I wonder if the philosophy (ethics) of termination of any life-support particularly if it doesn't contribute to some reasonable quality of life which the patient might expect or want is that the act is really unethical. I write this because such termination is ethical in the United States. If the patient is in no capacity to express at the time what quality of life the patient desires and has no capacity at the time to express their decision as to whether to undergo a procedure to reinsert fresh batteries and have the pacemaker continue functioning, then, without prior instructions from the patient when competent, "best-interest" is the decision that the surrogate has to make: "what would the average person in this patient's condition would have wanted to be done or not done?" From the ethics point of view, the decision has to be made with regard primarily to the patient's want and not the want of the surrogate or the want of society. Now, of course, in catastrophic situations within the social environment (such as an influenza pandemic), triage may be essential when resources (such as ventilators) are limited and in that case, the benefit to society of best use of resources may be the governing ethic.

With regard to laws, in the United States, a patient's desire, as expressed directly or through the "substituted judgment" by the legal surrogate, to terminate life-supportive treatment is now permissible under Constitutional law. When such expression is not available and a decision has to be made under "best interest", a not uncommon occurrence facing most hospital ethics committees, these decisions, made under a formal protocol, are carried out regularly without legal consequences. At least, so far. ..Maurice.

Maurice,

Thanks once again for raising difficult ethical and moral dilemma.

It is difficult to put such decisions and choices into words. The difficulty is that unintentionally by focusing on the terminally ill old person, one is being led into the obvious choice of termination. But if instead of an old person, it was in the early part of life as babies, the parents choice will be to keep the life support system. For politician like Ariel Sharon in coma, the question has never been discussed in the media. My main worry is that it may lead to cases where hospitals use it as unofficial policy to free beds for new patients, rich or well connected politicians or to increase turnover?

A physician who is the surrogate and makes a decision for the parent who has no capacity to make their own is, of course,is not "professionally treating" but making a legal and ethical "substituted judgment." This judgment must be made in the best interest of the patient and/or the patient's previously expressed desires and not the best interest of the family or anyone else. That means to cone down on the issue, is the benefit to the patient to continue to maintain functioning of the pacemaker the same as the presumed benefit for quality of life with the further life offered the patient when the pacemaker was initially implanted? If the patient now no longer has the chance to receive that benefit because of marked deterioration of mental functioning and awareness, then there would be a good ethical argument for not installing fresh batteries. It is only that question to be answered to make the decision rather than the consideration of other issues such as resource allocation and costs which would not be directly related to the patient's best interest. Given the information I provided would be inadequate for me to make the decision regarding what "severe Alzheimer's disease" meant in terms of alertness, recognition and communication as well as other needed mental functions. Would I "dare refuse to have the batteries replaced"? I would refuse if my mother was no longer awake or able to participate or apparently enjoy activities of being alive.

Failure to replace failing batteries in a life-supportive treatment can, perhaps, be looked at as a different act from an ethical point of view than removing the batteries or pacemaker itself with the intent to terminate an ongoing perhaps life-supporting treatment. It can be looked upon as a given opportunity to, by immediate necessity, re-evaluate benefit, since in this case the decision would be either to replace or not replace. Turning off a yet functioning pacemaker is not the result of a the unintended required choice of alternatives to the ongoing therapy but the direct intention, prematurely, to end treatment in progress. Both conclusions to decision-making should be based, as noted above, on the patient's best interest and/or based on what is known of the patient's previous desires. Of interest, ethically, in neither case may the acts be considered "killing" since the death, if it did occur after the act, would have been due to the underlying heart disease and not any life-supportive mechanism which was terminated.. or at least that is one way of looking at the death if it did occur. ..Maurice.

It should be noted by all that a cardiac pacemaker is a tool to relieve cardiac symptoms and may not necessarily prevent death and which which actually may occur from other causes and not necessarily related primarily to the heart.. This is different than a cardiac defibrillator which interrupts potentially fatal acute ventricular fibrillation attack which if left untreated will be fatal. One could say that failing to restore the function of the cardiac pacemaker does not have the same immediate anti-death benefit than failing to restore function of a defibrillator. ...Maurice.