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal From Dialysis: Clinical Practice Guideline. 2nd edn, Rockville, MD., www.renalmd.org. (2010).

  58. Williams, A. W. et al. Critical and honest conversations: the evidence behind the “Choosing Wisely” campaign recommendations by the American Society of Nephrology. Clin. J. Am. Soc. Nephrol. 7, 1664–1672 (2012).

    Article  PubMed  Google Scholar 

  59. Combs, S. A. et al. Update on end-of-life care training during nephrology fellowship: a cross-sectional national survey of fellows. Am. J. Kidney Dis. 65, 233–239 (2015).

    Article  PubMed  Google Scholar 

  60. Ladin, K. et al. Characterizing approaches to dialysis decision making with older adults: a qualitative study of nephrologists. Clin. J. Am. Soc. Nephrol. 13, 1188–1196 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  61. Bansal, A. D. & Schell, J. O. Strategies to address clinician hesitancy toward conservative care. Nephrol. Dial. Transplant. 34, 1286–1288 (2018).

    Article  Google Scholar 

  62. Galla, J. H. Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. J. Am. Soc. Nephrol. 11, 1340–1342 (2000).

    CAS  PubMed  Google Scholar 

  63. Miljeteig, I. et al. Financial risk protection at the bedside: how Ethiopian physicians try to minimize out-of-pocket health expenditures. PLoS One 14, e0212129 (2019).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Wong, S. P. et al. Care practices for patients with advanced kidney disease who forgo maintenance dialysis. JAMA Intern. Med. 179, 305–313 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  65. Hussain, J. A., Flemming, K., Murtagh, F. E. & Johnson, M. J. Patient and health care professional decision-making to commence and withdraw from renal dialysis: a systematic review of qualitative research. Clin. J. Am. Soc. Nephrol. 10, 1201–1215 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  66. Smith, C. et al. Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin. Pract. 95, c40–c46 (2003).

    Article  PubMed  Google Scholar 

  67. Rinehart, A. Beyond the futility argument: the fair process approach and time-limited trials for managing dialysis conflict. Clin. J. Am. Soc. Nephrol. 8, 2000–2006 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Morton, R. Do dialysis decision aids improve treatment decision-making? Perit. Dial. Int. 36, 359–361 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  69. Brown, M. A. et al. ANZSN renal supportive care guidelines. Nephrology 18, 401–454 (2013).

    Article  PubMed  Google Scholar 

  70. García-Llana, H., Bajo, M. A., Barbero, J., Selgas, R. & Del Peso, G. The communication and bioethical training (CoBiT) program for assisting dialysis decision-making in Spanish ACKD units. Psychol. Health Med. 22, 474–482 (2017).

    Article  PubMed  Google Scholar 

  71. Farrington, K. et al. Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR< 45 mL/min/1.73 m2): a summary document from the European Renal Best Practice Group. Nephrol. Dial. Transpl. 32, 9–16 (2017).

    Article  Google Scholar 

  72. Moss, A. H. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin. J. Am. Soc. Nephrol. 5, 2380–2383 (2010).

    Article  PubMed  Google Scholar 

  73. Li, P. K. & Chow, K. M. Peritoneal dialysis — first policy made successful: perspectives and actions. Am. J. Kidney Dis. 62, 993–1005 (2013).

    Article  PubMed  Google Scholar 

  74. Savla, D., Chertow, G. M., Meyer, T. & Anand, S. Can twice weekly hemodialysis expand patient access under resource constraints? Hemodial. Int. 21, 445–452 (2017).

    Article  PubMed  Google Scholar 

  75. Plantinga, L. C., Fink, N. E., Finkelstein, F. O., Powe, N. R. & Jaar, B. G. Association of peritoneal dialysis clinic size with clinical outcomes. Perit. Dial. Int. 29, 285–291 (2009).

