As economic pressures on the health care industry grew the influence of the ethicists likewise grew. The ethicists then retired to their ivory tower to ask questions and attempt to find meaningful answers. In time, their ranks were swelled by people of influence whose agenda and purpose was less noble. In time, the work of the ethicists was used to create a new world medical order ...

History may one day read this way. As a Nephrologist I shudder at the thought of the principles of Hippocrates and Maimanodies, which bound the duty of the physician to the patient, with a system which binds the duty of the physician to the government or 3rd party payor.

The reason that we find this prospect abhorrent is that our generation was raised with a strong Judeo-Christian tradition supported by the principles of individual liberty embodied in the revolution of the enlightenment.

However, before the first shots were fired in the Revolution, our founding fathers and their collegues in Europe worked to change the hearts and minds of the people of the world with the most powerful tool they had: the pen.

The younger generation of physicians are being asked to adopt a view that may even be something other than post-modern. Wesley Smith refers to this as a "Culture of Death" wherein the very meaning of life, liberty, soul, health, quality of life, are redefined to suit the new medical "ethics" of cost effectiveness, medical rationing, withdrawing care, with-holding care etc.

The dialysis population of the United States is represented by some of the poorest, uneducated and disenfranchised patients in the health care system. This is especially true of dialysis patients in the deep rural Southeast where I live and work. The cost of a year of hemodialysis has become the "standard" upon which all other diagnostic and theraputic items are compared in terms of cost-effectiveness. Decreasing the annual cost of care of dialysis patients lowers the bar for us all. Beware. Everyone should beware and take notice.

Increasingly, sick, elderly, complicated patients are seen as a burden to society. As Wesley Smith points out, creating a "heirarchy of Human life" is a recurring theme in our history. In the last century, the Eugenics movement, represented by "Die Freigabe der Vernichtung lebensunwertten Leben" (Permission to Destroy Life Unworthy of Life"), was believed to be the philosophical basis upon which Hitler formed his Eugenics program and Holocaust. This work was written by a famous law professor, Karl Binding, and a physician and "humanitarian", Alfred Hoche. It is an example of medical "ethics" gone bad. It is sobering to remember that physicians participated, administered and executed each and every part of Hitler's "Eugenic's Program" and "Final Solution."

Today, the Eugenicists are called Social Darwinists by their critics. The roles of Binding and Hoche, long dead and forgotten, are being played on the stage of this tragedy by another group of well-meaning philosophers and ethicists. History repeats itself.

Thankfully we have works like that of Norman Levinsky and Eli Freidman ("Legal and Ethical Concerns in Treating Kidney Failure Case Study Workbook"). As the first generation of nephrologists ages and retires they retire with them an important part of medical history. These physicians well remember the days before 1972 when only a fortunate few had access to life saving dialysis.

Patients were presented before "tribunals" composed of laymen, clergy, hospital administrators and doctors. They had to choose who was worthy of dialysis and who was not. A white 35 year old banker, father of two would receive treatment whereas a Black woman living in rural South had a snow ball's chance in Hades of receiving dialysis.

These older Nephrologists witnessed everyday what we rarely witness today: the pain, stench and suffering of a patient dying of uremia. The crys and stench rarely reach the top of the ivory tower where the great grandchildren of Binder and Hoche play their roles.

Levinsky's book should be a must read for every physician caring for sick patients. The issues raised are practical, everyday issues that go the heart and soul of the survival of the traditional medical ethics we have taken for granted. It is written with a balanced perspective. There is no political agenda. This is an academic work that combines experience, philosophy, law and ethics. The subject matter is comprehensive and I was impressed with the sections dealing with issues outside the USA.

There are no cookbook answers. Only the same old questions which will plague those who follow us well into the next millenium. Levinsky's book gives good food for thought as we try to help our patients, be their doctors and advocates. It gives us something to work with other than our own bias and preferences.

These great men witnessed something that my generation would find unthinkable. Physicians in need of a moral and ethical compass should look to such men for guidance. They won't be with us much longer.

Every Nephrologist and Transplant Surgeon should have this book on their shelf with the binder clearly cracked and worn from use.