Moral negotiations in the clinic: Navigating the purgatorial pressure in prophylactic implantable cardioverter defibrillator therapy
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.
Keywordsprophylactic ICD therapy clinical decision-making science and technology studies imperatives moral pathfinding, moral landscapes
- 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
- 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
- Danish Health and Medicines Authority. (2014) Pacemakere, ICD’er og andre avancerede pacemakersystemer. Copenhagen: Danish Health and Medicines Authority.Google Scholar
- Danish Society of Cardiology. (1999) Behandling Med Pacemaker og Implanterbar Defibrillator. Copenhagen: Danish Society of Cardiology. Klaringsrapport 1999, nr. 3.Google Scholar
- Danish Society of Cardiology. (2006) Retningslinjer for profylaktisk ICD-Behandling. Copenhagen: Danish Society of Cardiology. DCS vejledning 2006, nr. 2.Google Scholar
- Danish Society of Cardiology. (2014) National Cardiologisk Behandlingsvejledning. http://nbv.cardio.dk. Accessed 16 Jan 2015.
- Dussauge, I., Helgesson, C.-F. and Lee, F. (eds.). (2015) Value Practices in the Life Sciences and Medicine. Oxford: Oxford University Press.Google Scholar
- 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
- 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
- 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
- Medtronic. (2010) Protecta™ XT with SmartShock™ Technology. Tolochenaz: Medtronic International Trading Sàrl.Google Scholar
- Mouritsen, P. (2015) En plads i verden. Det moderne medborgerskab. København: Gyldendal.Google Scholar
- 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. http://www.england.nhs.uk/wp-content/uploads/2013/06/a09-cardi-implant-cardi-defib.pdf. Accessed 14 Jan 2015.
- Oudshoorn, N. and Pinch, T. (eds.). (2003) How Users Matter: The Co-Construction of Users and Technologies. Cambridge, MA: The MIT Press.Google Scholar
- 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
- Rabinow, P. (1999) French DNA: Trouble in Purgatory. Chicago and London: The University of Chicago Press.Google Scholar