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Outcomes are similar between hospital-based hemodialysis and less expensive home-based therapies, especially home peritoneal dialysis. Because of this, some have argued that all suitable patients should be forced to these less expensive modalities. However, such an approach would violate the ethical principles of autonomy and maleficence, and would run counter to the movement toward patient-centered care. Therefore, from a North American perspective, home dialysis should be actively promoted for suitable patients, but should not be mandatory. Extending these arguments into newer paradigms of home- and community-based dialysis, with paid assistance, will be a challenge as traditional cost effectiveness arguments may not be definitive and effective. Nephrology will need to embrace new methods for evaluation of therapies and to develop and endorse sophisticated principles of advocacy to influence health care policy and funding decision makers to maximize nonhospital-based, patient-centered care and improve outcomes in the future.