Can We Turn Off a Pacemaker?
Pacemaker overview, Mayo Clinic, https://www.mayoclinic.org/tests-procedures/pacemaker/about/pac-20384689
In this mini-sode Tyler and Devan discuss whether it is ethical to turn off a pacemaker if a patient will die without it.
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Transcript
0:23
So Tyler.I hear that this past week.You had a really good ethics consult.What was it about?Yeah.So super interesting question and it's not a question that's entirely unique, but I think one thing that's really interesting about bioethics and I think that's maybe one of your previous co-workers.
0:43
Tom Tomlinson said this, that bioethics is interesting because the issues are cyclical meaning that they come around again and again and again and usually it's technology that drives some of these reexaminations of previous So for example, the technology around Gene editing, for example, is always changing and always getting more precise and advanced.
1:10
And so the papers that were all written or the books that were written in the late 90s about Gene editing are being rediscovered or re used sometimes to apply to more contemporary iterations of the same problem.
1:27
Anyway so the question was about Pacemakers so an implantable device that helps regulate heartbeat.And the question was about whether or not turning off the pacemaker, either, the patient requesting it, which is really unusual or in the situation where a family is making our surrogate is making decisions.
1:54
Is it under what circumstances is it?Okay for a pacemaker to be terminated To be shut off.And part of the, the concern that was raised in this specific question.And also in the literature is is that not more like killing the patient directly, then withdrawing a patient from a ventilator for example, and how do we compare these different technological technologies?
2:23
That perpetuate somebody's life.In a way that is different or the same.And so the question came from a cardiologist or somebody working in the College of Cardiology with with a Cardiology service and so a patient was very ill and was unlikely to was was there's no reasonable expectation.
2:47
That the patient was going to recover and actually the pacemaker continuing to Fire and the way it was described, as that, the patient basically had no underlying In heart rate are heartbeat and so, all of the cardiac function was being stimulated by the pacemaker.
3:03
And so, by turning it off, there was there basically turning off the all cardiac function, which feels a lot different than withdrawing a ventilator and maybe the patient, breathes, maybe they don't, maybe they breathe for a little bit and then pass away peacefully.
3:20
So, that's the question, interesting.I mean, my first reaction to it is that it sounds exactly, like the Case of withdrawing a ventilator because you need to breathe.If you don't breathe, you die and if we take out, the means of breathing, we do expect you to die.
3:39
I mean, there are cases in which somebody kind of is breathing over the vent and we might anticipate that they could breathe a bit longer, or sometimes, it's apparently a surprise.Like, we didn't think they would continue to breathe, but they do.But the expectation, when you withdraw ventilator is in end-of-life cases, is that they won't breathe.
3:55
And and so, then that will lead to their death and And that could take minutes or it could take hours, sometimes it can take a well.I probably not more than a few hours.You can tell me if you have cases if they're not breathing.Alright, it's not going to, but if they do continue to breathe, it could take longer.
4:11
But, you know a pacemaker.We can predict that it is keeping cardiac function going and that turning it off.Would you know, your heart would totally stop.Maybe there are cases in which like the event.We didn't expect the heart to keep beating, but it could, and we don't for sure.
4:28
But that we do expect it to lead to death.So I guess I'm not sure how they're different.They sound the same to me.So what is the thinking about them being different?And that's really where the so there's a couple of reasons why they may be, they're not actually different, but they feel different particularly to the person who's turning them off.
4:48
And one of them is the immediacy of the patient's death, if there's no, underlying cardiac function, right?And in this situation, they were pretty confident that but the cardiologist Just said, it feels different.When I flip the switch or do whatever, and they immediately flatlined like, that feels like I am killing that patient.
5:08
And so, that's what.So the immediacy or the lack of uncertainty.So, in some ways that uncertainty provides a little bit of comfort or at least some distance from the action of withdrawing or term or shutting off and the actual patients demise the other question that Gets raised sometimes particularly in the literature is in what way is a pacemaker different than an implanted organ or a transplanted organ?
