Jay Bergeron, Anh M. Nguyen, Casey Ryan Alt, Nicole Brewster · 11 authors
Objective: Biomedical data processing generally requires the secure stepwise transfer of sensitive personal information across multiple parties. Mediating such operations using distributed secure digital ledgers, i.e., blockchains, is investigated in this article. Materials and Methods: The bitmark property rights blockchain was used to simulate the process of assessing individuals for enrollment to specific clinical trials. In the scenario presented, a sponsor publishes a recruitment call for a clinical trial and patients signal their willingness to participate in the trial through blockchain transactions. The blockchain creates and maintains digital references of the medical data assets of prospective study participants as well as digital property certificates for assigning access rights to corresponding medical data assets. Trial matching services review the patient blockchain records and recommend study participants that are likely to meet the enrollment criteria of recruiting clinical trials. Digital certificates assign transient access rights to the data assets of the prospective study participants. These certificates are transferred to pertinent matching services and sponsors, allowing these organizations to examine the candidacy of each prospective study participant. Results: The trial matching simulation demonstrates that property rights blockchains can implement complicated multiparty interactions, such as those associated with medical data exchange, without supplemental peer-to-peer communications. Conclusions: Blockchain-based data marketplaces of the type described, when coupled with data-controlled virtual infrastructure environments (i.e., Medical Data Trusts), provide a viable model for managing the transfer, provenance, and processing of individual health information.
The organ donation system in the United States is centralized and difficult to audit by the general public. This centralized approach may lead to data integrity issues in the future. The Organ Procurement and Transplant Network (OPTN) was built and maintained by a non-governmental organization called the United Network for Organ Sharing (UNOS) under its proprietary UNet(SM) umbrella platform. This platform is made up of proprietary closed source software and does not provide the general public easy access to the organ transplant data for auditing. This study investigates the feasibility, challenges, and advantages of a blockchain-based OPTN. A prototype of a blockchain-based OPTN was created using the Hyperledger Fabric framework. The policies and guidelines issued by the United States Department of Health and Human Services for UNOS and the OPTN were used as the basis of this prototype. Four factors were identified to have a direct effect on the performance of this system, viz. max batch time out, max block size, endorsement policy, and transaction rate. Additionally, two variants of the blockchain chaincode were also developed. The first variant performed the organ-candidate matching inside the blockchain (Scheme A), and the second variant performed it outside the blockchain (Scheme B). Analysis of these data showed that Scheme A outperformed Scheme B in all experiments for write-operations. However, the read operations remained unaffected by any of the experiment variables in the given environment. Based on these results, it is recommended to perform the organ-candidate matching on the blockchain with the max batch time out close to the transaction rate.
Internet of Things have brought exciting changes in the social norms, work environments and the prospects for future generations. These devices (Things) have already changed the way our networks are used for communication. With the introduction of machine to machine communication (M2M), where devices communicate without human involvement to perform routine day to day tasks.
An advantage of blockchain protocols is that a decentralized community of users may each update and maintain a public ledger without the need for a trusted third party. Such modifications introduce important economic and ethical considerations that we believe have been not been considered among the community of blockchain developers. We clarify the problem and provide one implementable ethical framework that such developers could use to determine which aspects should be immutable and which should not.
Aug 1, 2019·2019 18th IEEE International Conference On Trust, Security And Privacy In Computing And Communications/13th IEEE International Conference On Big Data Science And Engineering (TrustCom/BigDataSE)
Jack Huang, Yuan Wei Qi, Muhammad Rizwan Asghar, Andrew Meads · 5 authors
In New Zealand, there is currently no shared Electronic Health Record (EHR) system integrated between major healthcare organisations, such as hospitals, medical centres, and specialists. Thanks to its characteristics, blockchain technology can be a suitable platform for building a large-scale EHR system for New Zealand. In this paper, we present MedBloc, a blockchain-based secure EHR system that enables patients and healthcare providers to access and share health records in a usable yet privacy-preserving manner. MedBloc captures a longitudinal view of the patient's health story and enables patients to give or withdraw consent for regulating access to their records. To protect medical data, MedBloc uses an encryption mechanism and enforces a smart contract based access control mechanism for regulating access. MedBloc not only demonstrates how the blockchain can establish New Zealand's first shared EHR system but it shows how blockchain can potentially disrupt the entire medical technology domain.
