Deactivating permanent pacemakers in pacemakerdependent patients with terminal illness: an ethical perspective

Medical guidelines state that both implantable cardioverter defibrillator (ICD) and pacemaker deactivation may be ethically permissible when the patient requests their withdrawal based on the respect for the patient’s autonomy. However, they also state that most physicians make an ethical distinction between deactivating ICDs and deactivating permanent pacemakers in pacemaker-dependent patients, being reasonably uncomfortable when confronted with a petition for pacing deactivation in these patients. If a difference between both actions exists, what principles explain this ethical distinction? We analyze this question from the perspective of the bioethical principles and the standpoint of the distinction between substitution and replacement therapies for ethical decisions. Even if we recognize appropriate insights in these proposals, they are insufficient to provide an adequate ethical justification in case of pacemaker deactivation in pacemaker-dependent patients. We propose the burden of therapy and the configuration of the moral act as determinant factors in arriving at a solid answer. In these cases, it is necessary to arrive at a description as precise as possible of the moral action that is performed and to ask what is the basic intentionality that moves such action. Furthermore, we propose the communication virtues as an important aspect to practice in cases of request of a pacemaker withdrawal.