5:40
At what point does something implanted into your body?That is necessary for your biological function?When does it become part of you?So, for example, we don't, you know, turn off or terminate or, you know, shut down anyway.
5:58
It, it organs transplanted, organ.So some of these kidney, we're not going out going around turning that off, but it's so, so, I mean, there's definitely some differences, but I think it's it raises some interesting concerns, particularly for people who haven't thought about, who don't deal with the withdrawal or withholding of life-sustaining treatment, as commonly as it is done in like an ICU setting.
6:22
So a pulmonologist and I see you pulmonologist is pretty Experienced in with hot withdrawing or withholding a ventilator and seeing how that process plays out.It's less common.I think for a cardiologist to be asked to trot off a pacemaker.
6:42
I'm sure that's true, right?We do terminal excavations, quite frequently and it might just be that the cardiologist is Raising this because they're not doing that sort of thing.They're not taking away treatments that lead to death very often at all and so it feels different to them, they haven't gotten used to it.
6:58
I mean For Better or Worse, they're just not as experienced with that, but they're you're right about the immediacy.That feels very immediate and so that can feel pretty weird.It can feel like killing even if we might agree, ethically, it's not.I actually, I mean, I just make the case.
7:14
I don't think it's ethically, killing.I don't think it's equivalent to killing it.Is the you are actively doing something that cause Ali is associated with the death.But we try to justify these kind of All withdrawals of treatment by saying it's not.
7:32
It's the technology that was keeping them alive and we're merely withdrawing the treatment.The question though about the organs is so interesting because of course we would never equate like a human organ transplant with a medical technology that we could just deactivate.And in some ways that's may be merely because it's not something we can easily deactivate.
7:53
You'd have to like go in surgically and remove an organ, which is pretty different than like waving a magnet over.A Pacemaker.Isn't that how you deactivate it?I think, I think that's generally.It's some sort of external a wand, or a magnet or something like that.That is programmed to shut off the to shut it off.
8:11
Yeah.It's and that's, I mean, there's that movie from, I don't know.Maybe the mid-2000s called Repo Men.Did you ever see that movie?I've never seen it, but I know the movie, right?Yeah.So the idea, you know, just a little bit of background the movie.It's a, it follows these Folks whose job it is to go and reclaim surgically brutally transplanted.
8:36
Organs if folks who got the organs are unable to maintain their payments.So if they basically default on their payment for the organ, transplant procedure, then they go into default and just like you would have your car repossessed if you don't pay the loan on it same thing happens.
8:58
But so So that's kind of the idea, but if we start thinking about pacemakers and organs is being different, which I, you know, obviously that that is the case.But there are other things that we do medically, that maybe are a little bit in more in between like for example you and I have talked a lot about deep greens, brain stimulation.
9:18
So deep brain stimulation is where you go in and put, you know, very precise, electrodes and wires and such an even like a battery pack.Sometimes in implanted and at what point if ever does that device become so integrated into the individual that it becomes part of them such that you can't remove it, right?
9:43
Yeah.Well and sometimes deep brain stimulation is called like a brain pacemaker.So because it's firing in ways that may be more like a defibrillator would, but or maybe more like a pacemaker.Actually think it's a better analogy to a pacemaker.I haven't heard people claiming at this point, it may be just because it's pretty new that it's so integrated into your body that it could never be switched off.
10:06
But that might be the case, one day, I mean, I feel like I talk to people with various disabilities who use Prosthetics, who do consider those Prosthetics part of their body, like, it wouldn't be something, you could just take away from them.This came up during covid.I remember, when people were very afraid that if they went to the hospital with covid, their Ritual ventilators.
10:30
So people who need kind of breathing machines all the time that those would be taken away from them and used on other patients as kind of a triage.If folks thought they they individual wasn't really benefiting from their own breathing machine.And that really scared people and the claim was that it's part of my body.