    Article  PubMed  Google Scholar 

  76. Pieper, D., Mathes, T. & Marshall, M. R. A systematic review of the impact of center volume in dialysis. BMC Res. Notes 8, 812 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  77. Shimazono, Y. The state of the international organ trade: a provisional picture based on integration of available information. Bull. World Health Organ. 85, 955–962 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  78. Naqvi, S. A., Ali, B., Mazhar, F., Zafar, M. N. & Rizvi, S. A. A socioeconomic survey of kidney vendors in Pakistan. Transpl. Int. 20, 934–939 (2007).

    Article  PubMed  Google Scholar 

  79. Columb, S. Excavating the organ trade: an empirical study of organ trading networks in Cairo, Egypt. Br. J. Criminol. 57, 1301–1321 (2016).

    Google Scholar 

  80. Goyal, M., Mehta, R. L., Schneiderman, L. J. & Sehgal, A. R. Economic and health consequences of selling a kidney in India. JAMA 288, 1589–1593 (2002).

    Article  PubMed  Google Scholar 

  81. Anker, A. E. & Feeley, T. H. Estimating the risks of acquiring a kidney abroad: a meta-analysis of complications following participation in transplant tourism. Clin. Transplant. 26, E232–E241 (2012).

    Article  PubMed  Google Scholar 

  82. Canales, M. T., Kasiske, B. L. & Rosenberg, M. E. Transplant tourism: outcomes of United States residents who undergo kidney transplantation overseas. Transplantation 82, 1658–1661 (2006).

    Article  PubMed  Google Scholar 

  83. Prasad, G. R. et al. Commercial kidney transplantation is an important risk factor in long-term kidney allograft survival. Kidney Int. 89, 1119–1124 (2016).

    Article  PubMed  Google Scholar 

  84. Danovitch, G. M. et al. Organ trafficking and transplant tourism: the role of global professional ethical standards — the 2008 Declaration of Istanbul. Transplantation 95, 1306–1312 (2013).

    Article  PubMed  Google Scholar 

  85. Danovitch, G. M., Shapiro, M. E. & Lavee, J. The use of executed prisoners as a source of organ transplants in China must stop. Am. J. Transpl. 11, 426–428 (2011).

    Article  CAS  Google Scholar 

  86. Martin, D. E. et al. Strengthening global efforts to combat organ trafficking and transplant tourism: implications of the 2018 edition of the Declaration of Istanbul. Transplant. Direct. 5, e433 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  87. World Health Organization. WHO guiding principles on human cell, tissue and organ transplantation. Transplantation 90, 229–233 (2010).

    Google Scholar 

  88. Martin, D. E. et al. A new edition of the declaration of Istanbul: updated guidance to combat organ trafficking and transplant tourism worldwide. Kidney Int. 95, 757–759 (2019).

    Article  PubMed  Google Scholar 

  89. Domínguez-Gil, B., López-Fraga, M., Muller, E. & Gill, J. S. The key role of health professionals in preventing and combating transplant-related crimes. Kidney Int. 92, 1299–1302 (2017).

    Article  PubMed  Google Scholar 

  90. Domínguez-Gil, B. et al. Management of patients who receive an organ transplant abroad and return home for follow-up care: recommendations from the declaration of Istanbul Custodian Group. Transplantation 102, e2–e9 (2018).

    Article  PubMed  Google Scholar 

  91. Ambagtsheer, F., Van Balen, L. J., Duijst-Heesters, W. L., Massey, E. K. & Weimar, W. Reporting organ trafficking networks: a survey-based plea to breach the secrecy oath. Am. J. Transpl. 15, 1759–1767 (2015).

    Article  CAS  Google Scholar 

  92. Martin, D. E. et al. Prevention of transnational transplant-related crimes — what more can be done? Transplantation 100, 1776–1784 (2016).

    Article  PubMed  Google Scholar 

  93. Caulfield, T. et al. Trafficking in human beings for the purpose of organ removal and the ethical and legal obligations of healthcare providers. Transpl. Direct 2, e60 (2016).

