, Volume 13, Issue 3, pp 640–655 | Cite as

Moral negotiations in the clinic: Navigating the purgatorial pressure in prophylactic implantable cardioverter defibrillator therapy

  • Julie Christina GrewEmail author
  • Mette Nordahl Svendsen
Original Article


Who should be offered prophylactic implantable cardioverter defibrillator (ICD) therapy, which is lifesaving but costly, has side effects and only benefits some of the patients treated with the therapy? In Denmark, cardiologists play key roles in making decisions about who to include in the target group for prophylactic ICD therapy. In this paper, we explore what is at stake for Danish cardiologists making these decisions in a welfare state context. Based on fieldwork in ICD clinics and the device industry, we identify three different imperatives that cardiologists juggle in the process of identifying the target group. We conceptualise the cardiologists’ negotiations as ways of groping through a moral landscape and illuminate how cardiologists walk the path of including as many people as possible in the target group for ICD therapy, thereby also supporting the elite clinic. However, in expanding the target group, the cardiologists experience ‘purgatorial pressure’ and seek indulgence for placing the future of the welfare society at risk by implanting more ICDs than is financially sustainable.


prophylactic ICD therapy clinical decision-making science and technology studies imperatives moral pathfinding, moral landscapes 


  1. Akrich, M. (1992) The description of technical objects. In: W. Bijker and J. Law (eds.) Shaping Technology/Building Society. Cambridge, MA: The MIT Press.Google Scholar
  2. Bjørn, P. and Markussen, R. (2013) Cyborg heart: The affective apparatus of bodily production of ICD patients. Science and Technology Studies 26(2): 14–28.Google Scholar
  3. Bolse, K., Hamilton, G., Flanagan, J., Caroll, D.L. and Fridlund, B. (2005) Ways of experiencing the life situation among United States patients with an implantable cardioverter-defibrillator: A qualitative study. Progress in Cardiovascular Nursing 4: 4–10.CrossRefGoogle Scholar
  4. Burke, L.J. (1996) Securing life through technology acceptance: The first six months after transvenous internal cardioverter defibrillator implantation. Heart and Lung 25(5): 352–366.CrossRefGoogle Scholar
  5. Danish Health and Medicines Authority. (2014) Pacemakere, ICD’er og andre avancerede pacemakersystemer. Copenhagen: Danish Health and Medicines Authority.Google Scholar
  6. Danish Society of Cardiology. (1999) Behandling Med Pacemaker og Implanterbar Defibrillator. Copenhagen: Danish Society of Cardiology. Klaringsrapport 1999, nr. 3.Google Scholar
  7. Danish Society of Cardiology. (2006) Retningslinjer for profylaktisk ICD-Behandling. Copenhagen: Danish Society of Cardiology. DCS vejledning 2006, nr. 2.Google Scholar
  8. Danish Society of Cardiology. (2014) National Cardiologisk Behandlingsvejledning. Accessed 16 Jan 2015.
  9. Dickerson, S.S. (2002) Redefining life while forestalling death: Living with an implantable cardioverter defibrillator after a sudden cardiac death experience. Qualitative Health Research 12: 360–372.CrossRefGoogle Scholar
  10. Dussauge, I., Helgesson, C.-F. and Lee, F. (eds.). (2015) Value Practices in the Life Sciences and Medicine. Oxford: Oxford University Press.Google Scholar
  11. Fridlund, B., Lindgren, E.C., Ivarsson, A., Jinhage, B.M., Bolse, K., Flemme, I., Sandstedt, B. and Mårtensson, J. (2000) Patients with implantable cardioverter-defibrillators and their conceptions of the life situation: A qualitative analysis. Journal of Clinical Nursing 9: 37–45.CrossRefGoogle Scholar
