Sulmasy Daniel P
John J. Conley Department of Ethics, St. Vincent's Hospital-Manhattan, 153 W. 11th St., New York, NY, USA.
J Gen Intern Med. 2008 Jan;23 Suppl 1(Suppl 1):69-72. doi: 10.1007/s11606-007-0326-x.
As Implantable Cardioverter Defibrillators (ICDs) have become more common, ethical issues have arisen regarding the deactivation of these devices. Goldstein et al., have shown that both patients and cardiologists consider ICD deactivation to be different from the discontinuation of other life-sustaining treatments. It cannot be argued ethically that ICDs raise new questions about the distinction between withholding and withdrawing treatment, and neither the fact that they are used intermittently, nor the duration of therapy, nor the mere fact that they are located inside the body can be considered unique to these devices and morally decisive. However, frequent allusions to the fact that they are located inside the body might provide a clue about what bothers patients and physicians. As technology progresses, some interventions seem to become a part of the patient as a unified whole person, completely replacing body parts and lost physiological functions rather than merely substituting for impaired structure and function. If a life-sustaining intervention can be considered a "replacement"--a part of the patient as a unified whole person--then it seems that deactivation is better classified as a case of killing rather than a case of forgoing a life-sustaining treatment. ICDs are not a "replacement" therapy in this sense. The deactivation of an ICD is best classified, under the proper conditions, as the forgoing of an extraordinary means of care. As technology becomes more sophisticated, however, and new interventions come to be best classified as "replacements" (a heart transplant would be a good example), "discontinuing" these interventions should be much more morally troubling for those clinicians who oppose euthanasia and assisted suicide.
随着植入式心脏复律除颤器（ICD）越来越普遍，关于停用这些设备出现了伦理问题。戈尔茨坦等人表明，患者和心脏病专家都认为ICD停用不同于停止其他维持生命的治疗。从伦理角度而言，不能认为ICD引发了关于放弃治疗和停止治疗之间区别的新问题，而且它们间歇性使用的事实、治疗持续时间以及仅仅因为它们位于体内这些情况，都不能被视为这些设备独有的且具有道德决定性的因素。然而，频繁提及它们位于体内这一事实可能为困扰患者和医生的原因提供线索。随着技术进步，一些干预措施似乎成为患者作为一个完整统一个体的一部分，完全取代身体部位和丧失的生理功能，而不仅仅是替代受损的结构和功能。如果一种维持生命的干预措施可以被视为一种“替代物”——作为患者完整统一个体的一部分——那么停用似乎更好地归类为杀人行为，而不是放弃维持生命的治疗。从这个意义上说，ICD不是一种“替代”疗法。在适当条件下，ICD的停用最好归类为放弃特殊护理手段。然而，随着技术变得更加复杂，新的干预措施最好归类为“替代物”（心脏移植就是一个很好的例子），对于那些反对安乐死和协助自杀的临床医生来说，“停止”这些干预措施在道德上应该更令人困扰。
