In spite of ethical analyses assimilating the palliative deactivation of pacemakers to commonly accepted withdrawings of life-sustaining therapy, many clinicians remain ethically uncomfortable with pacemaker deactivation at the end of life. Various reasons have been posited for this discomfort. Some cardiologists have suggested that reluctance to deactivate pacemakers may stem from a sense that the pacemaker has become part of the patient’s “self.” The authors suggest that Daniel Sulmasy is correct to contend that any such identification of the pacemaker is misguided. The authors argue that clinicians uncomfortable with pacemaker deactivation are nevertheless correct to see it as incompatible with the traditional medical ethics of withdrawal of support. Traditional medical ethics is presently taken by many to sanction pacemaker deactivation when such deactivation honors the patient’s right to refuse treatment. The authors suggest that the right to refuse treatment applies to treatments involving ongoing physician agency. This right cannot underwrite patient demands that physicians reverse the effects of treatments previously administered, in which ongoing physician agency is no longer implicated. The permanently indwelling pacemaker is best seen as such a treatment. As such, its deactivation in the pacemaker-dependent patient is best seen not as withdrawal of support but as active ending of life. That being the case, clinicians adhering to the usual ethical analysis of withdrawal of support are correct to be uncomfortable with pacemaker deactivation at the end of life.
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ICDs are implanted devices that terminate lethal cardiac rhythm disturbances by automatically detecting them and administering an electric shock. Pacemakers are implanted devices that sense the electrical function of the heart and provide pacing impulses if those provided by the native cardiac electrical system are insufficient for normal cardiac function. Many pacemakers are not life-sustaining or are only so intermittently. Our argument in this paper is in regard to pacemakers that serve a life-sustaining function, such that a patient’s death might be reasonably anticipated after deactivation.
Kraemer’s suggested solution to the problem, which we shall not address here, is to posit that the patient’s perception of the device can guide our thinking as to whether the device is part of him/her or not and, hence, as to whether device deactivation is active or passive euthanasia in a given case. We suspect that this approach to the problem is too subjective to be satisfactory.
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Huddle, T.S., Amos Bailey, F. Pacemaker deactivation: withdrawal of support or active ending of life?. Theor Med Bioeth 33, 421–433 (2012). https://doi.org/10.1007/s11017-012-9213-5
- Pacemaker deactivation
- Withdrawal of support
- End of life care
- Medical ethics
- Physician assisted suicide