Skip to main content
SpringerLink
Log in

Death, Devices, and Double Effect

  • Published:
HEC Forum Aims and scope Submit manuscript

Abstract

Along with the growing utilization of the total artificial heart (TAH) comes a new set of ethical issues that have, surprisingly, received little attention in the literature: (1) How does one apply the criteria of irreversible cessation of circulatory function (a core concept in the Uniformed Determination of Death Act) given that a TAH rarely stops functioning on its own? (2) Can one appeal to the doctrine of double effect as an ethical rationale for turning off a TAH given that this action directly results in death? And, (3) On what ethical grounds can a physician turn off a TAH in view of the fact that either the intent of such an action or the outcome is always, and necessarily, death? The aim of this article is not to answer these questions but to highlight why these questions must be explored in some depth given the growing use of TAH technology.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. Indeed, this was a core point emphasized by both the Harvard Committee (Ad Hoc Committee of the Harvard Medical School 1968) and the WMA’s Declaration of Sydney (Gilder 1968) that codified the concept of brain death in 1968.

  2. We are here following Sulmasy’s discussion (Sulmasy 2007), especially his consideration of Jansen (2006).

  3. “Irreversibly” in the sense that the patient’s heart, once the TAH is implanted, cannot be restored to its prior state; either the TAH becomes permanent (it serves as the patient’s heart until the patient dies) or it must be fully and completely replaced by a transplanted heart.

  4. (a) A patient not receiving any sort of mechanical ventilatory support experiences pulmonary arrest AND simultaneous the TAH experiences mechanical failure; (b) a patient not receiving any sort of mechanical ventilatory support experiences pulmonary arrest AND simultaneous the TAH is unintentionally turned off; (c) a patient not receiving any sort of ventilatory support experiences pulmonary arrest AND simultaneous the TAH is intentionally turned off; (d) a patient not receiving any sort of mechanical ventilatory support experiences pulmonary arrest AFTER the TAH is unintentionally turned off; (e) a patient not receiving any sort of ventilatory support experiences pulmonary arrest AFTER the TAH is intentionally turned off; (f) a patient receiving ventilatory support experiences mechanical failure of that ventilatory support AND simultaneously the TAH experiences mechanical failure; (g) a patient receiving ventilatory support experiences mechanical failure of that ventilatory support AND simultaneously the TAH is unintentionally tuned off; (h) a patient receiving ventilatory support experiences mechanical failure of that ventilatory support AND simultaneously the TAH is intentionally tuned off; (i) a patient receiving ventilatory support has that support intentionally turned off AND simultaneously the TAH experiences mechanical failure; (j) a patient receiving ventilatory support has that support intentionally turned off AND simultaneously the TAH is unintentionally turned off; (k) a patient receiving ventilatory support has that support intentionally turned off AND simultaneously the TAH is intentionally turned off; and (l) a patient receiving ventilatory support experiences pulmonary arrest AFTER the TAH is intentionally turned off.

  5. The challenges associated with the concept of “irreversibility” are, of course, not new; these most clearly first sprung up with the development of the first protocol for recovering organs from non-heart-beating donors in the early 1990s and have continued to unfold as DCD has become more mainstream. Our point is simply that “irreversibility” in this particular context of TAH discontinuation is neither simple nor obvious.

  6. Similar linguistic challenges are part and parcel of Devettere’s still-relevant exploration of causality and the withdrawal of life sustaining treatments (Devettere 1989), Miller et al.'s work on moral fictions and the withdrawal of life sustaining treatments (Miller et al. 2010), and Pilkington’s work on withholding and withdrawing medical interventions (Pilkington 2014, forthcoming).

  7. Nearly 10% of all patients receiving a TAH suffer a stroke, over 60% develop an infection requiring treatment, and nearly 45% experience bleeding, all of which can become life-threatening (Cook et al. 2015).

  8. Both the 70 cc and 50 cc SynCardia Total Artificial Heart are FDA approved for humanitarian use device (HUD) designation (approval was granted in April 2012 and January 2013, respectively), meaning these devices may be used for destination therapy in addition to serving as bridges to transplant. It is likely that permanent FDA approval as destination therapy will occur in the future.

References

  • Ad Hoc Committee of the Harvard Medical School. (1968). A definition of irreversible coma. JAMA, 205(6), 337–340.

    Article  Google Scholar 

  • Allmark, P., Cobb, M., Liddle, B. J., & Toid, A. M. (2010). Is the doctrine of double effect irrelevant in end-of-life decision making? Nursing Philosophy, 11(3), 170–177.

    Article  Google Scholar 

  • Bica, C. C. (1999). Another perspective on the doctrine of double effect. Public Affairs Quarterly, 13(2), 131–139.

    Google Scholar 

  • Bronner, B. (2018). Two ways to kill a patient. The Journal of Medicine and Philosophy, 43(1), 44–63.

    Google Scholar 

  • Bucher, H. U., Klein, S. D., Hendriks, M. J., Baumann-Hölzle, R., Berger, T. M., Streuli, J. C., et al. (2018). Decision-making at the limit of viability: Differing perceptions and opinions between neonatal physicians and nurses. BMC Pediatrics, 18(1), 81. https://doi.org/10.1186/s12887-018-1040-z.

    Article  Google Scholar 

  • Chung, G. S., Yoon, J. D., Rasinski, K. A., & Curlin, F. A. (2016). US physicians’ opinions about distinctions between withdrawing and withholding life-sustaining treatment. Journal of Religion and Health, 55(5), 1596–1606.

