Heart Pump Creates Life-Death Ethical Dilemmas

"I was in pretty bad shape before this," said Clarence Horton, 64, of Edgewater Park, N.J., who recently received an LVAD. "I was very short of breath. I couldn't move around. I was on my way out. Now I feel 200 percent better."

Recipients, however, are prone to complications, including infections from the power line that protrudes from the skin, as well as strokes caused by clots that can form in the pumps. As more patients receive the devices, inevitably the risks outweigh the benefits for some, or the benefits are overtaken by complications.

"The hardest thing to grapple with is these patients often are not asking for relief from any acute distress, per se, but are asking for relief from the burdens of a life dependent on an artificial technology," said Scott D. Halpern, a bioethicist at the University of Pennsylvania. In some cases, patients wake up to discover that an LVAD has been implanted in an emergency.

Said Mary Lou O'Hara, who coordinates LVAD care for the University of Pennsylvania Health System: "Some patients go into this with their eyes wide open and others have an acute event and wake up with the device. It can be very challenging for individuals who don't have the coping skills to deal with it."

Most doctors and bioethicists equate the devices to ventilators, feeding tubes and other forms of life support that patients or their families have the right to discontinue if they believe they are fruitless or if their quality of life deteriorates.

"We need to respect the free will and autonomy of patients," said Timothy W. Kirk, a bioethicist at Villanova University. "It is not assisted suicide or euthanasia, because what's killing them is the underlying disease."

The devices are discontinued only after patients are evaluated emotionally and physically, all alternatives have been explored, and ethicists and family members are consulted, experts say.

"You want to rule out the idea that they are acutely depressed or there is an acute event that right now makes life look pretty grim but that they may get past," said Michael Petty, a nurse who works with LVAD patients at the University of Minnesota Medical Center, Fairview.

While agreeing that patients can decide to discontinue their LVADs, some say that the devices raise unique issues.

"This is unlike anything else we deactivate," said James Kirkpatrick, a cardiologist and ethicist at the University of Pennsylvania. "When you turn off an LVAD, it can make the person worse. You can basically worsen the heart function. So you're not just stopping something and letting nature take its course. You're actually doing harm, potentially."

But Simon and others go further, arguing that the technology represents something entirely different from other forms of life support.

"Once a patient leaves the hospital, the LVAD ceases to be a medical treatment and becomes effectively part of the patient himself, much like a transplanted organ or even a native one," Simon wrote in the January-February issue of the Hastings Center Report, which is published by the Hastings Center, a bioethics think tank. "We would not remove a patient's biological heart, transplanted or native, simply because the patient was suffering greatly from heart failure and did not want to go on; nor should we disable his LVAD."