A half-century ago, there was no cure for chronic kidney disease. When the kidneys failed to cleanse the blood of toxins, patients died. But in the early 1940s, a Dutch physician, Willem Kolff, hit upon an ingenious solution: pumping the blood of people suffering end-stage renal failure through a machine to filter it.
Kolff's first invention--50 feet of sausage tubing wrapped around a rotating wooden drum set in a special solution--wasn't perfect. The first 15 people hooked up to this primitive dialysis machine died. But in 1945, Kolff got his "artificial kidney" to work. When he moved to the United States, he and other scientists improved on his invention. By 1961, researchers in Seattle perfected a Teflon shunt that allowed doctors to dialyze people indefinitely, dramatically extending their lives. But there was a problem: The per-patient tab was more than $10,000 per year. When doctors at the University of Washington hospital sought to expand the use of dialysis, administrators worried that the hospital--and, by extension, the state of Washington--would get stuck with the cost. A local foundation provided funding for three dialysis beds, but the decision about how to fill them was a matter of life or death.
The King County Medical Society responded by establishing two committees. A panel of kidney specialists first examined people for medical suitability. Those who made it through this first vetting then went before another panel, which would make the final choices.
This panel was born of an effort to be fair. It consisted of a local pastor, union leader, homemaker, lawyer, doctor and businessman and based its decisions on an assessment of applicants' "social worth." It soon gained a nickname: the "God panel." Of the first 17 patients it saw, 10 were selected for dialysis. The remaining seven died.
As the technology spread, medical centers in other cities struggled to serve large numbers of patients with limited numbers of dialysis machines. The rise of home dialysis reduced the number of people excluded from treatment, but panels across the country still met to decide who would receive access to the life-saving treatment. Supply was one limitation. Money was another: The ability to pay clearly meant the difference between life or death.
Finally, in the summer of 1972, Medicare, the recently created health insurance program, stepped in and covered the procedure. The availability of treatment exploded, and today, dialysis saves more than 300,000 lives per year. But Medicare's effect on the treatment of kidney disease underscores a reality about government and health coverage: When a big public program steps into health care, it does so to expand access, not to curtail it. It eases the hard choices about who should live and who will die. Doing nothing, in contrast, sentences people to death.
Today--and especially this summer--death panels have become the scariest two words in the health care debate and have given end-of-life care a bad name. A consultation with a family doctor about how a patient wants to be treated when he or she faces an end-of-life condition--the actual provision originally included in some drafts of health care proposals--has nothing to do with denying care to someone who's old or sick. Nonetheless, that has become the translation of the term in many of the town hall debates.
And that may hurt all of us. "Having care clarification," says Dr. Ira Byock of Dartmouth-Hitchcock Medical Center and the author of Dying Well, "simultaneously improves quality and lowers overall costs." More important, it insures that patients and their families receive the care they want.
