Ontology or phenomenology? How the lvad challenges the euthanasia debate

Bioethics

Volumn 27, Issue 3, 2013, Pages 140-150

  Kraemer, Felicitas ^a  

^a EINDHOVEN UNIVERSITY OF TECHNOLOGY   (Netherlands)

Author keywords

Active passive euthanasia; End of life decisions; Hybrid technologies; Implant ethics; LVAD; Ontology; Phenomenology

Indexed keywords

ACTIVE EUTHANASIA; ARTICLE; DECISION MAKING; ETHICS; HEART ASSIST DEVICE; HEART LEFT VENTRICLE FUNCTION; HUMAN; PASSIVE EUTHANASIA;

DECISION MAKING; EUTHANASIA, ACTIVE; EUTHANASIA, PASSIVE; HEART-ASSIST DEVICES; HUMANS; VENTRICULAR DYSFUNCTION, LEFT;

EID: 84873990900     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2011.01900.x     Document Type: Article

References (51)

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2. J.R. Simon & R.L. Fischbach. Doctor, Will You Turn Off My LVAD? Hastings Cent Rep 2008; 38: 1: 14-15.
3. 2010 Recently, the American Heart Rhythm Society has launched an Expert Consensus Statement on Management of Cardiovascular Implantable Electronic Devices (CIEDs) in Patients Nearing End of Life or Requesting Withdrawal of Therapy, 14 May 2010 DOI: doi:10.1016/j.hrthm.2010.04.033 [Accessed 10 July]. The statement speaks to the need for clarification of these difficult issues. www.hrsonline.org/policy/clinicalguidelines/ceids_mgmt.cfm.
4. J.R. Simon. Commentary.
5. R.L. Fischbach. Commentary. Both in Hastings Cent Rep 2008; 38: 14-15.
6. T. Hofweber. 2004. 'Ontology' here means an account of what sorts of medical devices there are and how they are inter-connected: 'Ontology is the study of what there is.' Logic and Ontology. In Stanford Encyclopedia of Philosophy. Stanford CA: Metaphysics Research Lab. Available at [Accessed 3 April 2010]. http://plato.stanford.edu/entries/logic-ontology/.
7. J. Rachels. Active and Passive Euthanasia. N Engl J Med, Vol. 292, January 9, 1975: 78-80. Different frameworks for withdrawal schemes are already provided elsewhere in the literature.
8. D.M. Dudzinski. Ethics Guidelines for Destination Therapy. Ethics in Cardiothoracic Surgery 2006; 81: 1186.
9. T.P. Powell & M.C. Oz. Discontinuing the LVAD: Ethical Considerations. The Annals of Thoracic Surgery 1997: 63: 1223-1224.
10. K.A. Bramstedt. Left Ventricular Assist Devices: an Ethical Analysis. Science and Engineering Ethics. 1999; 5: 89-96.
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12. K.A. Bramstedt & N.S. Wenger. When Withdrawal of Life- Sustaining Care Does More than Allow Death to Take its Course: the Dilemma of Left Ventricular Assist Devices, J Heart Lung Transplant 2001: 584.
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14. S.-O. Hansson. 2009. Philosophy of Medical Technology. Handbook of the Philosophy of Science 9: Philosophy of Technology and Engineering Sciences. A. Meijers, ed., Amsterdam: Elsevier, 1275 ff.
15. Philip Brey. The Epistemology and Ontology of Human-Computer Interaction. Mind and Machines. 2005; 15: 383-398. For the notion 'hybrid system' or 'hybrid cognitive system' in another context.
16. A.G. Rizzieri et al. Ethical Challenges with the Left Ventricular Assist Device and Destination Therapy. Philos Ethics Humanit Med 2008; 3(20): 10ff.
17. Eric A. Rose et al. Long-term Use of a Left-Ventricular Assist Device for End-Stage Heart Failure. N Engl J Med 2001; 345(20): 1435-1443.
18. J.R. Simon. Constructive Realism and Medicine: an Approach to Medical Ontology. Perspect Biol Med 2008; 51(3): 353-366; see also the literature quoted by Simon.
19. B. Smith et al. Relations in Biomedical Ontologies. Genome Biol 2005; 6(R46). Available at: [Accessed 30 July 2010]. http://genomebiology.com/2005/6/5/R46.
20. In most states of the United States, active euthanasia is illegal, e.g. H.T. Stone & W.J. Winslade. Physician-Assisted Suicide and Euthanasia in the United States. J Leg Med 1995; 16: 481-507.
21. R.M. Veach. Inactivating a Total Artificial Heart: Special Moral Problems. Death Stud 2003; 27: 305-315: See deactivation of a TAH understood as active euthanasia in 'Throwing a switch that stops a TAH is more like injecting a drug that paralyzes the heart muscle or like excising the SA node. Either of these would be considered direct, active killing. How can it be that turning off the heart is any different? The direct and immediate result is death.
22. A more elaborate analysis would have to distinguish between the ontological structure of a device or organ on the one hand and the procedure of its explantation on the other.
23. This also depends on the type of pacemaker (flexible one for emergencies or constantly pulsing ones); cf. [Accessed 3 April 2010]. http://www.hrspatients.org/patients/treatments/pacemakers.asp.
24. Simon does not claim the identity of both relata, but only claims similarity. However, his concept of 'ethically relevant features' seems too vague here to indicate clearly what is meant.
25. M.-H. Derksen & K. Horstman. Engineering Flesh. Towards an Ethics of Lived Integrity. Med Health Care Philos 11(3), 2008: 269-283.
