End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die?

Abstract

BackgroundBioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die."DiscussionAdvances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death.SummaryDestination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy.

On the ethics of withholding and withdrawing medical treatment

“…In particular, does the moral irrelevance of the distinction between withholding and withdrawing hold in these contexts as well? One possible reason to deny that the moral irrelevance thesis holds with reference to such lifeprolonging treatments as artificial ventilation is the fact that, whereas withdrawing chemotherapy in the oncology case does not have a direct, immediate effect on the patient's life, and may even produce better overall consequences, withdrawing ventilatory support from a patient suffering from LAS, or otherwise unable to breathe spontaneously, has the direct effect of bringing about the patient's death [4]. Thus -it could be argued -while withdrawing chemotherapy is acceptable because it does not imply any direct killing of the patient, withdrawing artificial ventilation is impermissible because it amounts to VAE.…”

On the ethics of withholding and withdrawing medical treatment

“…In particular, does the moral irrelevance of the distinction between withholding and withdrawing hold in these contexts as well? One possible reason to deny that the moral irrelevance thesis holds with reference to such life-prolonging treatments as artificial ventilation is the fact that, whereas withdrawing chemotherapy in the oncology case does not have a direct, immediate effect on the patient’s life, and may even produce better overall consequences, withdrawing ventilatory support from a patient suffering from LAS, or otherwise unable to breathe spontaneously, has the direct effect of bringing about the patient’s death [ 4 ]. Thus - it could be argued - while withdrawing chemotherapy is acceptable because it does not imply any direct killing of the patient, withdrawing artificial ventilation is impermissible because it amounts to VAE.…”

Retraction Note: End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die?

“…The authors have voluntarily retracted this article [ 1 ] and it is no longer available for online public display because portions of the article are similar to a previous publication [ 2 ]. While there was no intention to use pre-existing work without appropriate attribution, the authors nonetheless extend their apologies to Dr. Miller and all others concerned.…”