  12. Helgason, A., and Pálsson, G. (1997) Contested commodities: The moral landscape of modernist regimes. Journal of the Royal Anthropological Institute 3(3): 451–471.CrossRefGoogle Scholar
  13. Ho, C., Li, H., Noorani, H., Cimon, K., Campbell, K., Tang, A. and Birnie, D. (2007) Implantable Cardiac Defibrillators for Primary Prevention of Sudden Cardiac Death in High Risk Patients: A Meta-Analysis of Clinical Efficacy, and A Review of Cost-Effectiveness and Psychosocial Issues. Technology report no. 81. Ottawa: Canadian Agency for Drugs and Technologies in Health.Google Scholar
  14. Kaufman, S.R. (2009) Making longevity in an aging society: Linking ethical sensibility and medicare spending. Medical Anthropology 28(4): 317–325.CrossRefGoogle Scholar
  15. Kaufman, S.R. (2010) Making longevity in an aging society: Linking Medicare policy and the new ethical field. Perspectives in Biology and Medicine 53(3): 407–424.CrossRefGoogle Scholar
  16. Kaufman, S.R., Shim, J.K. and Russ, A.J. (2004) Revisiting the biomedicalization of aging: Clinical trends and ethical challenge. The Gerontologist 44(6): 731–738.CrossRefGoogle Scholar
  17. Kaufman, S.R., Shim, J.K. and Russ, A.J. (2006) Old age, life extension, and the character of medical choice. Journal of Gerontology: Social Sciences 61B(4): 175–184.CrossRefGoogle Scholar
  18. Kaufman, S.R., Mueller, P.S., Ottenberg, A.L. and Koenig, B.A. (2011) Ironic technology: Old age and the implantable cardioverter defibrillator in US health care. Social Science and Medicine 72: 6–14.CrossRefGoogle Scholar
  19. Koenig, B. (1988) The technological imperatives in medical practice. In: M.M. Lock and D. Gordon (eds.) Biomedicine Examined. Boston: Kluwer Academic Publishers, pp. 465–496.CrossRefGoogle Scholar
  20. Medtronic. (2008) Prevention of Sudden Cardiac Death in Heart Failure Patients. The Evidence for Implantable Cardioverter Defibrillators (ICDs). Tolochenaz: Medtronic International Trading Sàrl.Google Scholar
  21. Medtronic. (2010) Protecta™ XT with SmartShock™ Technology. Tolochenaz: Medtronic International Trading Sàrl.Google Scholar
  22. Mouritsen, P. (2015) En plads i verden. Det moderne medborgerskab. København: Gyldendal.Google Scholar
  23. NHS England. (2013) 2013/14 NHS Standard Contract for Cardiology: Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronisation Therapy (CRT) (Adult). Service Specification No. A09/S/a. Accessed 14 Jan 2015.
  24. Oudshoorn, N. (2015) Sustaining cyborgs: Sensing and tuning agencies of pacemakers and implantable cardioverter defibrillators. Social Studies of Science 45(1): 56–76.CrossRefGoogle Scholar
  25. Oudshoorn, N. and Pinch, T. (eds.). (2003) How Users Matter: The Co-Construction of Users and Technologies. Cambridge, MA: The MIT Press.Google Scholar
  26. Pollock, A. (2008) The internal cardiac defibrillator. In: S. Turkle (ed.) The Inner History of Devices. Cambridge, MA: The MIT Press, pp. 98–111.Google Scholar
  27. Pols, J. (2005) Enacting Appreciations: Beyond the Patient Perspective. Health Care Analysis 13(3): 203–221.CrossRefGoogle Scholar
  28. Rabinow, P. (1999) French DNA: Trouble in Purgatory. Chicago and London: The University of Chicago Press.Google Scholar
  29. Shim, J.K., Russ, A.J. and Kaufman, S.R. (2006) Risk, life extension and the pursuit of medical possibility. Sociology of Health and Illness 28(4): 479–502.CrossRefGoogle Scholar
  30. Svendsen, M.N. and Koch, L. (2008) Unpacking the ‘spare embryo’: Facilitating stem cell research in a moral landscape. Social Studies of Science 38(1): 93–110.CrossRefGoogle Scholar

Copyright information

© Macmillan Publishers Ltd., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Intersectoral Research Unit for Health ServicesFrederiksberg HospitalFrederiksbergDenmark
  2. 2.University of CopenhagenCopenhagenDenmark

Personalised recommendations