This paper addresses a dichotomy in the attitudes of some clinicians and bioethicists regarding whether there is a moral difference between deactivating a cardiac pacemaker in a highly dependent patient at the end of life, as opposed to standard cases of withdrawal of treatment. Although many clinicians hold that there is a difference, some bioethicists maintain that the two sorts of cases are morally equivalent. The author explores one potential morally significant point of difference between pacemakers and certain other life-sustaining (...) treatments: specifically, that the former are biofixtures, which become part of the patient in a way that the latter do not. The concept of the pacemaker as biofixture grants pacemakers a unique moral status that gives reason to treat a pacemaker the same as other parts of the patient that are necessary to sustain life. The author employs this biofixture analysis to affirm the intuition that deactivating a pacemaker in a highly dependent patient at the end of life is, in moral terms, more analogous to active euthanasia than it is to standard cases of withdrawal of treatment. The paper concludes with consideration of potential implications for further implantable medical technologies, such as ventricular assist devices and total artificial hearts. (shrink)

Life-saving health resources like organs for transplant and experimental medications are persistently scarce. How ought we, morally speaking, to ration these resources? Many hold that, in any morally acceptable allocation scheme, the young should to some extent be prioritized over the old. Govind Persad, Alan Wertheimer and Ezekiel Emanuel propose a multi-principle allocation scheme called the Complete Lives System, according to which persons roughly between 15 and 40 years old get priority over younger children and older adults, other things being (...) equal. They defend this ‘modified youngest first’ principle in part by appealing to the greater social investment that has been made in 15-year-olds than in younger children. Ruth Tallman has proposed a distinctive defense of modified youngest first, one that appeals not at all to social investment. We find this defense wanting. Tallman’s argument depends on the idea, which we try to show to be implausible, that allocations should maximize the number of people in the midst of a possibly complete life who actually complete their lives. Moreover, Tallman does not justify the priority modified youngest first gives 15-year-olds over, for example, 5-year-olds. Tallman fails to dispel a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. (shrink)

Based on Nathan Goldstein’s case report, “But I have a pacer…there is no point in engaging in hypothetical scenarios”: A Non-imminently Dying Patient’s Request for Pacemaker Deactivation, it is reasonable to conclude that it was, all-things-considered, ethically appropriate to grant the patient’s request to deactivate her pacemaker. Philosophically, and as a clinical bioethicist, I support the team’s decision to honor the patient’s request for pacemaker deactivation. However, it is worth exploring a bit further whether the distress on the part of (...) the outside hospital’s ethics committee and providers—who declined to honor the patient’s request for pacemaker deactivation—may actually track something of moral significance. Might their discomfort around deactivation be “truth-tracking” in moral terms? (shrink)