In A Few Words
How Much Is a Life Worth?
“How much is a human life worth?” That was Professor Kenneth Feinberg’s main concern when he was appointed by George W. Bush as the Special Master for the September 11th Victim Compensation Fund. Did society have an obligation to
pay victims’ families?
I wonder about posing a similar question in health
care. How far should society go in caring for in- dividuals receiving treatments that control but do not cure underlying disease, such as the treatments for kidney failure? The cost incurred by society in caring for individuals who need dialysis has been the sub- ject of enormous debate. For the individuals involved, the opportunity to live is invaluable. How much is the life of an individual receiving dialysis worth?
I first met Althea* in the 1980s. She was thin, with bulging eyes partially masked by thick, horn-rimmed glasses. She stared at me and said, “If you tell me that I need dialysis, I will get up from this chair and leave.” I was young, nervous, and new to private practice. After mustering all my courage, I said, “Listen … I know nothing about you. I have not asked you a single question, examined you, or seen your laboratory re- sults. You can pick up your stuff and leave if I use the ‘D’ word.” She nodded.
Althea’s primary care doctor told her she was losing kidney function. Althea was “skin and bone,” with a bulging belly and 2 massive kidneys that I could feel with my bare hands. Her blood tests suggested moderately severe kidney failure. She would need dialysis soon.
When I explained this to Althea, she responded with a sigh of despair and said, “You remember what I told you?” I nodded and replied, “No dialysis.”
Althea started telling me her story. She had become a widow in her 20s. She suffered from severe degenerative joint disease. Her children were now married and had decided not to have children of their own. She looked straight at me and said she simply had nothing to look forward to. I told her I respected her decision. I never saw her in my office after that encounter. I had almost forgotten her until a year later.
It was 2 o’clock on a Sunday morning when my phone rang. The physician at the other end told me that one of my patients was in the emergency room. It was Althea. “We gave her over 400 mg of furosemide, morphine, and nasal oxygen and are thinking of intu- bating her. She needs dialysis … now.” I got dressed and drove to the hospital. Althea was in agony, gasping
for breath. She opened her eyes slightly and mumbled: “You remember?” I nodded and said, “Yes. No dial- ysis.” I found out that she had not been doing well for more than a week and had increasing shortness of breath. I spoke with the emergency room physician and the nurse caring for her. I asked Althea whether I could call one of her children or anyone else in the family to discuss her situation. She shook her head and said no. I told Althea that unless I acted, the emergency room doctor wanted to place a tube in her throat and connect her to a breathing machine, which would be quite uncomfortable.
“Do whatever you have to,” she said. “Just make me feel better. I am tired.”
The dialysis nurse was ready. I quickly inserted the catheter in the vein in her groin so that Althea could receive ultrafiltration to remove the excess fluid from the blood. Around daybreak, her breathing became less agonizing, and she fell asleep. I went home. When I returned to the hospital around noon, I saw Althea sitting on the bed with her lunch tray in front of her. With half smile and half smirk and her left eye half closed, she said: “I decided to live.”
Althea did well on dialysis for the next couple of years despite some dialysis-related problems. Her story would have ended there and would not have been any different than thousands of other in- dividuals who started dialysis, except for what happened next.
Her 2 adult children’s decision not to have children was because of the family history of an inherited form of kidney disease. The elder knew they had the condi- tion, and the younger one did not want to know. Then the elder adopted 2 kids, and Althea became a proud grandmother overnight! Subsequently the other sibling changed their mind and went in for tests and was surprised to learn that they did not have the disease. Soon, Althea had 4 grandchildren and had something to look forward to in her life.
Still, life on dialysis was not easy for Althea. She experienced clotted vascular accesses, catheter in- fections, myocardial infarctions, and minor strokes, and underwent a nephrectomy for an infected renal cyst. Despite all these setbacks, Althea wanted to continue to live on dialysis because of the things she had to look forward to: buying toys for her grand- children, celebrating their birthdays, and much more. Althea always told me those were the best years of her life. When Althea and her family finally decided she should discontinue dialysis, she died peacefully at home.
IN A FEW WORDS

In A Few Words
IN A FEW WORDS
Health care economists and bureaucrats remind us about the high cost of dialysis care. They specify that 1% of Medicare beneficiaries on dialysis account for spending corresponding to nearly 7% of the annual Medicare budget. Neither the Gottschalk Report of 1967 nor the subsequent amendment to Social Security Law to include dialysis and kidney transplants as disease- specific coverage under Medicare could have predicted the impact these changes would have on lives. In Althea’s case, Medicare’s “disproportionate” spending made her life worth living—something that truly cannot be quantified in the end.
J. Ganesh Bhat, MD
College Point, New York
Dr Bhat is a practicing kidney specialist caring for individuals with kidney failure, dialysis, and transplants. He splits his time between New York, where he resides, and Oranjestad, Aruba, where he is Chancellor and Professor Emeritus of Medicine and Physiology at Xavier University School of Medicine.
Parts of this essay are excerpted from his address to the New York Chapter of the American Kidney Fund Annual Gala in 2018.
*Names and details have been altered to protect patient privacy. Address for correspondence: jbhat@atlanticdialysis.com
doi: 10.1053/j.ajkd.2023.03.016
© 2023 The Author. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).