Danyal Akarca, X. Y., Dave Ebbitt, Mustafa Baydar · 6 authors
There have been significant efforts in the UK to embrace health technology to improve provisions of care. Yet, healthcare offers unique challenges to innovation, particularly with regard to data siloing. Blockchain is a shared distributed ledger technology that decentralises information storage with the potential to improve health outcomes by concurrently optimising data sharing practices and data privacy. In this paper, we explore how blockchain technology may facilitate the handling of health data in the context of regulatory frameworks, patient rights, cybersecurity and provider-centric perspectives. This is essential if this developing technology is to be considered for implementation at scale.
We propose that blockchain technology complemented by secure computation methods can foster implementation of a learning healthcare system (LHCS) by minimizing upfront patient-facing compromises with unsurpassed data security and privacy, and by optimizing the system’s fulfillment of its obligations to respect patients through transparency, engagement, and accountability. We demonstrate how a blockchain-enabled LHCS could foster patient willingness to contribute to learning by providing desired security and control over health data. In addition, secure computation methods could enable meta-analysis without exposing individual-level data, thus allowing the system to protect patients’ privacy while simultaneously learning from their data. The transparency and immutability of blockchain ledgers would also support the public’s trust in the system by allowing patients to audit and oversee which of their data are used, how they are used, and by whom. Furthermore, blockchain communities are community-governed peer-to-peer networks in which sharing builds mutually beneficial value, offering a model for engaging patients as LHCS stakeholders. Smart contracts could be used to ensure accountability of the system by embedding feedback mechanisms by which patients directly and automatically realize benefits of sharing their data.
Yan Zhuang, Lincoln Sheets, Zon‐Yin Shae, Yin-Wu Chen · 6 authors
Patient recruitment for clinical trials is known to be a challenging aspect of clinical research. There are multiple competing concerns from the sponsor, patient and principal investigator's perspectives resulting in most clinical trials not meeting recruitment requirements on time. Conducting under-enrolled clinical trials affects the power of conclusive results or causes premature trial termination. The Blockchain is a distributed ledger technology originally applied in the financial sector. Its features as a peer-to-peer system with publicly audited transactions, data security, and patient privacy are a good fit for the needs of clinical trials recruitment. The "Smart Contract" is a programmable self-executing protocol that regulates the blockchain transactions. Given current recruitment challenges, we have proposed a blockchain model containing multiple trial-based contracts for trial management and patient engagement and a master smart contract for automated subject matching, patient recruitment, and trial-based contracts management.
Blockchain-based platforms are emerging to provide solutions for technical and governance challenges associated with genomic data sharing. Providing capabilities for distributed data stewardship and participatory access control along with effective ways for enforcement of the data access agreements and data ownership are among the major promises of these platforms.
The electronic sharing of medical imaging data is an important element of modern healthcare systems, but current infrastructure for cross-site image transfer depends on trust in third-party intermediaries. In this work, we examine the blockchain concept, which enables parties to establish consensus without relying on a central authority. We develop a framework for cross-domain image sharing that uses a blockchain as a distributed data store to establish a ledger of radiological studies and patient-defined access permissions. The blockchain framework is shown to eliminate third-party access to protected health information, satisfy many criteria of an interoperable health system, and readily generalize to domains beyond medical imaging. Relative drawbacks of the framework include the complexity of the privacy and security models and an unclear regulatory environment. Ultimately, the large-scale feasibility of such an approach remains to be demonstrated and will depend on a number of factors which we discuss in detail.
