Ethics vs. Legality of Deactivating Cardiovascular Implantable Electronic Devices

A colleague suggested that my blog post about Lars Noah's new article on deactivating CIEDs lacked an important piece of context.  



While Noah may be right that the legal literature has neglected the issue, the issue of deactivating cardiac devices was thoroughly addressed in a set of authoritative guidelines published in 2010.  Rachel Lampert et al., "HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in Patients Nearing End of Life or Requesting Withdrawal of Therapy, 7 HeartRhythm 1008 (2010).  In short, failure to respect a patient wish to deactivate(or at least refer to a willing clinician) is outside standard of care and unacceptable violation of patient autonomy.



Noah, of course, acknowledges the Consensus Statement:



After fifteen years of debate in the medical literature, the views of those defending the ethics of CIED deactivation secured official endorsement in 2010. The Heart Rhythm Society (HRS), along with half a dozen other professional groups (including the American College of Cardiology and the American Heart Association), produced a “consensus statement” covering the subject, with several of the individuals who previously had penned defenses of deactivation listed as co-authors.



The Report emphasized the importance of improving dialogue about the question between physicians and their patients. Viewing the matter as no different than requests to withdraw other forms of life-sustaining treatment, buttressed by the previously described points about causation and intent, the HRS consensus statement concluded as follows: “Deactivation of a CIED, whether a pacemaker, ICD or other device is not assisted suicide or euthanasia and is ethically and legally permissible.”



In spite of the mildly remarkable confidence expressed in the report, an ethical consensus in favor of the practice informs but ultimately cannot settle questions about its legality.