    Article  Google Scholar 

  94. Lentine, K. L., Lam, N. N. & Segev, D. L. Risks of living kidney donation: current state of knowledge on outcomes important to donors. Clin. J. Am. Soc. Nephrol. 14, 597–608 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  95. Steiner, R. W. “You can’t get there from here”: critical obstacles to current estimates of the ESRD risks of young living kidney donors. Am. J. Transpl. 19, 32–36 (2019).

    Article  Google Scholar 

  96. Dew, M. A. & Jacobs, C. L. Psychosocial and socioeconomic issues facing the living kidney donor. Adv. Chronic Kidney Dis. 19, 237–243 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  97. Delmonico, F. L. et al. Living and deceased organ donation should be financially neutral acts. Am. J. Transpl. 15, 1187–1191 (2015).

    Article  CAS  Google Scholar 

  98. Rodrigue, J. R. et al. Mood, body image, fear of kidney failure, life satisfaction, and decisional stability following living kidney donation: findings from the KDOC study. Am. J. Transpl. 18, 1397–1407 (2018).

    Article  CAS  Google Scholar 

  99. Ralph, A. F. et al. Living kidney donor and recipient perspectives on their relationship: longitudinal semi-structured interviews. BMJ Open. 9, e026629 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  100. Ralph, A. F. et al. The experiences and impact of being deemed ineligible for living kidney donation: semi-structured interview study. Nephrology 25, 339–350 (2020).

    Article  PubMed  Google Scholar 

  101. Thiessen, C. & Kulkarni, S. The psychosocial impact of withdrawing from living kidney donation. Curr. Transplant. Rep. 5, 64–71 (2018).

    Article  Google Scholar 

  102. Reese, P. P. et al. Outcomes for individuals turned down for living kidney donation. Clin. Transplant. 32, e13408 (2018).

    Article  PubMed  Google Scholar 

  103. Fagerlin, A., Zikmund-Fisher, B. J. & Ubel, P. A. Helping patients decide: ten steps to better risk communication. J. Natl. Cancer Inst. 103, 1436–1443 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  104. Tong, A., Chapman, J. R., Wong, G. & Craig, J. C. Living kidney donor assessment: challenges, uncertainties and controversies among transplant nephrologists and surgeons. Am. J. Transpl. 13, 2912–2923 (2013).

    Article  CAS  Google Scholar 

  105. Thiessen, C., Gordon, E. J., Reese, P. P. & Kulkarni, S. Development of a donor-centered approach to risk assessment: rebalancing nonmaleficence and autonomy. Am. J. Transpl. 15, 2314–2323 (02015).

    Article  CAS  Google Scholar 

  106. Abramowicz, D. et al. European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care. Nephrol. Dial. Transplant. 30, 1790–1797 (2014).

    Article  PubMed  Google Scholar 

  107. Lentine, K. L. et al. Summary of kidney disease: improving global outcomes (KDIGO) clinical practice guideline on the evaluation and care of living kidney donors. Transplantation 101, s7–s105 (2017).

    Article  PubMed Central  Google Scholar 

  108. Witasp, A. et al. How can genetics and epigenetics help the nephrologist improve the diagnosis and treatment of chronic kidney disease patients? Nephrol. Dial. Transplant. 29, 972–980 (2014).

    Article  CAS  PubMed  Google Scholar 

  109. Dugan, R. B. et al. Duty to warn at-risk relatives for genetic disease: genetic counselors’ clinical experience. Am. J. Med. Genet. C. Semin. Med. Genet. 119, 27–34 (2003).

    Article  Google Scholar 

  110. Husted, J. in The Right to Know and the Right Not To Know: Genetic Privacy and Responsibility (eds Chadwick, R., Levitt, M., & Shickle, D.) 24–37 (Cambridge University Press, 2014).

  111. Forrest, L. E., Delatycki, M. B., Skene, L. & Aitken, M. Communicating genetic information in families — a review of guidelines and position papers. Eur. J. Hum. Genet. 15, 612–618 (2007).

