Journal of General Internal Medicine

, Volume 28, Issue 11, pp 1511–1516 | Cite as

Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis

  • Bjorg Thorsteinsdottir
  • Keith M. Swetz
  • Jon C. Tilburt


The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.


ethics health policy Medicare renal disease shared decision making 


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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Bjorg Thorsteinsdottir
    • 1
  • Keith M. Swetz
    • 2
    • 3
  • Jon C. Tilburt
    • 2
    • 3
    • 4
    • 5
  1. 1.Primary Care Internal MedicineMayo ClinicRochesterUSA
  2. 2.Division of General Internal MedicineMayo ClinicRochesterUSA
  3. 3.Program in Professionalism and EthicsMayo ClinicRochesterUSA
  4. 4.Biomedical Ethics Research UnitMayo ClinicRochesterUSA
  5. 5.Knowledge Evaluation Research UnitMayo ClinicRochesterUSA

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