When the United States Congress established the Medicare End-Stage Renal Disease (ESRD) Program in 1972, they did not specify patients for whom dialysis would be appropriate. The ESRD program has grown beyond expectation in patient numbers and in costs, partly because patients who were not initially considered by the dialysis community to be candidates are now routinely accepted. The appropriateness of dialysis for some of these patients has been questioned. Recognizing that practice guidelines are a means to promote appropriate health care, the Institute of Medicine Committee to Study the Medicare ESRD Program recommended the development of practice guidelines for ESRD patient selection. This article reviews the arguments for and against guideline development for dialysis patient selection and the guidelines that have been proposed. It describes what appears to be an emerging consensus on the appropriate use of dialysis and recommends a process for the establishment of dialysis patient selection guidelines based on this consensus.