sorts of people don ' t do very well ' : race and allocation of health care resources

Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renalfailure. The epidemiology of renalfailure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given to issues ofjustice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues andjustice are likely to be adequately addressed. CD, a 53-year-old Australian Aboriginal woman, was admitted from a regional hospital with pulmonary oedema and worsening renal failure. She had a long history of hypertension, hyperlipidaemia and type-2 diabetes mellitus and in the past year had developed cataracts, diabetic retinopathy, intermittent claudication and exercise-induced angina pectoris. CD had been known to have renal disease for over ten years and a renal biopsy two years prior to this admission demonstrated mesangioproliferative glomerulonephritis. Renal failure had progressed to the point that she now required either haemodialysis or renal transplant. Her sister had indicated willingness to donate her kidney. After thorough investigation it was decided that she should not be offered a renal transplant. Her doctor summarised her case with the statement: 'These sorts of people don't do very well....' Kidney disease and other 'western' diseases common in indigenous peoples belong to a group of diseases we label 'diseases of racism'. In this paper we discuss how ostensibly neutral utilitarian criteria used to ration the use of resources for such diseases are biased and may embody subtle forms of racism. We argue that the prevention and successful treatment of such diseases will follow the reversal of the racial inequities that are their root cause.