The Total Artificial Heart: A Change of Heart

 The first total artificial heart (TAH) was implanted in a person in 1982, and since then has been used to help extend human life. The total artificial heart is a new medical innovation that replaces the ventricles of the heart while one waits for a biological heart transplant. It is used as a “last resort” device after all other forms of treatment have failed. Although this device could save many lives, it is very costly and decreases one’s quality of life. The quality of life of a patient is determined based on the patient’s attitude towards life. A high quality of life would be judged if the patient is truly satisfied with their life, regarding health, family, wealth, education, and possible religious beliefs. After receiving an artificial heart, one is closely monitored in the intensive care unit of the hospital and provided with medicine to prevent infection and malfunction. This paper will focus on the ethical implications involving the case study of Mr. N, which reveals a man who wished to deactivate his TAH due to his low quality of life. Mr. N believes that his life is no longer worth living due to the previous suffering he has endured. Twelve years before receiving the TAH, Mr. N’s heart failed and he was implanted with a HeartMate II left ventricular assist device (VAD) to keep him alive while he waited for a biological heart. The LVAD (left ventricular assist device) works by attaching to the heart and vessels. Both a VAD and a TAH may be used to allow for an extension of one’s live while waiting for a biological heart transplant. Even though there is a law which states a patient has the right to refuse lifesaving treatments when the burdens exceed the benefits, it has not been authorized when deactivating a medical circulatory support (MCS) device. Therefore, how should one handle deactivating a total artificial heart? Is it ethically permissible? Would deactivating such a device be viewed as murdering the patient, or just respecting their consent?


Introduction

This paper will focus on a new medical innovation, the Total Artificial Heart (TAH), but specifically focusing on the question is it ethically permissible to deactivate the device upon request. The TAH is a type of mechanical circulatory support (MCS), and other types include ventricular assist devices  (VAD) and pacemakers. These devices help support a failed heart so it is able to pump enough blood efficiently throughout the entire body. However, the TAH replaces the entire heart, which is different than the other MCS devices as one’s failing heart remains and the devices typically attach to the original heart. The first TAH (TAH) was implanted in a person in 1982, and since then has been used to help extend human life. The TAH is a device that replaces the ventricles of the heart while one waits for a biological heart transplant. It is used as a “last resort” device after all other forms of treatment have failed. Although this device could save many lives, it is very costly and decreases one’s quality of life. The quality of life of a patient is determined based on the patient’s attitude towards life. A high quality of life would be judged if the patient is truly satisfied with their life, regarding health, family, wealth, education, and possible religious beliefs.

The TAH is an essential innovation that will help save many lives, since every ten minutes, someone is added to the national transplant list, and on average 20 people die a day waiting for a transplant (Organ Donation Statistics). After receiving an artificial heart, one is closely monitored in the intensive care unit of the hospital and provided with medicine to prevent infection and malfunction. Although the TAH saves many lives, there are case where one wishes to deactivate it. This paper will be investigating the situation of a man by the name of Mr. N who wished to deactivate his TAH. Even though there is a law which states a patient has the right to refuse lifesaving treatments when the burdens exceed the benefits, it has not been addressed as legally acceptable when deactivating a medical circulatory support (MCS) device. Although deactivations have taken place before, there are no specific rules and regulations relating to deactivating a TAH. It is a highly controversial topic, as many different people have firm opinions on what they believe is ethical or unethical. Often, the values of autonomy and responsible come into play, as one ponders the responsibility of the doctor treating the patient and the autonomous patient. Therefore, how should one handle deactivating a TAH? Under what conditions, if any, is doing so ethically permissible?   

 

The Process of Organ Donation

The TAH is mainly used while one is waiting on the heart transplant list and waiting to receive a biological heart. This medical innovation helps prolong the life of one, as they might not be able to wait for an extended period of time for a new, healthy organ. Organ transplants are when a person, who is either living or dead, donates their organs to another person or multiple people. There are many qualifications that one must meet in order to become eligible to receive a healthy, potential life saving organ. First, a person must get a referral from their doctor after it is discovered an organ transplant will be needed. The next step is for the patient to become educated about the process, and the fiances, recovery, and all the other information surrounding it. The third step is then choosing where the operation will take place when the time eventually comes. Next, the person will be instructed to make an evaluation appointment with their transplant center. This appointment will give them the chance to get to know the transplant team and the people that will be assisting them during the transplantation. Lastly, the transplant team will then come to the final conclusion and decide if the person is truly a good recipient for an organ. The person will be notified within ten days if they are a good fit, and if so, the operation will take place as soon as possible.

