A case of justifying dubious medical ethics by treating epistemology as ontology
Keith S. Taber
I was puzzled by something I heard a hospital doctor say regarding kidney functioning. The gist of his comments were that
- once kidney function was below about 10% of normal functioning…
- then protecting remaining kidney function was not important…
- because estimates of function at that level are unreliable.
I thought this was an illogical argument as it confused ontology (the state of the kidneys and their functioning) and epistemology (how well we can measure kidney function).
The kidneys are essential organs that regulate hydration levels and eliminate toxic materials from the body. They are 'essential' in the sense that without kidney function someone soon dies. Typically healthy people have plenty of scope for contingency in the capacity of their kidneys. (Living kidneys donors give up one of their two kidneys for transplantation, so, after donation, they will only have, at best, 50%,of normal functioning.) So when people's kidneys start to deteriorate due to disease the patient can continue with normal life for some time. I am not an expert, but from what I understand, a person can manage a normal life with 20% of normal functioning.
Of course there reaches a point in progressive kidney disease when the remaining capacity is not enough to keep someone alive for an extended period. So if kidney function drops to something like an eighth of normal healthy functioning, the situation gets critical.
Kidney dialysis
These days people can have dialysis if their kidneys fail. Someone with 0% kidney function – someone who never excretes any urine at all – can be kept alive indefinitely by dialysis. However this is not ideal. The patient has to attend a clinic and have treatment for 3-4 hours at a time, usually three times a week. No time off – no holidays from dialysis if the patient wants to continue living (and some decide they would rather not continue living, although most 'tolerate' the treatment). Often patients feel unwell on, or after, dialysis – they may say they feel 'washed out', for example. Dialysis also costs the health service (or in some countries, the patient) a good deal of money.
Dialysis patients also have to be very careful about diet and avoid some foods (e.g., eating bananas can lead to dangerously high levels of potassium that can interfere with heart function and could lead to a heart attack), as sessions of dialysis (with no, or very little, blood filtration occurring in-between) is never as good as having constantly functioning kidneys.
Then there's the problem of fluid intake
Dialysis patients are asked to limit their intake of fluids. A healthy person who drinks a lot (whether tap water, tea, beer, etc.) simply produces more urine. Most dialysis patients, however, produce little, if any, urine, and the difference between what they 'should' excrete (to maintain homeostasis), and what they can actually excrete, needs to be removed during the dialysis process. So, whatever water a patient takes in drinks during the 45 or so hours between sessions (and is not lost through some other mechanism such as sweating or breathing), is all taken off during three or so hours on the machine. This brings about changes in the blood volume much more quickly than is comfortable. As the body cannot remove excess fluid via the kidneys, fluid intake means the fluid levels build up between dialysis sessions which can lead to various complications such as increases in blood pressure.
So, having kidney function of, say, 10% or less of normal is a real pain and requires reorganising your entire life around your dialysis sessions (or perhaps getting a transplant if you are strong enough for surgery and are lucky enough that a good match can be found).
That provides some background in considering whether, once kidneys have deteriorated below, say 10%, it really makes any difference in worrying about the actual level. If you have 8% of normal functioning and are on dialysis for life, why would it matter if that fell to 6%?
An actual case
The context of this question was a patient with kidney failure or end-stage renal disease (a haemodialysis* patient, who would only live a matter of days without regular treatment) who was given a CAT scan** using a contrast medium*** to show up features that would not be observable otherwise. Such media are widely considered to have some toxicity in relation to the kidneys (Ahmed, Williams & Stott, 2009), but in a healthy person they are eliminated through the kidneys quite quickly and any risk is considered small. A person with kidney failure does not eliminate toxins in this way, and so when a scan is indicated, it can be scheduled for just before their next dialysis session.
"In every study comparing patients with and without some degree of renal insufficiency [kindeys not functioning adequately], renal insufficiency increased the likelihood of RCIN [radiocontrast-medium-induced nephropathy, i.e., kidney damage due to the use of contrast media]"
"Both peritoneal and hemodialysis remove substantial amounts of the contrast medium (50% to 90% of the dose); hemodialysis is more effective."
Solomon, 1998: 230, 236.
This patient, however, was admitted to a hospital very ill. The emergency department doctor ordered an immediate scan – late at night, at a weekend – but told the patient that the on-call dialysis staff could be called in to give dialysis after the scan. At the X-ray department, the radiographer then said that this was not needed, as long as the patient had dialysis within 24 hours of the scan.
The renal doctor's viewpoint
The next afternoon, the patient had still not gone for dialysis when the hospital renal doctor visited the patient. This doctor took the view that as the patient was due their regular dialysis the following day (i.e., about 38 hours after the scan), there was no point sending the patient for an additional dialysis session, as – after all – the kidneys had already failed sufficiently for the patient to be relying on dialysis for survival.
The patient's viewpoint
The counter-argument presented to the renal specialist (by the patient's spouse) was that even at this point further deterioration should be avoided if possible – that even if 8% of normal kidney function was not good, it was inherently better than 6% of normal kidney function.
