Editor's note: This is the root of everything that went wrong in U.S. dialysis care. It has led to patients having virtually no voice in their system of care. With no focus on the patients' needs to remain productive, it has led to decades of stagnant technology. It has led to a perverse field of medicine that extends lives, but has never developed the necessary subspecialties (renal re/habilitation) that allow those lives to have meaning and purpose. It has led to U.S. dialysis care being dominated by junk-bond-financed corporations with mid-level managers focused on producing metrics and profits, instead of advocating for patients' well-being in their systems of care.