After the doctors and the transplant team comes to the conclusion that a transplant will be the best option for a patient, there must be consent between the patient and the doctor to be placed on the national organ transplant list. When these patients are “listed for transplant,” they are placed on the national waiting list, which is regulated and maintained by the United Network of Organ Sharing, otherwise known as UNOS. Some basic information needed when entering data into the database is blood type, body size, and clinical status. Donor hearts are distributed by the UNOS and the regional organ procurement organization, which is the Gift of Life Donor Program. In order to be a donor, one must have a suitable blood type for the recipient and be about the same size as the previous recipient organ. The different blood type groups are A, B, A/B and O.

When waiting for a heart transplant on the national transplant list, there are four UNOS classifications which are determined based on the condition of the recipient. The first group is Status 1A, and this is a group where one is placed if a heart transplant is needed urgently. The qualifications to be placed in this group include intensive care hospitalization, life-supporting measures, and mechanical-assist device(s) (Penn Medicine). This includes if one is being supported by a VAD or a TAH. The second group that one waiting for a heart transplant can be placed in is Status 1B. The qualifications for this group include that one has to be dependent on intravenous medications or a mechanical-assist device, either at the hospital or at home. The difference between being placed in Status 1B or 1A when one is using a TAH is if they meet all of the qualifications listed. Both 1A and 1B listed waiting recipients are in need of immediate attention to receive this life saving organ. The third group is Status 2, which one is placed in if they are “stable on oral medications and able to wait at home” (Penn Medicine). Lastly, the final group that one can be placed in while waiting to receive a heart transplant is Status 7, which is an inactive list. This list is inactive because of a change in the condition of the patient.

There are different wait times depending on the organ; the wait can either be a few months or a few years. When one has an artificial heart, they are typically waiting for a biological heart transplant, in which the wait time is around six months. There are exceptions, however, where one remains the rest of their life on a TAH, even though the life span at this point is not very long, and only at a maximum of four years. One crucial aspect to consider when receiving an organ donation is the distance between where the organ donor is and the organ recipient. Certain organs can only last for specific times outside of the body, and the quicker the recipient receives the organ, the better. Therefore, if the distance is too great between these two people, then the transplant cannot occur. The heart can only last 4-6 hours outside of the body, which by comparison to other organ times is a lot less (Kessel).

This is where the artificial heart steps in, as it serves as an answer to the common question asked of “what happens if one needs an organ immediately and cannot afford waiting for a period of time, or there are not enough organ donations available for transplantation?” The TAH will save many lives, since heart failure is the leading cause of death in both women and men; 610,000 people die a year due to it (“Heart Disease”).  Having this artificial heart will allow for a patient to remain alive even after one’s heart has failed. The TAH could help reduce this number by prolonging life for someone while they are waiting to receive a biological heart, or even under certain circumstances remain the rest of their life on an artificial heart.

 

Background Information on the TAH

Before diving into how a TAH works and the logistics, it is important to understand how a regular, biological heart functions in the body. The heart is an organ which is part of the circulatory system in your body which consists of one’s heart and blood vessels.The heart has 4 chambers: 2 ventricles and 2 atrias. The atrias drain and squeeze blood into the ventricles, whereas the ventricles squeeze blood through the heart and then to the blood vessels. The heart is divided into left and right halves: left atrium, left ventricle, right atrium, and right ventricle. The right atrium and ventricle carry deoxygenated blood to the lungs. The left atrium and ventricle receive oxygenated blood that is carried to the entire body. When implanting a TAH, we are mainly focusing on the ventricles and the heart valves. The main, most popular artificial heart, known as the SynCardia, replaces both lower chambers of one’s heart, otherwise known as the left and right ventricles, as well as the four heart valves (SynCardia). Replacing all of these different parts of the heart helps terminate the symptoms and eradicates the source of the original heart failure.