    Article  PubMed  Google Scholar 

  112. De Rechter, S. et al. Clinicians’ attitude towards family planning and timing of diagnosis in autosomal dominant polycystic kidney disease. PLoS One 12, e0185779 (2017).

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  113. Bierzynska, A. et al. Genomic and clinical profiling of a national nephrotic syndrome cohort advocates a precision medicine approach to disease management. Kidney Int. 91, 937–947 (2017).

    Article  PubMed  Google Scholar 

  114. Riella, L. V. & Sheridan, A. M. Testing for high-risk APOL1 alleles in potential living kidney donors. Am. J. Kidney Dis. 66, 396–401 (2015).

    Article  CAS  PubMed  Google Scholar 

  115. Davison, S. N. et al. Executive summary of the KDIGO controversies conference on supportive care in chronic kidney disease: developing a roadmap to improving quality care. Kidney Int. 88, 447–459 (2015).

    Article  PubMed  Google Scholar 

  116. Tucker, P. S., Kingsley, M. I., Morton, R. H., Scanlan, A. T. & Dalbo, V. J. The increasing financial impact of chronic kidney disease in Australia. Int. J. Nephrol. 2014, 120537 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  117. Turchetti, G. et al. The social cost of chronic kidney disease in Italy. Eur. J. Health Econ. 18, 847–858 (2017).

    Article  PubMed  Google Scholar 

  118. Coyne, D. Influence of industry on renal guideline development. Clin. J. Am. Soc. Nephrol. 2, 3–7 (2007).

    Article  PubMed  Google Scholar 

  119. Ransohoff, D. F., Pignone, M. & Sox, H. C. How to decide whether a clinical practice guideline is trustworthy. JAMA 309, 139–140 (2013).

    Article  CAS  PubMed  Google Scholar 

  120. Loewenstein, G., Sah, S. & Cain, D. M. The unintended consequences of conflict of interest disclosure. JAMA 307, 669–670 (2012).

    Article  PubMed  Google Scholar 

  121. McCoy, M. S. et al. Conflicts of interest for patient-advocacy organizations. N. Engl. J. Med. 376, 880–885 (2017).

    Article  PubMed  Google Scholar 

  122. Nissen, S. E. Conflicts of interest and professional medical associations: progress and remaining challenges. JAMA 317, 1737–1738 (2017).

    Article  PubMed  Google Scholar 

  123. Shiffman, J. Donor funding priorities for communicable disease control in the developing world. Health Policy Plan. 21, 411–420 (2006).

    Article  PubMed  Google Scholar 

  124. Esser, D. E. & Bench, K. K. Does global health funding respond to recipients’ needs? Comparing public and private donors’ allocations in 2005–2007. World Dev. 39, 1271–1280 (2011).

    Article  Google Scholar 

  125. Body, A. & Breeze, B. What are ‘unpopular causes’ and how can they achieve fundraising success? Int. J. Nonprofit Volunt. Sect. Mark. 21, 57–70 (2016).

    Article  Google Scholar 

  126. Merchant, A., Ford, J. B. & Sargeant, A. Charitable organizations’ storytelling influence on donors’ emotions and intentions. J. Bus. Res. 63, 754–762 (2010).

    Article  Google Scholar 

  127. Novogrodsky, E. et al. The role of media in non-directed (altruistic) living kidney donation. Health Commun. 34, 259–267 (2019).

    Article  PubMed  Google Scholar 

  128. Macauley, R. The ethics of cultivated gratitude. HEC Forum 26, 343–348 (2014).

    Article  PubMed  Google Scholar 

  129. Reid, L. Ethical issues in health philanthropy. Healthc. Manage. Forum 30, 298–301 (2017).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. School of Medicine, Deakin University, Geelong Waurn Ponds Campus, Geelong, VIC, Australia

