On the deactivation of implantable devices

Tough ethical questions

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There is an interesting thread on Twitter generated by a BBC article relating the case of a British patient who was granted the right to have her pacemaker deactivated.  Dr. Wes Fisher was interviewed in the article.

The question posed is whether this constitutes assisted suicide or not.  Dr. John Mandrola pointed to the position document of the Heart Rhythm Society regarding such cases and seems firm that pacemaker deactivation is not euthanasia.

This is a tough topic.  To get straight to the point, I disagree with the position taken by the HRS that there is no material importance to the fact that implanted devices are integrated to the body (page 1011).  The HRS therefore thinks that deactivating an implanted device is akin to withdrawing ventilator support.

I disagree and think the distinction is important.  The HRS document refers to a paper by Daniel Sulmasy (reference 43) to support its position.  Sulmasy rejects the material importance of distinguishing an implanted device from an external life-supporting therapy with the following argument:

Does the fact that a technology has become internal to the body mark the boundary between killing and allowing to die?…

Upon further reflection, the fact that a treatment is “inside” the body does not, of itself, seem to do the moral work some might think it does. Consider and compare the following technological interventions: an LHRH agonist implant for prostate cancer and a skin transplant after a severe burn. If one were to discontinue these therapies, however, the mere fact that one treatment is placed under the patient’s skin, whereas the other is placed over the patient’s skin does not constitute the difference between killing and allowing to die. If the patient with prostate cancer were experiencing hot flashes from the LHRH action of the drug and having pain at the site of the implant, his request to have it removed should be honored. But what if the burn patient were to ask that the skin transplant be removed, saying that she had grown tired of the need to take anti-rejection medication? Without an intact integument, the patient would experience sepsis and die. Most plastic surgeons would refuse to do this on the grounds that they would be mutilating, if not killing, the patient, even if she were otherwise dying from some other comorbid disease. The mere fact that a technological intervention has been placed under the skin does not seem to mark the moral difference between killing and allowing to die.

I’m afraid the example used by Sulmasy is invalid.  It is not a question of whether a therapy is “inside” versus “on the surface” that matters.  It is whether the therapy is integrated (which is the term appropriately used by the HRS document, incidentally) or not.  Both the LHRH implant and the skin graft are integrated and, in my opinion, should be considered part of the person’s body.

The reason it is acceptable to remove the LHRH implant as opposed to honoring the removal of the skin graft is because in the first case, the removal of the implant is therapeutic, and would be akin to removing an abscess.  Furthermore, the risk of the removal is proportionate to the burden of the hot flashes.  In the case of the skin graft, the removal is not therapeutic and its removal disproportionate to the risk of the removal.  Besides, if the patient had grown tired of taking anti-rejection medication, she could easily stop taking them.

Sulmasy’s example, therefore, does nothing to refute the contention that deactivation of an internal, integrated device should be treated differently compared to deactivation or withdrawal of external therapy.

Integrated devices, which function without the need for any intervention on the part of the patient or on the part of others should be considered like body parts.  Decisions to intervene on these devices, therefore, should follow the same ethical reasoning regarding intervening on a body part.

Deactivating a device should be done if the action is therapeutic in some sense and, if death is foreseeable for deactivation, the deactivation should fulfill the principle of double effect.

In the case of defibrillators that shock incessantly in a burdensome way, there is no problem deactivating, particularly if the patient is otherwise terminally ill or dying:  the intention is therapeutic, to relieve symptoms.  Death is not intended and is not the means by which the relief will come about.  The risk of deactivating is not disproportionate (particularly if the patient is terminally ill).  Double effect is fulfilled.

In the case of a pacemaker in a pacemaker-dependent patient, deactivation does not usually meet the criteria for double effect: death is the means that will bring about the relief of the patient’s symptoms (whatever these may be).  Deactivation would therefore be a form of assisted suicide or euthanasia.

Keep in mind that the foregoing had no bearing on whether assisted suicide is justifiable or not (I believe it is not).  I just wanted to make sure that the concept are kept clear.

UPDATE 1: Drs. Bittner and Kay came to a similar conclusion

UPDATE 2:

A good discussion on Twitter regarding this blog post leads me to elaborate a bit more for clarification.

My main contention is that an implanted device which requires no outside source of support (beyond what the body would ordinarily require) must be considered as a part of the person, just like any other body parts.

I make that claim because such an implant is fully integrated to the body: wherever the body goes, it goes, just like any other parts of the body.  Like for any part of a biological organism, there is a bi-directional, mutual sustenance between the whole and the part.  The device functions for the sake of the body (the the case of a pacemaker, to stimulate the heart), but the body also “protects” the device and ensures it remains connected to the rest of the body (so long as the body is alive).  The two are intrinsically connected into “one” organism.

In other words, an implanted pacemaker is fully integrated to the body, just like a hand or a kidney is.  Doing something to the pacemaker is akin to doing something to other body parts.  It is not the same as doing something to a ventilator or to some other external means of life support.

The distinction is important because one can make claims about one’s own body parts that one cannot make about external devices, especially if those devices are owned by other people and must be managed by other people.  That’s why turning off a pacemaker is not in the same category of actions as turning off a ventilator.  Because the pacemaker is integral to the body, turning it off in someone who is dependent on it is akin to ablating someone’s native conductive cardiac tissue: both are material actions that involve energy and external resources; both actions are taken by others and result in disruption of a functioning body part; both actions directly violate the integrity of the body.  Turning off a ventilator, on the other hand, does not violate the integrity of the body.

Now one may object to my argument that the pacemaker is a body part on the basis of the fact that it has been artificially implanted by a physician, or that it is made of non-biological material, or that it requires a battery.  None of these objections obtain, however.

The first two objections would entail that we should consider things like implanted kidneys or implanted artificial valves as not part of the recipient’s body, which is untenable.   The third objection implies that there is an ontological distinction that keeps a battery-powered implant from being considered a body part.

I don’t see why that would be the case.  A part of a body is a part of a body not on the basis of whether it has it own energy supply or not, but on the basis of whether it is integrated to the other body parts, as discussed above, so long as the maintenance of the part requires no special attention compared to what the body would ordinarily require.

Of course, the prudent maintenance of a pacemaker entails periodic battery checks and battery replacement at its end of battery life, but that is also true of other native parts:  prudent care for the teeth entail periodic dental cleaning or dental work, etc.  Also, the fact that a pacemaker battery is expected too run out at some point does not imply that it is not a body part.  Native body parts also have limited time spans and may or may not have artificial replacements.

Finally, the fact that a pacemaker is a body part does not compel its replacement when the battery runs out, just like there is no absolute obligation to replace someone’s liver if that liver fails.

UPDATE 3:  The real problem with the passage quoted by Sulmasy is that he considers the distinction between “internal” versus “external” to immediately leap to the settlement of the question “killing” versus “letting die.”  As a result, he is unable to provide an answer to the question of pacemaker deactivation and his paper is very ambiguous in that regard.  So much so that refers to Sulmasy in support of one position, whereas Guevin refers to Sulmasy to support the opposite position.