10:48
It's not something you can just take away from me and give to somebody else.And so there is this kind of fine line between just because it's a machine, doesn't mean it's not part of your body.But it does seem like there's something pretty different with a transplanted, organ like ontologically.
11:07
Then a pacemaker.It's hard to kind of pinpoint.Maybe somebody at one of our good philosophy.Friends can come up with a schema for us and it can't.But it can't be simply as easy as one is like from a human to human.And the other is a machine like that that won't hold up.
11:23
I don't think right because we are you know moving towards a Ality of transplanting, non human organs into individuals, whether they're xenotransplantation, which means from nonhumans into humans like a pig heart, for example, or pig.
11:39
Valves, but also like genetically engineered or fully mechanical organs being implanted.And so for example a total artificial heart for that is medical technology that is exists and is available and people receive it.
11:59
But the process of doing that is you actually remove the person's disease heart and put in a fully functional mechanical heart, it does that become part of the person to the point that it's you, I don't know.
12:16
It just gets it feels very sci-fi sometimes but also maybe we're just overthinking this.Well, that's what we do is bioethicist as we open.That's true thing.That's and then try to come up with simplistic policies that work for everything.
12:35
Yeah, yeah.So I don't know where the line is.But so what did you say?Did you say it was permissible to deactivate the pacemaker?Yeah, so that was the recommendation was we talked a lot about the difference between You're actively killing somebody and what that would look like.
12:53
And so the clinician who I was talking with, was using some terminology inconsistently or kind of misusing some terminology and unhelpful ways, like physician assisted suicide.For example, thought that he was being asked to help an individual commit suicide, which is a completely different type of issue or that it was euthanasia, some sort of like See Killing.
13:19
And that he was his medical expertise was being co-opted in a way that was inappropriate.And so, kind of talk through all of those issues and those topics and I think at the end of the day, he was comfortable doing it.But only because there was still some a little bit and more ambiguity than he, let on it the beginning about whether or not the person had an underlying heart rate.
13:42
So it was actually suggesting so because there was the he felt that there was some potential.That when he turned off the pacemaker that it wasn't going to be an immediate Flatline that that ambiguity or that uncertainty was comforting for him.
13:58
Hmm I can see that right?It feels a little less like direct killing.Yeah.If you allow sort of the natural process to linger and then happen, what feels like more on its own.Like, it feels less causal.If it doesn't immediately happen and I think again, ethically would say that's that's not important difference.
14:19
In theory.But in practice to the person doing it it might feel important.Yeah and oftentimes we're as clinical Ephesus put in a position where we are trying to reassure professionals that what they're doing is okay, right?
14:35
That it's not you're not actually killing your patient that here's how you can understand or think through this processor, what's going on in order to give them some comfort.But and I was I think I was successfully able to do that in this particular case.But Man, it's set me down, a couple of different rabbit holes, and I've been annoying my colleagues with wait a second.
14:56
What about this?What about this?What about this about this issue of pacemakers?Which it was kind of 2010, 11, 12, there was a kind of a rash of papers talking about this and I don't know, maybe it's time to re address those questions that were raised.
15:14
Well, do you think anything new has come of this question?Like is there any reason that it needs to be thought about a new other than it's happening still and and it's still making people uncomfortable or is there something different about Pacemakers in the last 10 years that warrants a new investigation in my mind.
15:30
It's not that the pacemaker itself has changed it's that there are so many other technologies that are either more or less like an implanted pacemaker like deep brain stimulation.For example that maybe the whatever framework was used to make it make sense 10 or 15 years ago Maybe we need to readdress that, that maybe there are other things are other ways to look at it.
15:53
But yeah.So that's what I'm obsessed about this week.Yeah, that's a good one.I mean, we don't want to let people feel like they're killing their patients, right?And I know that sometimes will use this concept of double effect to talk about it to talk to say, you know, it's not you, that's killing the patient, it's their disease, that's killing them, right?