The process of getting a TAH implanted is similar to the process of receiving a biological heart transplant. It is important when undergoing this surgery to do so as soon as possible so increased blood flow does not cause any harm to any crucial organs. According to SynCardia.com, “the  day your failing heart is the day your recovery from heart failure can begin.” The procedure of getting a TAH implanted can last anywhere from 5-9 hours and requires specific, specialized surgeons, surgical nurses, perfusionists, and trained professions to assemble the TAH and to check if it is working properly. The surgery begins by removing the ventricles of the original, biological heart. Once the ventricles are removed, the surgeons attach the TAH to the upper chambers of the heart. After the implant is complete, the heart-lung machine that was aiding the biological heart in pumping before the implant will be turned off, and the artificial heart will take over.

The TAH is a medical innovation that is used as a last-minute resort for end-stage biventricular failure that can be used to prolong the life of one whose heart failed. When one’s heart fails, the heart muscle becomes weaker and is unable to pump blood effectively. There are a few different types of artificial hearts that are available for use. The most common artificial heart is the SynCardia temporary TAH. This artificial heart is the first and remains the only FDA, Health Canada, and CE (in Europe) approved artificial heart; yet as of 2014 there are now 13 different types of artificial hearts. For this paper, I will be mainly focusing on the SynCardia. The other common types of artificial hearts include the Abiocor TAH and the CardioWest TAH. They are both incredibly similar, with the main difference being that the Abiocor TAH remains charged with a magnetic charger, whereas the CardioWest TAH is attached to an external power source, otherwise known as a driver. One will be able to do activities with both types of artificial hearts, yet with the Abiocor it is important to have the magnetic charger at all times. For the CardioWest TAH, it is portable as the external power source has wheels, so one will be able to walk around and complete some restricted activities.

The SynCardia, the most popular type of artificial heart, mimics and is very similar to a heart transplant. In contrast to a biological heart, this artificial heart is available right away at SynCardia certified centers. There are two different models of SynCardia one with end-stage heart failure can obtain: the 70cc and the 50cc Syncardia. Typically, it is noted that the 70cc SynCardia is capable of pumping at an average of seven liters of blood per minute and is able to reach 9.5 liters of blood per minute at maximum. The other model, the 50cc SynCardia, is able to meet the rate of blood that a biological heart can pump at around five liters per minute and can reach a maximum at 7.5 liters of blood per minute. In comparison, the average biological heart pumps around five liters of blood per minute on average. According to SynCardia.com, it is recorded that “many doctors and families have described watching patients and loved ones turn from a sickly grey to a healthier pink as the SynCardia TAH restores blood flow to their bodies and vital organs.” This increase in blood flow is essential to aid the recovery of crucial organs, which helps the patient become a better applicant for receiving a biological heart.

As of now, the SynCardia and artificial hearts are used as temporary devices for one while they are waiting for a biological heart transplant. The average a person survives while living with an artificial heart is one year. Although, the longest person reported to be on the SynCardia was for more than four years, and there has been no reports to date of the artificial heart failing and not functioning properly. The diaphragm, a portion of the artificial heart that is responsible for pumping the blood in and out of the ventricles, has more than a 99.99% success rate. Once one is implanted with an artificial heart and are considered stable, these patients are then listed as the United Network for Organ Sharing Status 1A and will be moved to the top of the transplant list (ColumbiaSurgery.org, 2017). The UNOS status code 1A is “designated for candidates on the waiting list who have the highest priority on the basis of medical urgency” (Bogaev 2011).

 

Medical Advancements / Downsides

Surprisingly, there are actually a few advantages that an artificial heart has over receiving a biological heart, although the activity that one will be able to do will be restricted. The main advantage of receiving an artificial heart is that it prolongs the life of a patient. It does so by replacing the failed heart’s ventricles and keeps the blood throughout the body pumping, as the body needs a certain amount of blood to survive. Prolonging the life of a patient by using the artificial heart helps extend their chance of eventually receiving a biological heart transplant, since the number of biological heart’s available are so scarce. There is the possibility that one day there will be a healthy, heart available for transplantation.

Another essential advantage of an artificial heart is that it is available when it is needed right away, as there is no waiting list. When one’s heart fails, there is limited time in which the patient may not be able to wait six months for a biological heart transplant, and will need some type of device to pump blood efficiently and effectively. Another positive upside of receiving a SynCardia instead of a biological heart is that it is not restricted by blood type or antibody levels, as matching these are not required as they are in a biological heart transplant. This allows the SynCardia artificial heart to be compatible with any type of body. As mentioned previously, there is a tremendous increase of blood flow when one receives a TAH typically, which allows for the body to quickly recover from initially not receiving enough blood. For some, the idea of having your heart removed may seem somewhat scary and frightening, yet in reality it is truly not very different than the process of receiving a biological heart transplant.

Although this device can help prolong one’s life, there are downsides to receiving one. There are many possible risks that come with receiving a TAH. One risk is developing blood clots and having potential bleeding. Since it’s not a natural part of the body, the blood tends to clot more easily, and there could be potential bleeding during and after the surgery. Another risk is potential inflection or malfunction. With these permanent tools running through one’s body, the risk of infection is very high. However, no medications or anti-rejection medication is needed prior to receiving a TAH, since it is biocompatible with the body (Syncardia). Lastly, there is always a slight possibility of device malfunction, as the power may fail or the pumping may not be right. It is important to keep in mind that it is a technological device and there is that risk one must take where technology does not always works 100% perfectly and effectively, as one is putting all of their trust into a machine.

Another major downside of receiving an artificial heart, such as the SynCardia, is that it does restore one’s life forever. It simply extends the life of the patient, as the main purpose is to do so while waiting to receive a biological heart transplant. Although some spend the rest of their life on an artificial heart, the lifespan of one who is on a SynCardia TAH is not very long. The longest individual who has used this device has lasted four years. It is also very expensive to acquire an artificial heart; the price can range from low 100,000 dollars to a possible 300,000 dollars. Medicare, welfare, and health care expenses would help cover for artificial hearts, yet the majority of the payment is on the individual. This is incredibly expensive, as the average household income in America is around 81,000 dollars, just to put it in perspective (Wikipedia, 2018).

In general, the SynCardia artificial heart has a positive effect on one’s life is the procedure and implantation all goes smoothly. There are few downsides to the possible effect of one’s quality of life, which is defined a one’s perception of life which can either be positive or negative, yet the benefits truly outweigh the burdens. One burden is that the percentage of people who return back to work after receiving an artificial heart is 20-25 percent. This is because the artificial heart leaves the body prone to infections. For many, this can cause a potential decrease of quality of life as many people pursue their passions while at work, and may impact one’s income.

 

Case Study Introduction

To further understand the ethical implications of deactivating a TAH, the rest of this paper will be investigating a case study surrounding a man who wished to deactivate his SynCardia TAH due to his low quality of life. Mr. N, a patient who has just received his second artificial heart, wished to die and have his artificial heart deactivated. 12 years prior to his wish of deactivating his TAH, Mr. N obtained viral myocarditis which caused his heart to fail. He was hospitalized for a year and was implanted with a HeartMate II left ventricular assist device (VAD) (Thoratex Corp) to keep him alive before he received a biological heart transplant. This transplant was successful, and he lived happily and healthy for 10 years. Yet after these ten healthy years, Mr. N started showing signs of post transplant vasculopathy, which limits long term survival after receiving a heart transplant. After showing signs of this, he was put back on the biological heart transplant list to receive a new heart. He continued to suffer from this and cardiac dysfunction, so therefore turned to the SynCardia TAH to prolong his life while he waited on the heart list once again. Five months after receiving his new TAH, he requested deactivation and was well aware and educated that this would result in an immediate death. Mr. N believes he has gone through enough suffering between the multiple surgeries he has undergone and his current low quality of life on his artificial heart. The question that this paper will be investigating is: do you think that Mr. N should be able to deactivate his artificial heart?

It is important to note that Mr. N’s quality of life was viewed as very poor:

“His postoperative course was complicated by renal failure requiring dialysis and hemorrhagic pancreatitis requiring no oral intake and total parenteral nutrition dependency. Liver dysfunction led to jaundice and GI bleeding, requiring multiple blood transfusions. He also received a tracheostomy for postoperative respiratory failure. Due to comorbidities and high antibody titers, he was removed from the transplant list pending further recovery.”

After five months of having the SynCardia TAH, Mr. N yearned to be removed off the heart transplant list since he wanted to end his suffering and would rather die than live with a low quality of life and the artificial heart. He was educated and aware that by removing this device, it would result in instant death. He was also deemed competent, which implies that he was completely mentally aware. When a patient is competent, it allows for him/her to be fully autonomous, and can allow them to make their own decisions regarding their body.

Deactivating an artificial heart is a quite a complex process, as many factors must go into it before official deactivation. The deactivation of  TAH would usually occur at the hospital, and not typically at one’s home. This is because the doctors have a moral obligation to not abandon his/her patient. However, if a medical professional does not feel comfortable and object with deactivating the TAH, then they would not be forced to follow through with the procedure. If a member who is willing to perform the deactivation cannot be found, the patient’s wishes should be valued higher than the medical professional’s objections. Lastly, this deactivation should take place when many people are present, and the family is informed and educated of the process of deactivation. It is noted that family participation leading up to the death should be encouraged; the patient should be addressed if they have any death wishes.

Initially, there was opposition for the “right to die” as the states wanted to preserve the life of their patients, limit suicide rates, and to protect other parties that will be effected from the death (ex: children). However, these arguments are often ignored in the case of a patient being terminal ill, or has very little hope of improvement in health. The American Medical Association, along with many other national associations, considers the patient’s autonomy and that there may be a request to discontinue life saving technologies. Natural Death Acts often include a “conscientious objection” exemption that allows physicians to exempt from discontinuing a life saving treatment if it objects with their moral or religious values. To accommodate for the patient, a transfer to another hospital or another physician who is willing to perform the task may be called upon. Although there are many regulations surrounding Natural Death Acts, there is no distinct clarification of withholding and discontinuing life supporting devices, such as an artificial heart.

When coming to the conclusion of whether or not deactivating a TAH is ethical or not, it is crucial to evaluate the difference between an immediate death and a natural death. In this specific case, an immediate death could be viewed as directly killing the patient. Once the TAH is removed, it will instantly result in death since the heart will fail. Therefore, this will not be deemed as a natural cause of death, and that one took action on the patient to essentially murder them. Yet, a death after a few days is deemed as a natural cause of death. If this was another life saving technology, for example a dialysis machine, one would have a few days after removing before death. Eventually the disease will cause the liver, in the previous example, will result in heart failure, which will lead to death.

 

Responsibility

Deactivating the artificial heart could be seen as directly murdering the patient, as it will result in an instantaneous death. The doctors have a moral responsibility to“do no harm” to their patient they are treating when they take the Hippocratic oath.  According to the Oxford English Dictionary, the Hippocratic oath is “an oath stating the obligations and proper conduct of doctors, formerly taken by those beginning medical practice.” The word “harm” is defined as a “physical injury, especially that which is deliberately inflicted” (Oxford English Dictionary). All medical professionals must abide by this Hippocratic oath, as they are sworn to follow it when treating a patient. The role of the medical professional is to ensure the patient is receiving treatment which will maintain their life and hopefully return them to their happy, healthy state. However, this is a slippery slope because by not deactivating the artificial heart, can that be causing more harm to the patient?

It is important to consider the responsibility of the doctor to cause no harm and follow nonmaleficence. Without the artificial heart, the patient would no longer be alive. All medical professionals have to abide by the Hippocratic oath, which states that the doctor must do no harm to the patient they are treating. There is an obligation that the doctors treat the patient; without the TAH the patient would have a very limited chance of survival, and would most likely result in death. They have available a new life saving treatment to help sustain the life of the patient, and the medical professionals want to put it to good use. There is also the slight change of uncertainty within the patient, and that one day they will receive a biological heart, return to a slightly altered version of their old life, and will no longer need the TAH. As well as the possibility of uncertainty, there is the chance of regret that the patient, specifically Mr. N in our case, may feel if he chooses to end his life. Once receiving a biological heart transplant, the patient’s quality of life would be restored as they would be able to perform similar activities as they were before their heart failure. It is important to keep in mind that if Mr. N deactivates his SynCardia TAH, he is not the only one being affected by this decision; his family and friends will feel the effect as well. Keeping Mr. N on the SynCardia artificial heart will ultimately cure their heart failure and provides a patient the possibility of returning back to their previous life.