Liver disease is a significant problem in Pakistan. In a country of approximately 200 million people, 5% (10 million) are infected with hepatitis C virus, and more than 2 million are in need of liver transplantation to save their life.1,2 Pakistan's first liver transplant was performed in 2003 in an international collaborative effort at the Sind Institute of Urology and Transplantation in Karachi. Activities in liver transplantation had been on a hiatus until 2011 when a team of local doctors performed a deceased donor liver transplant in Lahore. From 2012 onward, a number of centers undertook the challenges in developing living donor liver transplant programs across the country. The provinces of Punjab and Sind have been in the forefront of liver transplant activity in Pakistan (Figure 1).FIGURE 1: Centers with liver transplant activity across Pakistan until February 28, 2017.MEDICAL AND SURGICAL CHALLENGES Certain factors have been highlighted as potential obstacles to successful liver transplant activity in Pakistan.3 In the recent past, there has been a significant progress in assessing the burden of need while improving public awareness and readiness of medical facilities. However, a significant gap remains in supply and demands and is linked to funds, technical competence, skill transfer, and sustainability through incentivization and outcome assessment. The most critical factor in developing high-volume transplant programs across the country remains a lack of skilled workforce. Other than in 2 centers run by local teams, transplant numbers in centers that work with international collaboration remain very low (Table 1). Security concerns and visa delays make frequent travel by international teams a difficult proposition. Moreover, the parachuting approach of international transplant teams at various centers for short periods leads to interruptions in the continuity of care. Thus, the presence of efficient local transplant teams is critical in developing successful and sustainable transplant programs (Table 1). Until February 28, 2017, a total of 539 liver transplants have been performed in Pakistan, and approximately 95% of these were performed in the 2 centers run by local teams.TABLE 1: Transplant activity across various centers in the country up to February 18, 2017HEALTH ECONOMICS AND INSURANCE PATTERNS With the exception of a few countries, healthcare in the developed world is the government's responsibility.4 In contrast, healthcare financing in Pakistan is predominantly out of pocket.5 Although the healthcare system in Pakistan has evolved to a well-planned, district-based network of health facilities, the present system is finding it difficult to cope with growing pressure from an ever increasing population and awareness in people regarding their civil rights.4 Living donor liver transplantation is different from deceased donor liver transplantation in that, although requiring highly skilled surgical, medical, and intensive care facilities and infrastructure, it can be successfully accomplished by focusing resources and expertise in a single hospital rather than attempting to develop an entire transplantation infrastructure.6 Insurance coverage has not gained widespread acceptance in Pakistan owing to various sociopolitical and financial reasons. It has been shown that information asymmetry, adverse selection, moral hazard, and fraud raise concerns for the sustainability of insurance programs in developing countries.7 A living donor liver transplant in Pakistan costs between US $35 000 and US $45 000. Most of our patients are self-funded; however, in recent years, there has been increased support from government and philanthropic organizations. Financial restrictions continue to be the biggest hurdle in making liver transplant accessible to patients in need. RECIPIENT AND DONOR OUTCOMES Most transplant programs are still in their infancy in Pakistan, and published outcomes have therefore been limited. Nevertheless, 1-year survival rates of 87% have been demonstrated by one of the busiest transplant centers in Pakistan.3 Grade 3 or above Clavien-Dindo complications were seen in 52% patients, with 23% patients experiencing biliary complications. With regard to donor outcomes, an overall morbidity of 17% has been reported with a biliary complication rate of 3%.8 Based on personal communication, one donor mortality has been reported from one of the institutes in the Sind province resulting in a donor mortality of 0.2% in the country (Gambat Institute of Medical Sciences, oral communication, November 30, 2016). Until February 28, 2017, we have performed 408 LDLTs in our center. Estimates of 1- and 4-year overall survival are 83% and 77%, respectively. Overall, 21.4% of patients had a biliary complication, and there was no donor mortality. With a limited availability of deceased donors, auxiliary, swap, and domino transplants have also been performed to increase the donor pool. We have also accepted donors with hepatitis B core antibody positivity and Gilbert syndrome. ETHICS The Human Organ and Transplantation Authority regulates legal and ethical aspects of liver transplantation in Pakistan. The donors have to be legally (spouse, brother/sister-in-law) or blood related to the patient to be eligible for donation. This has been mandated based on previous reports of commercialization in kidney donations in the country.9 The decentralization of Human Organ and Transplantation Authority with the 18th amendment under the constitution of Pakistan has moved various ministries including the Ministry of Health from a central to a provincial control.10 Those changes have resulted into 5 autonomous provincial bodies regulating transplant activity, allowing a more stringent legal and regulatory process at the provincial level. At the same time, the current decentralized approach challenges the implementation of a future national transplant registry that may monitor transplantation activity and outcomes countrywide. FUTURE DIRECTIONS It is expected that transplant activity will continue to rise in the near future in Pakistan based on the tremendous burden of chronic liver disease and hepatocellular carcinoma. With structured training programs in place, current limitations in surgical/medical workforce are expected to improve. The self-sufficiency in regard to transplant infrastructure will reduce the reliance on international collaborations while providing a continuity of care for the ever increasing numbers of cirrhotic patients. Financial constraints will play a major role in expanding private sector transplant centers. The government will have to consider innovative ideas including private-public sector partnerships and proper incentivization of transplant personnel to make liver transplantation available to the underprivileged in Pakistan. The implementation of a National Transplant Registry is inevitable to ensure transparency in various steps of organ donation and outcome reporting while providing transplant services of international credibility.