After all, if for some reason a patient was further compromised (by an unrelated illness, or by delay in accessing normal dialysis due to some unexpected contingency) a few percentage points – making a small difference in how much the body could remove toxins and excess fluid from the blood by itself between dialysis sessions – could still be the critical factor in determining whether the person survived. (Those attending hospital dialysis notice the high frequency of fellow regular patients who, suddenly, are no longer attending for treatment.)
The renal doctor's justification
The doctor responded to this with the counter-argument that once kidney function was this low, there was no reason to be concerned about a change in measured kidney function from (say) 8% to 6% as the difference between such measurements was within the usual variations in measurements found in patients from time to time.
There are two issues here of interest.
Consent that is conditional is not consent if the conditions are broken
One issue relates to ethics (here, medical ethics). A patient consented to a diagnostic procedure with a possible risk of side effects on the understanding that a suitable counter measure would be taken immediately after the procedure to minimise any detrimental effect. The hospital undertook the procedure, but then decided (when it was too late for the patient to withdraw consent) not to follow through on the promised counter-measure. In effect, a procedure was carried out without consent as the consent was (as was made absolutely clear by the patient) conditional on the scan being followed by dialysis.
Reasons for refusing to provide treatment
The second issue relates to the justification given by the doctor as reported above.
The day after the explanation about measurement not clearly distinguishing between 8% and 6% functioning had been made, when dialysis was finally provided, another renal specialist offered a different justification entirely – that the potential risk to kidneys of the contract medium was just a myth. However, the earlier conversations
- in the emergency department;
- in the X-ray department; and
- with the first renal doctor within 24 hours of the scan,
were all clearly undertaken on the basis that both patient and medical staff thought the contrast medium was potentially damaging to kidneys.
"These contrast media can occasionally cause kidney damage, especially in patients who already have kidney disease"
Ahmed, Williams & Stott, 2009
In the context of that discourse, the first renal specialist had argued that because (a) the precision of estimates of kidney function was not great enough to reliably measure a difference between 6% and 8% functionality, then (b) there was no need to be concerned about treatment which could potentially cause damage bringing about deterioration of this order.
Presumably,
- at any one time, a person's kidney function will be at a certain level.
- If the kidney is then further damaged by toxins then that functionality will drop.
- A more damaged kidney is inherently less desirable than a less damaged (better functioning) kidney.
- So further damage to an already damaged kidney is inherently undesirable,
- and should be avoided if possible, if the costs of doing so are not too high.
The state of a diseased person's kidneys could vary slightly 'naturally' in response to various factors related to their general health, diet, environment, etcetera. This is an ontological consideration – the actual state of the kidneys changes. This may well mean that changes of a few percent between measurements could just be natural fluctuation.
It may therefore be difficult to tell if a person's kidneys have become more damaged due to a particular event, such as a diagnostic scan. That is an epistemological issue – the limitation on how well we can identify a specific change that is masked by noise.
Presumably, there are also various factors that limit the precision of such estimates – all measurements are subject to errors, and small (real) differences may be difficult to identify if they are at the level of the likely measurement error. That is also an epistemological issue.
But, just because an effect cannot be clinically measured (epistemology), that does not mean it is not real and will not have consequences (ontology). A drop from 8% kidney function to 6% kidney function is only a change of 2% compared with normal functioning, BUT it is a loss of 25% of the patient's actual kidney function.
A small deterioration in already severely compromised kidneys may seem insignificant to the renal doctor because he does not think he could reliably measure the change. One day it could be the difference between life and death to the kidneys' owner.
Sources cited:
- Ahmed, A., Williams, G., & Stott, I. (2009). Patient information-What I tell my patients about contrast medium nephrotoxicity. British Journal of Renal Medicine, 14(3), 15-18.
- Solomon, R. (1998). Contrast-medium-induced acute renal failure. Kidney international, 53(1), 230-242.
* haemodialysis involves the patient having permanent 'plumbing' installed that allows their vascular system to be connected to a dialysis machine, so the blood can be diverted to the machine to be cleaned. This usually done using blood vessels in the arm. In the case discussed the surgeon cut into the neck and chest (with the patient fully conscious), and connected tubing to a vein in the neck. The tubing was run beneath the skin to exit in the chest below the neckline, where a fitting acted as a tap and connector for the external tubing to the machine. Very special care has to be taken to keep the area clean, and the dressing dry, as the plumbing provides a direct route into the bloodstream. (Baths, swimming, hot-tubs, etc. are not advisable.)
[Peritoneal dialysis is an alternative treatment that involves a catheter being implanted in the abdomen, and being used to allow a solution into the abdominal cavity, which is later removed after it has absorbed waste materials. The patient can manage the process at home, but needs to change the solution in the abdomen a number of times each day.]
** computerised tomography: a process that uses a series of X-ray bursts to collect data that can be compiled into a 3-D image.
*** a substance that shows up on X-ray scans, and which when injected into the blood helps detect vascular structures. (The term is generic – it also applies to substances swallowed before scans of the alimentary canal.)
Note: this post was originally prepared in October 2015, but was not published at the time when the patient was alive and attending for treatment.