Policies Regarding Treatment of End-Stage Renal Disease in the United States and United Kingdom

The treatment of End-Stage Renal Disease (ESRD) represents a victory for medical technology. Dialysis and kidney transplantation, developed in the early 1960s, offer alternative treatments to patients whose own kidneys no longer function; before, these patients faced a terminal diagnosis. Dialysis is a mechanical treatment in which the patient is connected to a machine that cleanses the blood of impurities and returns it to the body. Although recent innovations (e.g., continuous ambulatory peritoneal dialysis—CAPD) facilitate patient independence from a machine, replacement of the diseased kidneys is the most desirable and least expensive treatment for many patients (33;39). Kidney transplantation remains the most effective and common type of transplantation, and a new kidney (from a living-related or cadaver donor) often dramatically improves the recipient's health and general well-being (20;39). Now, in the mid-1980s, these technologies are no longer new and innovative. Further analysis of these established but costly technologies provides a perspective on the long-range implications of innovations in patient care: while some new issues have emerged, many problems originally associated with these treatments seem to have intensified. Access to treatment remains a central issue, closely linked to the dilemma of equity versus cost. The contrast in the access provided by the United States and Great Britain is dramatic (40); in 1982, the rate of ESRD treatment within the U.S. was twice that of the U.K. (353 versus 160 patients per million) (37). The U.S. policy is basically one of unlimited access, whereas the U.K. has restricted access.