Sunday, January 02, 2011

The God Committee, Africa-style

Who knows when bioethics started? Like other annoying questions (When did philosophy start? When did romantic love start? When did rock and roll start?) there is probably no way to definitively answer it, but that does not stop people from trying. For some, bioethics started in the United States with the so-called 'Seattle God committee', the body of health care professionals and laypersons that was formed to decide who among patients with kidney failure should receive (then new, and very scarce) dialysis treatment. The situation in Seattle seemed to open a new field of inquiry: while the question 'who should get dialysis?' was partly a medical question, it went beyond that. It was not enough for doctors to invoke medical criteria alone, since many patients were medically needy -- the fundamental question was how to choose among them, if there are not enough machines for everyone. If not using medical criteria, what other criteria should be used, and how should we best come to reach such decisions? And so, the story goes, the idea was born of non-physicians assisting in resolving ethical problems within medicine.

This is an old tale. To read about it, you have to go back to a yellowed Life Magazine article from 1962. I was reminded of this piece of history when reading a recent article in BBC news about the rationing of dialysis machines in South Africa. It is striking that Tygerberg Hospital in Cape Town is wrestling with the same problems faced fifty years ago in Seattle, and from the reports, is not fairing much better. More specifically: just as the 'God committee' brought in controversial subjective criteria to decide who should gain access to dialysis, the committee in Tygerberg apparently cannot avoid doing the same. Part of the criteria are having 'good home circumstances' (i.e. running water, electricity, toilet, etc.), the motivation of the patient to adhere to the treatment plan and improve his/her health, and having a good social support network. It is fairly obvious that this criteria does not favor the poor. All other things being equal among needy dialysis patients, those who are better off socially and economically are more likely to gain access to dialysis. One could argue that these non-medical criteria have a medical justification: if a patient does not have good social circumstances, dialysis will not produce a favorable outcome for that patient. Probably. But the upshot is brutal. If you are really poor in Africa, and suffer from renal failure, you are seriously screwed.

In the United States, the federal government in 1972 made the unprecedented decision to extend Medicare provisions to enable the vast majority of patients with chronic renal failure to gain access to dialysis. Basically, faced with a very public rationing problem, they threw money at it. This is not an option in Africa. As chronic diseases become more and more prevalent in the region -- certainly more prevalent than new clinics, new technology and new medical professionals -- there are going to be a lot more stories like this.

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