16:12
There's a reason this patients heart stopped actually.The only reason they're still alive at all is because of this technology and that might not be what they would have wanted.And so it's not you doing it, you know, initially when I teach about double effect, my students are often Like that just sounds like a weaselly way to, you know, say what you're doing is actually right when it's actually wrong, but I don't think that's right.
16:34
I think that there is an important difference between saying, you know, this thing is killing your patient.Versus you're removing the thing that is, you know, sort of prolonging their death in unreasonable, burden, some ways and you're allowing the disease, the underlying disease to be the thing that allows them to die.
16:55
Versus, you know, sort of prolonging that with a technology.So I think it is important to have those differences but at the same time like you said a really important job of the clinical ethicist is talking about moral distress and so insofar as the clinician feels like they're killing someone that obviously is going to lead to some moral distress, if you feel like you're killing your patients unless you're like a sociopath like most Physicians, don't want to kill their patients.
17:22
So or you know, unless it's in some parameters.Of Legally acceptable physician Aid in dying but most are not trying to kill their patients.And so they need to like be able to Think Through the differences and that's really important because otherwise we would be vitalists.
17:37
Otherwise we'd force all of our patients to remain on all the technology ever to sustain a heartbeat.Simply because we think everything else is killing and I hope we would never get to that point.We need to allow patients to die.It's everybody dies.
17:53
And if, you know, we don't want to keep people.In states, where it's just a bunch of machines pushing blood through their bodies.That's not how anybody wants to.That's not really living perhaps.Yeah, and I think from if we're focusing just on the pacemaker issue, there's a difference between turning off a pacemaker that is continually firing with somebody who is otherwise clinically dead, right?
18:17
So or so, so far along the pathway towards Death, that the firing of the Pacemakers actually harming them causing harm right perpetuating suffering, so that's kind of one end of the spectrum.The other end of the spectrum might be an otherwise, healthy individual walks into a cardiologists Outpatient Clinic and says, you know what?
18:40
I'm just, I just go ahead and shut this off.I'm done, right?So being completely, that's the hard case.Yeah, yeah.And and being, you know, an obvious case and man, the more, I think about it the more I You know, so for me like the one of the analogies that we are thinking through with my, you know, my my colleagues was, what about contact lenses.
19:04
Like at what there's like glasses, there's contact lenses.There's surgeries you can do like, at what point does that become?Is it because it's so necessary for me to live in the world being able to see well that those contacts are more part of me than they're not part of me.
19:22
Is it something about being inside my eye?Why not?But like on the surface of my eyelid, or My Lens wear glasses and contacts are different in some way or should we think about them the same or I don't know, it's a great ski.
19:37
These are great spitting.Great philosophy questions, right?Like, what is your body and it's not as simple as you might think.Like I think the more I think about these things I get in the exact same head space of like well what is my body?What is it my body?Like when I'm pregnant is that is that baby?
19:54
My body?Is it not?My body is my yeah my contact lens.What?If it's a surgically implanted contact lens, is that my body now, these are great questions, and does it have to be inside me to be my body?Can it be an Tension of my body.These are these are really good questions.
20:09
Yeah.So if I do some body modification and have like no piercings or some sort of implants that change the way my face looks, it does that become part of me?Does it mean?Yeah.And what about like nanotechnology, it's things that like devices that are.
20:26
So my very very very small and can like actually go through your circulatory system.Are those Foreign, are they part of you?Does it depend on whether there's an immuno reaction to it?I don't know.I What if and if they're not part of you, then what about our whole microbiome?
20:44
Like more of our cells are not human than our human and so if we were to say like nanotechnology is not part of us, then how do we account for all the nonhuman stuff that's already inside of our bodies?Yeah, there is no person.Devon we are, we are, we are So anyway, so that's that's what I'm obsessed about this week.
21:07
It's a peacemakers, it's a good one.Let us know what you think, what, what is our body if I would?I put the listeners out there, we know they can give us a good definition.What's part of our body?What's not?What's a machine?