The rise of distributed ledger technology, initiated and exemplified by the Bitcoin blockchain, is having an increasing impact on information technology environments in which there is an emphasis on trust and security. Management of electronic health records, where both conformation to legislative regulations and maintenance of public trust are paramount, is an area where the impact of these new technologies may be particularly beneficial. We present a system that enables fine-grained personalized control of third-party access to patients' electronic health records, allowing individuals to specify when and how their records are accessed for research purposes. The use of the smart contract based Ethereum blockchain technology to implement this system allows it to operate in a verifiably secure, trustless, and openly auditable environment, features crucial to health information systems moving forward.
Who shall live when not all can live? Although this question has been urgently forced upon us by the dramatic use of artificial internal organs and organ transplantations, it is hardly new. George Bernard Shaw dealt with it in “The Doctor's Dilemma”: Sir Patrick.Well, Mr. Savior of Lives: which is it to be? That honest decent man Blenkinsop, or that rotten blackguard of an artist, eh?Ridgeon.It's not an easy case to judge, is it? Blenkinsop's an honest decent man; but is he any use? Dubedat's a rotten blackguard; but he's a genuine source of pretty and pleasant and good things.Sir Patrick.What will he be a source of for that poor innocent wife of his, when she finds him out?Ridgeon.That's true. Her life will be a hell.Sir Patrick.And tell me this. Suppose you had this choice put before you: either to go through life and find all the pictures bad but all the men and women good, or go through life and find all the pictures good and all the men and women rotten. Which would you choose?1 A significant example of the distribution of scarce medical resources is seen in the use of penicillin shortly after its discovery. Military officers had to determine which soldiers would be treated—those with venereal disease or those wounded in combat.2 In many respects such decisions have become routine in medical circles. Day after day physicians and others make judgments and decisions “about allocations of medical care to various segments of our population, to various types of hospitalized patients, and to specific individuals,”3 for example, whether mental illness or cancer will receive the higher proportion of available funds. Nevertheless, the dramatic forms of “Scarce Life-Saving Medical Resources” (hereafter abbreviated as SLMR) such as hemodialysis and kidney and heart transplants have compelled us to examine the moral questions that have been concealed in many routine decisions. I do not attempt in this paper to show how a resolution of SLMR cases can help us in the more routine ones which do not involve a conflict of life with life. Rather I develop an argument for a particular method of determining who shall live when not all can live. No conclusions are implied about criteria and procedures for determining who shall receive medical resources that are not directly related to the preservation of life (e.g. corneal transplants) or about standards for allocating money and time for studying and treating certain diseases.Just as current SLMR decisions are not totally discontinuous with other medical decisions, so we must ask whether some other cases might, at least by analogy, help us develop the needed criteria and procedures. Some have looked at the principles at work in our responses to abortion, euthanasia, and artificial insemination.4 Usually they have concluded that these cases do not cast light on the selection of patients for artificial and transplanted organs. The reason is evident: in abortion, euthanasia, and artificial insemination, there is no conflict of life with life for limited but indispensable resources (with the possible exception of therapeutic abortion). In current SLMR decisions, such a conflict is inescapable, and it makes them so morally perplexing and fascinating. If analogous cases are to be found, I think that we shall locate them in moral conflict situations.An especially interesting and pertinent one is U.S. v. Holmes.5 In 1841 an American ship, the William Brown, which was near Newfoundland on a trip from Liverpool to Philadelphia, struck an iceberg. The crew and half the passengers were able to escape in the two available vessels. One of these, a longboat, carrying too many passengers and leaking seriously, began to founder in the turbulent sea after about twenty-four hours. In a desperate attempt to keep it from sinking, the crew threw over board fourteen men. Two sisters of one of the men either jumped overboard to join their brother in death or instructed the crew to throw them over. The criteria for determining who should live were “not to part man and wife, and not to throw over any women.” Several hours later the others were rescued. Returning to Philadelphia, most of the crew disappeared, but one, Holmes, who had acted upon orders from the mate, was indicted, tried, and convicted on the charge of “unlawful homicide.”We are interested in this case from a moral rather than a legal standpoint, and there are several possible responses to and judgments about it. Without attempting to be exhaustive I shall sketch a few of these. The judge contended that lots should have been cast, for in such conflict situations, there is no other procedure “so consonant both to humanity and to justice.” Counsel for Holmes, on the other hand, maintained that the “sailors adopted the only principle of selection which was possible in an emergency like theirs,—a principle more humane than lots.”Another version of selection might extend and systematize the maxims of the sailors in the direction of “utility”; those are saved who will contribute to the greatest good for the greatest number. Yet another possible option is defended by