26. K.A. Bramstedt. Replying to Veach's Concerns: Special Moral Problems with Total Artificial Heart Inactivation. Death Stud 2003; 27: 317-320.
27. T. Powell. LVADs and the Limits of Autonomy. Hastings Cent Rep 2008; 38(3): 4-5.
28. In fact, this is a reply written jointly by Fischbach and Simon, but for the sake of the argument I will present it here as Simon's opinion, because it is not completely clear why Fischbach should agree with all its implications, see e.g.: 'Simon believes that the line between pacemaker and transplant has been crossed with destination LVADs. Fischbach does not agree.'.
29. J.R. Simon & R.L. Fischbach. Reply to Powell. Hastings Cent Rep 2008: 38(3): 4-5.
30. Because the patient's heart was already severely damaged prior to implantation of the device, the patient's death is due to underlying cardiac disease just as when the ventilator is withdrawn, the patient dies of impaired lung function.' (p. 1186).
31. I wish to thank an anonymous referee for this remark.
32. However, some polio survivors and many other people with permanent respiratory problems are supported 24 hours per day by mobile ventilators. These ventilators are not in hospital, but owned by the patient and transportable (often on the patient's wheel chair). I wish to thank an anonymous referee for pointing this out to me.
33. However, the formulation of a 'natural death' pervades the literature.
34. '[.] [I]nformed consent for implantation should explicitly indicate that inactivation of the device may in a small way contribute to the death of the patient.'.
35. 2006 Dudzinski goes into the same direction as Fischbach 2008 and Bramstedt & Wenger 2001, cf. Dudzinski 2008: 'deactivation is not [active, FK] euthanasia because the therapeutic goal is patient comfort, not hastened death'.
36. For an alternative understanding of 'hybrid': 'LVADs present a hybrid of these scenarios, in that these devices may be powered off without explantation for discontinuation of therapy.'.
37. F. Sveneaus. The Hermeneutics of Medicine and the Phenomenology of Health. 1999. Dordrecht: Kluwer.
38. M. Merleau-Ponty. 1962. The Phenomenology of Perception (1945), translated by C. Smith. New York: Humanities Press.
39. D.W. Smith. Phenomenology. Stanford Encyclopedia of Philosophy, last changed 2008, http://plato.stanford.edu/entries/phenomenology/#5 [accessed 3 April 2010].
40. Due to the lack of any phenomenological accounts, at this point, this is mere speculation.
41. L. Nancy. L'intrus. 2010. Paris: Editions Galilée.
42. Other issues surround the empirical evidence that a device that used to be opaque can successively gain transparency for the user. For positive opacity.
43. About the scope and contents of such guidelines. A phenomenological account is understood as being descriptive here, because it describes the 'lived experience' of patients and doctors in the context of the use of LVADs. From this, it does not follow immediately how things should be and how one should act. However, an understanding what a certain situation is like for a doctor and patient can certainly provide a future normative debate with valuable input.
44. B. Herrmann. 2007. Die normative Relevanz der körperlichen Verfasstheit zwischen Selbst- und Fremdverfügung, Kommerzialisierung des menschlichen Körpers, J. Taupitz, ed., Berlin/Heidelberg: Springer: 173-184.
45. Accordingly, one could even ask whether the starting point of the discussion should rather be the distinction between voluntary and involuntary euthanasia instead of the Acts-Omissions Doctrine (AOD), being even more obviously linked to the problem of autonomy. However, the legal system in numerous countries still operates on it. For instance, in the US law you still find the distinction between active and passive euthanasia. Further, the debate in the Hastings Center Report that is discussed here starts out from the assumption that the AOD is valid, and both authors involved take sides in the debate.
46. 'It is the patient or surrogate's assessment of what is beneficial that dictates the ethical permissibility of deactivation.'.
47. Y. Mak. Patients' Voices Are Needed in Debates on Euthanasia. Br Med J 2003; 327 (7408): 213-215.
48. W. Houkes & A.W.M. Meijers. The Ontology of Artefacts: The Hard Problem. Stud Hist Philos Sci Part A 2006; 37(1): 118-131.
49. Simon and Fischbach are sensitive to phenomenological accounts and the 'voice of the patients'. For the sake of the argument, this article works with an oversimplified opposition between ontological and phenomenological accounts.
50. Future research could analyse that being internal or external of the human body is a dispositional property that is actualized by means of the respective phenomenological content (i.e. as what the patient perceives it).
51. M.-H. Derksen, 2008. Engineering Flesh, Towards Professional Responsibility for 'Lived Bodies' in Tissue Engineering. Eindhoven/Delft: Simon Stevin Series in the Ethics of Technology: 165-175.