In the wake of progress--ethical problems of renal failure treated by dialysis.

The ability of dialysis in the 1960s to prolong the lives of patients with terminal renal failure created a running and changing debate in bioethics. The first issue was the selection of suitable individuals to be treated in the limited facilities available. Progress in technology was ahead of any medical or ethical consensus. The costs of treatment soon exceeded the will or means of health funders to pay, creating a system of covert rationing and fiscal fudges with which physicians reluctantly colluded. Evidence, epidemiology and public opinion eventually prevailed and the UK now provides a satisfactory, if imperfect, programme of renal replacement therapy (RRT) for most patients with end-stage renal failure who can benefit. The ethical challenges in developed countries are now different and relate to end of life decisions. In poorer countries the issues are starker as treatment has to be rationed or provided only for those who can afford it.