Edmond Cahn in The Moral Decision. He argues that in this case we encounter the “morals of the last days.” By this phrase he indicates that an apocalyptic crisis renders totally irrelevant the normal differences between individuals. He continues, In a strait of this extremity, all men are reduced—or raised, as one may choose to denominate it—to members of the genus, mere congeners and nothing else. Truly and literally, all were “in the same boat,” and thus none could be saved separately from the others. I am driven to conclude that otherwise—that is, if none sacrifice themselves of free will to spare the others—they must all wait and die together. For where all have become congeners, pure and simple, no one can save himself by killing another.6 Cahn's answer to the question “who shall live when not all can live” is “none” unless the voluntary sacrifice by some persons permits it.Few would deny the importance of Cahn's approach although many, including this writer, would suggest that it is relevant mainly as an affirmation of an elevated and, indeed, heroic or saintly morality which one hopes would find expression in the voluntary actions of many persons trapped in “borderline” situations involving a conflict of life with life. It is a maximal demand which some moral principles impose on the individual in the recognition that self-preservation is not a good which is to be defended at all costs. The absence of this saintly or heroic morality should not mean, however, that everyone perishes. Without making survival an absolute value and without justifying all means to achieve it, we can maintain that simply letting everyone die is irresponsible. This charge can be supported from several different standpoints, including society at large as well as the individuals involved. Among a group of self-interested individuals, none of whom volunteers to relinquish his life, there may be better and worse ways of determining who shall survive. One task of social ethics, whether religious or philosophical, is to propose relatively just institutional arrangements—which criteria and procedures of selection is most satisfactory in view of the human condition (man's limited altruism and inclination to seek his own good) and the conflicting values that are to be realized?There are several significant differences between the Holmes and SLMR cases, a major one being that the former involves direct killing of another person, while the latter involve only permitting a person to die when it is not possible to save all. Furthermore, in extreme situations such as Holmes, the restraints of civilization have been stripped away, and something approximating a state of nature prevails, in which life is “solitary, poor, nasty, brutish and short.” The state of nature does not mean that moral standards are irrelevant and that might should prevail, but it does suggest that much of the matrix which normally supports morality has been removed. Also the necessary but unfortunate decisions about who shall live and die are made by men who are existentially and personally involved in the outcome. Their survival too is at stake. Even though the institutional role of sailors seems to require greater sacrificial actions, there is obviously no assurance that they will adequately assess the number of sailors required to man the vessel or that they will impartially and objectively weigh the common good at stake. As the judge insisted in his defense of casting lots in the Holmes case: “In no other than this [casting lots] or some like way are those having equal rights put upon an equal footing, and in no other way is it possible to guard against partiality and oppression, violence, and conflict.” This difference should not be exaggerated since self-interest, professional pride, and the like obviously affect the outcome of many medical decisions. Nor do the remaining differences cancel Holmes' instructiveness.Which set of arrangements should be adopted for SLMR? Two questions are involved: Which standards and criteria should be used? And, Who should make the decision? The first question is basic, since the debate about implementation, e.g. whether by a lay committee or physician, makes little progress until the criteria are determined.We need two sets of criteria which will be applied at two different stages in the selection of recipients of SLMR. First, medical criteria should be used to exclude those who are not “medically acceptable.” Second, from this group of “medically acceptable” applicants, the final selection can be made. Occasionally in current American medical practice, the first stage is omitted, but such an omission is unwarranted. Ethical and social responsibility would seem to require distributing these SLMR only to those who have some reasonable prospect of responding to the treatment. Furthermore, in transplants such medical tests as tissue and blood typing are necessary, although they are hardly fully developed.“Medical is not as as many since there is debate in medical about the relevant and Although can contribute little or nothing to this two may be in First, should be used only to determine the group from which the final selection will be and the attempt to of to should be Medical would exclude some but would not as a of between those who the first For example, if two for were the physicians would not choose the one with the better medical selection would be made on other Second, and should be to an absolute and should be only when they are without related to medical the to with the of which might to most significant moral questions when we to the final the of has been and the number is than the other criteria should be used? should the final selection be First, I shall examine some of the that from to make the final selection in of social these about the and of the I shall the possible for selection or criteria of social on but most they are The and to the society is although this obviously be from his of and the of his to society an is in of these social