    Dominique E. Martin & Dominique E. Martin

  2. University of Sydney at Westmead Hospital, Westmead, NSW, Australia

    David C. H. Harris & David C. H. Harris

  3. George Institute for Global Health, UNSW, New Delhi, India

    Vivekanand Jha & Vivekanand Jha

  4. University of Oxford, Oxford, UK

    Vivekanand Jha & Vivekanand Jha

  5. Manipal Academy of Higher Education, Manipal, India

    Vivekanand Jha & Vivekanand Jha

  6. International Society of Nephrology, Brussels, Belgium

    Luca Segantini & Luca Segantini

  7. European Society for Organ Transplantation – ESOT c/o ESOT, Padova, Italy

    Luca Segantini & Luca Segantini

  8. Renal Division and Department of Medical Humanities and Bioethics, University of Rochester School of Medicine, Rochester, NY, USA

    Richard A. Demme & Richard A. Demme

  9. Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA

    Thu H. Le & Thu H. Le

  10. American Society of Nephrology, Washington, DC, USA

    Laura McCann & Laura McCann

  11. Renal Division, Emory University School of Medicine, Atlanta, GA, USA

    Jeff M. Sands & Jeff M. Sands

  12. Center for Ethics, Emory University, Atlanta, GA, USA

    Gerard Vong, Paul Root Wolpe, Gerard Vong & Paul Root Wolpe

  13. European Renal Association - European Dialysis and Transplant Association, Parma, Italy

    Monica Fontana & Monica Fontana

  14. Manhes Hospital, Nephrology Department GEPIR, Fleury-Mérogis, France

    Gerard M. London & Gerard M. London

  15. University Hospital, Gent, Belgium

    Bert Vanderhaegen & Bert Vanderhaegen

  16. Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Corneel Heymanslaan 10, B9000, Gent, Belgium

    Raymond Vanholder & Raymond Vanholder

Authors
  1. Dominique E. Martin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David C. H. Harris
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Vivekanand Jha
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Luca Segantini
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Richard A. Demme
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Thu H. Le
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Laura McCann
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jeff M. Sands
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Gerard Vong
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Paul Root Wolpe
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Monica Fontana
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Gerard M. London
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Bert Vanderhaegen
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Raymond Vanholder
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

ASN-ERA-EDTA-ISN Joint Working Group on Ethical Issues in Nephrology

  • Dominique E. Martin
  • , David C. H. Harris
  • , Vivekanand Jha
  • , Luca Segantini
  • , Richard A. Demme
  • , Thu H. Le
  • , Laura McCann
  • , Jeff M. Sands
  • , Gerard Vong
  • , Paul Root Wolpe
  • , Monica Fontana
  • , Gerard M. London
  • , Bert Vanderhaegen
  •  & Raymond Vanholder

Contributions

Dominique E. Martin, David Harris, Vivekanand Jha, Richard A. Demme, Thu H. Le, Jeff M. Sands, Gerard Vong, Paul Root Wolpe, Gerard M. London, Bert Vanderhaegen and Raymond Vanholder wrote the text. Dominique E. Martin, David Harris, Vivekanand Jha, Luca Segantini, Richard A. Demme, Thu H. Le, Laura McCann, Jeff M. Sands, Gerard Vong, Paul Root Wolpe, Monica Fontana, Gerard M. London, Bert Vanderhaegen and Raymond Vanholder reviewed and/or edited the manuscript before submission. Dominique E. Martin, David Harris, Vivekanand Jha, Richard A. Demme, Thu H. Le, Laura McCann, Jeff M. Sands, Gerard Vong, Paul Root Wolpe, Monica Fontana, Gerard M. London, Bert Vanderhaegen and Raymond Vanholder made substantial contributions to discussions of the content:

Corresponding author

Correspondence to Dominique E. Martin.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Peer review information

Nature Reviews Nephrology thanks Bruce Gelb, Alvin Moss and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Martin, D.E., Harris, D.C.H., Jha, V. et al. Ethical challenges in nephrology: a call for action. Nat Rev Nephrol 16, 603–613 (2020). https://doi.org/10.1038/s41581-020-0295-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41581-020-0295-4

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing