This paper addresses a dichotomy in the attitudes of some clinicians and bioethicists regarding whether there is a moral difference between deactivating a cardiac pacemaker in a highly dependent patient at the end of life, as opposed to standard cases of withdrawal of treatment. Although many clinicians hold that there is a difference, some bioethicists maintain that the two sorts of cases are morally equivalent. The author explores one potential morally significant point of difference between pacemakers and certain other life-sustaining treatments: specifically, that the former are biofixtures, which become part of the patient in a way that the latter do not. The concept of the pacemaker as biofixture grants pacemakers a unique moral status that gives reason to treat a pacemaker the same as other parts of the patient that are necessary to sustain life. The author employs this biofixture analysis to affirm the intuition that deactivating a pacemaker in a highly dependent patient at the end of life is, in moral terms, more analogous to active euthanasia than it is to standard cases of withdrawal of treatment. The paper concludes with consideration of potential implications for further implantable medical technologies, such as ventricular assist devices and total artificial hearts.

Background: Children with decompensated heart failure are at high risk for arrhythmias, and ventricular assist device placement is becoming a more common treatment strategy. The impact of ventricular assist devices on arrhythmias and how arrhythmias affect the clinical course of this population are not well described. Methods and results: A single-centre retrospective analysis of children receiving a ventricular assist device between 1998 and 2011 was performed. In all, 45 patients received 56 ventricular assist devices. The median age at initial placement was 13 years (interquartile range 6–15). The median duration of support was 10 days (range 2–260). The aetiology of heart failure included cardiomyopathy, transplant rejection, myocarditis, and congenital heart disease. In all, 32 patients (71%) had an arrhythmia; 19 patients (42%) had an arrhythmia before ventricular assist device and eight patients (18%) developed new arrhythmias on ventricular assist device. Ventricular tachycardia was most common (25/32, 78%). There was no correlation between arrhythmia and risk of death or transplantation (p=0.14). Of the 15 patients who weaned from ventricular assist device, post-ventricular assist device arrhythmias occurred in nine (60%), with five (33%) having their first arrhythmia after weaning. Patients with ventricular dysfunction after ventricular assist device were more likely to have arrhythmias (p<0.02). Conclusions: Arrhythmias, especially ventricular, are common in children requiring ventricular assist device. They frequently persist for those able to wean from ventricular assist device.