    Article  Google Scholar 

  • Cook, J. A., Shah, K. B., Quader, M. A., Cooke, R. H., Kasirajan, V., Rao, K. K., et al. (2015). The total artificial heart. Journal of Thoracic Disease, 7(12), 2172–2180.

    Google Scholar 

  • Devettere, R. J. (1989). Reconceptualizing the euthanasia debate. Law, Medicine and Health Care, 17(2), 145–155.

    Article  Google Scholar 

  • DuBois, J. M. (1999). Non-heart-beating organ donation: A defense of the required determination of death. The Journal of Law, Medicine & Ethics, 27(2), 126–136.

    Article  Google Scholar 

  • Giannin, A., Pessina, A., & Tacchi, E. M. (2003). End-of-life decisions in intensive care units: Attitudes of physicians in an Italian urban setting. Intensive Care Medicine, 29(11), 1902–1910.

    Article  Google Scholar 

  • Gilder, S. S. B. (1968). Twenty-second world medical assembly. British Medical Journal, 3(5616), 493–494.

    Article  Google Scholar 

  • Jansen, L. A. (2006). Hastening death and the boundaries of the self. Bioethics, 20(2), 105–111.

    Article  Google Scholar 

  • Kon, A. A., Shepard, E. K., Sederstrom, N. O., Swoboda, S. M., Marshall, M.F., Birriel, B., et al. (2016). Defining futile and potentially inappropriate interventions. Critical Care Medicine, 44(9), 1769–1774.

    Article  Google Scholar 

  • Marquis, D. B. (1991). Four versions of double effect. The Journal of Medicine and Philosophy, 16(5), 515–544.

    Article  Google Scholar 

  • McIntyre, A. (2004). The double life of double effect. Theoretical Medicine and Bioethics, 25(1), 61–74.

    Article  Google Scholar 

  • Miller, F. G., Truog, R. D., & Brock, D. W. (2010). Moral fictions and medical ethics. Bioethics, 24(9), 453–460.

    Article  Google Scholar 

  • Misak, C. J., White, D. B., & Truog, R. D. (2016). Medically inappropriate or futile treatment: Deliberation and justification. The Journal of Medicine and Philosophy, 41(1), 90–114.

    Google Scholar 

  • Pellegrino, E. D., & Thomasma, D. C. (1981). A philosophical basis of medical practice: Toward a philosophy and ethic of the healing professions. New York: Oxford University Press.

    Google Scholar 

  • Pilkington, B. C. (2014). On omissions and artificial hydration and nutrition. The Journal of Medicine and Philosophy, 39(4), 430–443.

    Article  Google Scholar 

  • Pilkington B. C. (forthcoming). Treating or killing? The divergent moral implications of cardiac device deactivation. The Journal of Medicine and Philosophy.

  • President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (1983). Deciding to forego life-sustaining treatment. Washington, DC: Government Printing Office.

    Google Scholar 

  • Sprung, C. L., Cohen, S. L., Sjokvist, P., Baras, M., Bulow, H. H., Hovilehto, S., et al. (2003). End-of-life practices in European intensive care units: The Ethicus Study. JAMA, 290(6), 790–797.

    Article  Google Scholar 

  • Stolz, E., Grossschadl, F., Mayerl, H., Rasky, E., & Feidl, W. (2015). Determinants of acceptance of end-of-life interventions. BMC Medical Ethics, 16(1), 81. https://doi.org/10.1186/s12910-015-0076-y.

    Article  Google Scholar 

  • Sulmasy, D. P. (2007). Within you/without you: Biotechnology, ontology, and ethics. Journal of General Internal Medicine, 23(Suppl 1), 69–72.

    Google Scholar 

  • Sulmasy, L. S., Mueller, P. S., & The Ethics, Professionalism and Human Rights Committee of the American College of Physicians. (2017). Ethics and the legalization of physician-assisted suicide: An American College of Physicians position paper. Annals of Internal Medicine, 167(8), 576–578.

    Article  Google Scholar 

  • Tollefsen, C. (2006). Is a purely first person account of human action defensible? Ethical Theory and Moral Practice, 9(4), 441–460.

    Article  Google Scholar 

  • Trankle, S. A. (2014). Decisions that hasten death: Double effect and the experiences of physicians in Australia. BMC Medical Ethics, 15, 26. https://doi.org/10.1186/1472-6939-15-26.

    Article  Google Scholar 

  • Truog, R. D., Brock, D. W., & White, D. B. (2012). Should patients receive general anesthesia prior to extubation at the end of life? Critical Care Medicine, 40(2), 631–633.

    Article  Google Scholar 

  • Uniform Law Commission. (2008). Determination of Death Act. 12A Uniform Laws Annotated 777. http://www.uniformlaws.org/shared/docs/determination%20of%20death/udda80.pdf. Accessed 30 Aug 2018.

Download references

Author information

Author notes

  1. Stuart G. Finder and Michael Nurok have contributed to conception, design and writing of the manuscript.

Authors and Affiliations

  1. Center for Healthcare Ethics, Cedars-Sinai Medical Center, 8700 Beverly Blvd, TSB 240, Los Angeles, CA, 90048, USA

    Stuart G. Finder

  2. Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd, Suite 3100, Los Angeles, CA, 90048, USA

    Michael Nurok

Authors
  1. Stuart G. Finder
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Nurok
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stuart G. Finder.

Ethics declarations

Conflicts of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Finder, S.G., Nurok, M. Death, Devices, and Double Effect. HEC Forum 31, 63–73 (2019). https://doi.org/10.1007/s10730-018-9361-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10730-018-9361-8

Keywords

Search

Navigation