Intentions Regarding Turning Off the Pacemaker of Reverend G
In the “Controversies” section of the Journal of the American Medical Association for February 23, 2000 there is a viewpoint as presented by Rhymes and colleagues titled “Withdrawing Very- Low Burden Interventions in Chronically Ill Patients”. The authors present a case about a severely demented elderly Reverend G who is “abusive, aggressive and assaultive” and “hallucinating”. His mental state and behavior cannot be controlled with any drug treatment. There is, on the other hand, an approach to management of this difficult patient.
Reverend G has a cardiac pacemaker “which the wife, with agreement from their children, has asked that the patient be given treatment to keep him comfortable and they asked that his pacemaker be turned off, on the assumption that the pacemaker may prevent an otherwise natural death.” The description of the case states that Reverend G had a living will written “before his dementia became severe” however it is not clear what the will stated except “he said that he did not want to commit suicide.” The authors provide arguments which support view that the wishes of the family is based on the rationale that turning off the pacemaker will end a “burdensome life” without representing physician-assisted suicide, euthanasia or “killing” the patient.
Ethicist Ed Pellegrino in a companion article in the same section of the Journal presents a moral algorithm for “Decisions to Withdraw Life Sustaining Treatment.” In it he finally argues that the reason for turning off the pacemaker should be if the intention was to remove a futile treatment but not if the intentions of the surrogates or medical attendants “were to hasten death…or to end a life which they unilaterally judged to be of ‘no quality’”
Which view would you hold? Is the pacemaker a futile treatment? Could one argue that the pacemaker is futile treatment, not because it can’t keep the heart beating normally, but because as a life-supportive mechanism it is failing to treat the patient’s dementia and what the family believes is simply maintaining a “burdensome life”? Can one call the pacemaker’s value as futile with regard to treating the mental disorder when it was inserted to treat the heart rhythm disturbance? And whose “burdensome life”? On the other hand could the decision by the family represent a loving concern for the patient who probably in recent times experienced not only the mental burdens but also most likely the physical burdens of physical restraints? What is your take on this scenario? ..Maurice.