As of now, there are no laws which clearly state if it is ethical for a doctor to deactivate an artificial heart by the request of a patient. This medical innovation has the power to either extend a patient’s life or end it with the help of a doctor. However, the deactivation is a highly controversial issue, as it is a similar ethical dilemma to assisted suicide, where a doctor has the ability to essentially murder the patient with their consent. In the case study introduced, the doctor technically has the power to deactivate the artificial heart to end the patient’s life, yet morally it could be viewed as unethical and possibly a direct form of murdering the patient.

Dr. Robert Veatch is an example of a man who believes that removing the TAH is a direct form of killing. Dr. Veatch is a professor at the Medical Ethics of Georgetown and is a research scholar (Kennedy Institute of Ethics). He mainly focuses on the ethics surrounding transplantation and death. He argues that according to the legal definition of death in the United States, deactivating an artificial heart is directly murdering the patient. The definition of death in the United States is noted as the “irreversible stoppage of either all functions of the entire brain or irreversible stoppage of cardiac function.” This clearly states that death occurs immediately when the heart can no longer beat, which is what will occur once the TAH is deactivated. Once the deactivation occurs, there is no going back, as the action cannot be undone. When the switch is turned off on an artificial heart, the mechanical device will shut down and will stop the blood flow, as it will no longer pump blood throughout the body. Due to the body not receiving blood flow and oxygen provided by the blood cells, death will occur. Therefore, Veatch believes in order to deactivate an artificial heart, there must change the definition of death or official legalize the removal of the TAH for it to not be seen as a form of directly killing the patient. He argues that it is not ethical to deactivate such a device upon the request of the patient.

Dr. Veatch also believes that “throwing a switch that stops a TAH could be considered active killing of a patient” since the death is instantaneous and not natural. A natural death is defined as a death occurring in the course of nature and from natural causes, as age or disease, as opposed to accident or violence (Merriam Webster Dictionary 2018). In contrast, a non natural death is caused by external causes, such as turning off the switch to an artificial heart (The Free Medical Dictionary 2018). Dr. Veatch is a firm believer that instantly switching the switch to a device like the TAH is identical to injecting a drug, a lethal injection, which can paralyze the heart muscle and result in an immediate death. As mentioned previously, he believes the only way it would be remotely ethical to deactivate a device would be if there was an alteration in these definitions. One parallel, yet a slightly different situation to deactivating the SynCardia TAH is the removal of a dialysis machine. If one is using a dialysis machine and then chooses to be taken off of it, the patient will then survive for a couple of days after being removed from the dialysis machine. It will then be deemed that the patient died of a natural death due to the original kidney disease causing the heart to stop beating. According to Veatch, “it is sufficiently convincing that the American Medical Association, most religious groups, and the courts all accept the claim that the patient died a natural death” (Robert M. Veatch 2002).

In conclusion, Dr. Veatch believes that “throwing a switch that stops a TAH could be considered active killing of a patient” since the death is instantaneous and not natural. Relating to the sample kidney case introduced above, Dr. Veatch is a firm believer that instantly switching the switch to a device like the TAH is identical to injecting a drug, a lethal injection, which can paralyze the heart muscle and result in an immediate death. However, I believe the TAH could make us question what is truly considered to be a “natural death,” as the device itself would not be considered “natural” and is made by artificial means. Initially, one is inflicting on their “natural death” by using a TAH, so I believe these definitions be reconsidered when dealing with such a device. Nonetheless, Dr. Veatch deems that deactivating such a device like the SynCardia TAH is completely unethical.

 

Autonomy

The opposing side to this argument considers the value of autonomy and argues that removing the TAH is not a direct form of killing, as the patient has the right to make their own decisions regarding their body. The concept of nonmaleficence is extremely prevalent in this case study. According to Regis University, the principle of nonmaleficence is described as “we should act in ways that do not inflict evil or cause harm to others.” As described earlier, Mr. N is experiencing a low quality of life and feels he has gone through enough suffering. This brings us to the “slippery slope” question: although doctors have an obligation to do no harm, is it causing more harm to Mr. N to keep him on the artificial heart? How does one go about measuring the harm of a patient?

