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Medical dilemmas: the old is new

Nature Medicine volume 8, pages 1066–1067 (2002)Cite this article

Reflecting on discovery, invention and politics after many years in medicine, I feel that my colleagues and I have been fortunate. We have been able to contribute to the revolution in technology and medicine that has enabled artificial organs to be devised and improved. We have also seen the ethical dilemmas that arise from our inventions, and notice the weaknesses of the current practices and see important areas that should be addressed. In this brief commentary, I will discuss the inventions that my colleagues and I made, the medical problems that motivated these discoveries and related ethical concerns.

When chronic hemodialysis first became available in 1960, the resources available for treatment were limited. To decide who should be treated, a two-committee process was established in Seattle7,8. The first committee was composed of physicians charged with determining who was suitable for the new treatment based on medical and psychiatric criteria. The second committee was composed of seven anonymous individuals, representing a cross-section of the community, who chose which patients among those deemed suitable by the first committee would be offered dialysis9. The second committee considered personal factors such as age, achievement, future potential and many intangible factors. Only a few individuals could be treated because of the limited resources available. Each decision to treat one individual rather than another offered the possibility of a longer life for the one chosen, and each decision not to treat an individual made an earlier death a near certainty for the one not treated. The decisions were made in a manner similar to those made by a triaging medical officers in war, except that the second committee based their decisions not on the need to return wounded soldiers to battle but on the social and community values that they shared. Those two committees were both criticized and praised. We have never had a national or international forum in which to discuss the issues of allocation of scarce medical resources. Given the economic, racial, political and religious ramifications of every decision, perhaps no moral high ground or final ethical resolution could be found. Our improved treatments do not address the question of who should be treated when the resources are inadequate or the question of when treatment should be stopped. Such moral and ethical issues must be decided primarily by society, and not by us alone, the medical caregivers. But the issues must be addressed squarely and openly.

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Figure 1: Scribner Shunt.
Figure 2: Celebration of the first three long-term patients on chronic hemodialysis on the tenth anniversary of chronic hemodialysis in Seattle, 1970.

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Acknowledgements

I thank my co-workers and patients for their help and inspiration, and my colleagues, friends and family for their encouragement and support over many years. For help in writing this commentary, I thank W.J. Lederer, A.R. Jonsen, C. Blagg, B. Charra and H. Tenckhoff.

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  1. Department of Medicine University of Washington, Seattle, Washington, USA

    Belding H. Scribner

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Scribner, B. Medical dilemmas: the old is new. Nat Med 8, 1066–1067 (2002). https://doi.org/10.1038/nm772

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