and has been to suggest the of that affect social value or we encounter the first major of this do we determine the relevant criteria of social of various social are only too does one and the of the life, that day we may how to or or the value in in the same and way that has I am not that we can or that we should attempt to do if the various social and human in could be how do we determine how much we will to Which will have in case of more in the light of which values and principles do we social possible way of determining the values which should be in selection has been by He that our medical decisions about allocating resources are on an of values by there is no way of we should be and about it. should we He that we the values that most in our society and use them as criteria for distributing SLMR. values can be by or if in this put a greater on than men would have a greater on our SLMR than of is significant and the who was SLMR in might be in as the greatest American since George is criteria that could be applied but at the and as well as individual the criteria of social value that are used in is this more than in the and decisions of the selection committee of the where such as and have been significant for determining who shall As two conclude after these criteria and they who the the way but who have so much to the making of The is no for a with bad to this first of determining social values is a only is it if not to on social but it is easy to our will be in a few and the of actions will it is to which persons will their in in and the of of For these as has might be a but we simply the to the which we must is more than when we think in make us that such an approach to SLMR is the of but this should not be The on another the approach would in the person to his social and it and the of the his as a person which be to his or to It is not at all that we are to live with these of who the artificial has we to the principle that social should determine we patients to be with only when they are go to have have a a good and to the that any for for selection is a to the of view which The is not to all but to that SLMR cases are which involve The however, can have and for from by and can go and seek for criteria for the question of life or death in the of the artificial these criteria to the of human the to which they can be little more than that at by casting The he will be to those in American medical is most to a certain or in of which when is this of the and where it only as a and It only us how all selection criteria and procedures the to us in the of the human condition and its This approach is with his view of the task of us how to and ethics, I would can help us the and in light judgments can be made. Even if all actions in SLMR should involve some may human to a greater than others. that a on any criteria is more than that at by casting selection by would the to the moral and values that we are to maintain a of is that we use some of or such as first or such as a to determine who shall be as a to when and judgments can and must be made. Edmond Cahn who the casting of lots as Cahn it, crisis involves too for and too for other as a to which human these values are with the of it is to have persons rather than determining who shall they are with the outcome of the the such as and of being which make human life it is are to be and in the the it must be that the use of seems and the of criteria in SLMR to make their as and as possible so that does not determine who shall however, the moral and values which might be supported by selection by or A more is that the procedure that I develop the relevant moral too That so the argument might the society and its and not the individual with his illness and upon SLMR. is that the values and principles at work in the may well over those in the both of their and and of the of selection in of social As “The more is the to be made of an and the more the life and the more the for human as a moral principle I is in certain conflict situations, it a significant of by of it be as a and procedure without an the including human which might it. this about the Holmes case: of our upon as the all the and the in our should think rather of of as the of the of those individuals to one another that might have been and by casting The and which on the approach would be in his social role and can be and to by a recognition of his equal to be a is by procedures which of selection by more the by human than does It is not but it is to the of letting all die or only those who have the greatest social and argument can be by values other than individual and of value in the medical is the of between and Which selection criteria are most in with this of Which will and it? is that selection by or is from this which is to for human is an of about It is not simply the that another will a particular but more that another will him in certain will him as a As Although has to do with on a of another person, it is on a of a the to to with or live to and so to another is first of all to him to the principle of morality in his with to as a person, This be in situations when a person decisions about him to be made in of his social for such decisions his as a on of in social value or would have reason for that his had been the that one is being not as an in himself but as a means in medical progress or the of a greater social good is with and of this in the which was after the after the first heart The of between the and is not only an value in the of being an in the treatment. It is to be of its as a the related values of individual and are maintained in selection by other the argument for this Which criteria and procedures would men have to a in which several men are to determine for themselves and their the criteria and procedures by which they would to be to and from SLMR if the need need to two and ask which set of criteria and procedures would be as the most and, indeed, the The are The men are are interested in their