Ethical Implications of Switching Off a Pacemaker

On the 24th of September, the BBC reported the story Nina Adamowicz. Nina, a 72 year old lady with an Implantable Pulse Generator (IPG) who, after having the device for almost 20 years, has requested it be switched off.

After suffering a minor infarct, Adamowicz had said that her continued deteriorating health became too much to bear, said she felt like she was waiting in line to be executed, so she requested her device be switched off. She is reported as stating “It isn’t about ‘I want to die’; I’m dying”.

Her case was referred to her local trust’s ethics committee, who, after careful deliberation decided to proceed in line with the wishes of Mrs Adamowicz.

Before passing away on the same night that her device was switched off, Nina Adamowicz stated that she believed she had the right to decide whether or not she wanted the IPG on or off, and stood by her decision.

This case is thought to be the first of its kind in the UK, but Chicago device specialist Dr Westby Fisher professes to doing this exact thing on a dozen separate occasions. Westby considers the ceased action of an implantable device to removing a feeding tube, or switching off a ventilator.

In particular, in a piece for massdevice.com, Fisher tells of a patient who refused dialysis, saying he’d rather let nature take its course. The patient, who also had an IPG, requested that this was switched off, so Westby agreed, and the next day switched off tachyarrhythmia detection on the device. Fisher says that he feels that both he and his patient did the right thing, together.

I for one, am confused as to the ethical pathway involved in coming to both this decision, and that of the ethics committee associated with Nina Adamowicz.. Assisted suicide is complex, but with respect to these scenarios, is defined as the intentional encouragement or assistance to a patient in ending their own life and it is still illegal under the 1961 Suicide Act of UK law . A medic who administers an overdose of muscle relaxants to a patient whose condition is diagnosed as being terminal, even at the behest of that patient, would be punishable by UK law with manslaughter or murder and potentially serve the maximum terms associated with each.

Why then, is hitting the off switch on a pacemaker not considered to be comparable to the example given previously? Patients with implantable devices often have them to combat life-threatening arrhythmias, so in turning them off, this can effectively issue a death sentence to that patient.  I’m not arguing for or against any form of assisted death; I neither understand its intricacies or feel it is my place to denounce or advocate something with which I have had precisely zero experience, I’m simply confused as to why an immediate form of assisted dying is outlawed, and something so similar (on the surface at least), is not. Adamowicz’ clinician has said that other professionals are split in their opinion on his decision, with some feeling it to be “uncomfortably close to euthanasia”.

Is it fair to patients with terminal diagnoses that are forced to travel to countries such as Switzerland, wherein some forms of euthanasia are legal, simply because they do not have an IPG? Does the severity of the condition have any part to play? How similar do individual cases have to be so as to render one illegal and another not so? I have a feeling that this case will spark long debate throughout the medical and legal professions in the UK, and will follow its progress closely.

BBC article

Westby Fisher’s blog

Heart

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Christopher

I'm a qualified clinical physiologist with a keen interest in free open access meducation (FOAMed), pacing and electrophysiology.

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