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Semin Nephrol. 2017 May;37(3):273-286. doi: 10.1016/j.semnephrol.2017.02.007.

Ethical Challenges in the Provision of Dialysis in Resource-Constrained Environments.

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Institute of Biomedical Ethics, University of Zurich, Zurich, Switzerland; Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Electronic address:
Research Group in Global Health Priorities, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Department of Research and Development, Helse Bergen Health Trust, Bergen.
Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.


The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process.


Dialysis; accountability for reasonableness; ethics; low- and middle-income countries; priority setting; rationing

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