own that of members of their and of they are not by Furthermore, they are of their own and to the social do not how they would in a the for SLMR in of social these which would be all or the use of Which would seem the most The By which set of criteria would they to be in or from the of those who will be The choice in this and of would be selection or since this of A possible is that one would to a and choose the I think especially since I that the in this are for their as well as for selection or could be more to the It would make more for men who are self-interested but about their to society to a set of criteria which would in of would selection by as relatively just and for or The and those who are would be greater if the is on social than if it is on and be in these situations, but they would be by the of being relatively by makes this A to would make for the and those who have a specific in It would be for them to his by relatively of criteria in is involved. the of life have us to the of and to the of or human life is an after has an absolute to most of us would that we have as much to it as in Although it is as selection by is in in I am not of any which some of its patients from kidney in to make for later who are better in of social Furthermore, few would it. few would a person from a kidney on the that a person better had just In a of the of by at the of from to patients but were not the had its of in and is at least certain is that we extend this principle first to determine who the patients shall live or that we artificial such as a or first would be more than a since the make their over a of time rather than as a group at one This procedure would be in with at least one principle in our and with our of individual and in to these values can be by how the can be to the one easy way of this task is to maintain the of which to a patients are not that they are being for SLMR in to the treatment. whether is or not is not the significant it is rather for would be most to the is that can be more if of and are and that they are by selection by or has another since it would the need for a committee to examine in of their social This responsibility can be there is a possible of use of selection which is interesting to although I do not it as a good reason for It can be as of the of has that SLMR cases would if these scarce resources were rather than on social would no be a the of and would make certain that they would not be by a selection they would help to or so that medical would be and the that I have are the of to be without If we would we not just after we had in it The direction of argument has been against any and I would this as the way to me one possible way of while at the same time them so that they would be of the approach is that which make it necessary to that one man is indispensable for a society in view of a particular set of it the when the is a for the argument to this has that the of would on those who think that the social in this is so that they simply by the outcome of a or a first first the reason must be rather than that is, we from in this not we to of this to the of our but his would be the in a social value the should be used as a of exception in for example, only if it would a reason to another person from a kidney if all were this to the has been made to we would be to put this of another for a only if we would be in which all are being to a by from it. would make an exception I do not this procedure of I think that one can it while about selection by or If it is a lay committee would be upon to with the since the or others would in be the outcome of or This lay committee would determine whether this was so indispensable at this time and that he had to be saved by the values by It would make it that exception is if at only as the of two a defense would be only if and so many moral and values in SLMR
The main aim of this report is to present a picture of the current organization of nephrology in Spain. The Spanish health system offers almost universal coverage, a wide variety of services and a high-quality network of hospitals and primary care centers. Spain has a specialized health care training system that is highly developed, highly regulated, with the capacity to provide high-quality training in 54 different specialties. Nephrology is basically a hospital-based specialty. There are no private dialysis patients in Spain. Hemodialysis centers are 40% public, 15% private and 45% run by companies. The National Health System covers 95% of the population, and there is no cost to patients for treatment of renal disease (dialysis and transplant). We observed a clear decrease of nephrology in residents' election rankings, with position 29 out of 47 specialties in 2007. Some of the reasons for this are the complexity of the subject, no clear information at the university, reduction of professional posts and a very good public service with minimal private practice. In Spain, a model of organization for transplantation was adopted based on a decentralized transplant coordinating network. For cadaveric donors, it compares favorably with rates in other Western countries. Living donor transplantation is very low in Spain--just 10% of total renal transplantation activity. New programs due to financial constraints need to include reduced dialysis costs, greater cost-effectiveness of prescriptions, better handling of ethical issues related to the need for using a clinical score of chronic kidney disease patients to make decisions about conservative or renal replacement therapy and an action plan for improvement of organ donation and transplantation. Recovery of skills (acute kidney injury, biopsies, vascular access, etc.), research and advances in autonomous activities (imaging, surgical and medical vascular training, etc.) are some of the future educational paths needed in nephrology. Adequate decisions in the context of economic restrictions need to be discussed for the sustainability of nephrological care.