It is also important to note that Mr. N was fully mentally aware and was not depressed, which deems his competence and shows he was capable of making this life changing decision. Competency is the ability to make a decision for yourself, as it is important to make sure one is mentally stable and not under the influence of alcohol, drugs, etc. when making critical decisions. A competent person is able to recognize the hazards associated with a decision, and takes those into consideration when deciding the final outcome. It is required for a patient to be competent when autonomous. In this case study, the patient Mr. N was deemed competent and mentally stable, and therefore the ability to make this life changing decision was allowed to be placed in his hands. He stayed constant in his belief to disable himself from the artificial heart, and clearly stated that if there was a biological heart available for him at the moment he would not accept it and would still wish to die. Mr. N believed that the burdens exceeded the benefits of living with this artificial heart. However, even though there is a law which states a patient has the right to refuse lifesaving treatments when the burdens exceed or are equal to the benefits, it has not been authorized when deactivating a medical circulatory support device, such as an artificial heart.

Katrina Bramstedt is an example of a woman who is a firm believer that deactivating the artificial heart is not directly killing the patient and is therefore just respecting the desired wishes of the patient. Bramstedt, one of the few formally trained transplant ethicists, believes the decision should be made by the physician through thorough discussion with the patient, the surrogate, and the patient’s medical team (Transplant Ethics). She also addresses the issue of how this could potentially go against the values of the doctor. If a physician does not feel comfortable performing the act of deactivating the device, they may call on another physician to complete the tasks. Bramstedt quotes: “if physicians are morally uncomfortable with a patient’s request, they can arrange transfer of care to another physician or facility that will follow through with what they believe to be the “inappropriate” request.” Lastly, she counter argues Veatch’s statement that removing the artificial heart is directly killing the patient, and states that it is the patient’s underlying disease is what causes the death when the TAH therapy comes to an end. The TAH is used while waiting for a transplant, but if one refuses the transplant it seen as natural death and will let disease play its course.

Mr. N’s specific case allowed his wish of deactivation to become a reality, yet it is important to note that there are boundaries to autonomy. A doctor can deny autonomy to a patient for many reasons, some including that the doctor does not believe it will be in the best interest of the patient, if a medication has not been fully tested yet to ensure credibility, and if the patient is not fully competent. Mr. N’s case study allowed for his requests to be fulfilled, as he was deemed competent and had previously gone through so much suffering years prior. As it was his second time using a TAH due to the rejection of a biological heart transplant, the doctors began to come to the realization that there was little hope for his life to return to the way it was prior to his heart failure. Mr. N had also gone through years of surgery and medications, and had not improved since. The doctors have the responsibility of doing what is in the best interest for their patient, yet in the case of Mr. N, his best interest could be to respect his autonomy.  

 

Conclusion

In conclusion with the case study, Mr. N had decision-making capacity and was not in any state of depression and was competent. His family agreed with his wishes, and therefore his TAH was deactivated and he passed away. I personally agree with this decision, and I am on the side of Bramstedt. I view that removing the artificial heart as not a direct form of killing due to the consent the competent patient has provided. The value that helped guide me through in making this decision was autonomy, in which I believe the patient should have the right to self-govern their own body. If I were Mr. N who believed I had gone through years of suffering with a low quality of life, I would choose to end my life before receiving a rare, biological heart. I value empathy in this situation as well, by reason of that this biological heart could go to someone else who would want and value it more than I would.

I believe that it is incredibly important for the medical professionals to really educate the patient and it’s family of the quality of life before receiving a TAH and about the process of receiving an artificial heart. This could include educating the patient on the activities one can perform, if they can return to their previous job, and overall mentioning anything that can inflict on their life satisfaction. In the case study of Mr. N, it seemed that Mr. N was very well aware of the consequences and I am assuming that the family was educated as well. One must have all of the facts before making a life changing, irreversible decision. Not only the patient, but the doctor and the medical team should be well educated on the conditions of the patient as well, since they are stakeholders in this ethical dilemma. Yet, I believe it is crucial to recognize that Mr.N will not be the only one affected by the decision of deactivating the TAH, but so will his friends and family. Upon making his final, definite decision, I personally believe it is important to consult with close friends and family to check if they support you in such a major decision. However, at the end of the day it does come down to the patient’s autonomy and competence which can certainly overrule any family or friends opinion. Nonetheless, since Mr. N was educated and insisted his request of deactivating his TAH multiple times, I believe that it was the correct decision to make.


Works Cited

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