FOT 744, Division of General Internal Medicine, University of Alabama at Birmingham (UAB) School of Medicine, Birmingham VA Medical Center, Birmingham, AL 35294, USA.
Theor Med Bioeth. 2012 Dec;33(6):421-33. doi: 10.1007/s11017-012-9213-5.
In spite of ethical analyses assimilating the palliative deactivation of pacemakers to commonly accepted withdrawings of life-sustaining therapy, many clinicians remain ethically uncomfortable with pacemaker deactivation at the end of life. Various reasons have been posited for this discomfort. Some cardiologists have suggested that reluctance to deactivate pacemakers may stem from a sense that the pacemaker has become part of the patient's "self." The authors suggest that Daniel Sulmasy is correct to contend that any such identification of the pacemaker is misguided. The authors argue that clinicians uncomfortable with pacemaker deactivation are nevertheless correct to see it as incompatible with the traditional medical ethics of withdrawal of support. Traditional medical ethics is presently taken by many to sanction pacemaker deactivation when such deactivation honors the patient's right to refuse treatment. The authors suggest that the right to refuse treatment applies to treatments involving ongoing physician agency. This right cannot underwrite patient demands that physicians reverse the effects of treatments previously administered, in which ongoing physician agency is no longer implicated. The permanently indwelling pacemaker is best seen as such a treatment. As such, its deactivation in the pacemaker-dependent patient is best seen not as withdrawal of support but as active ending of life. That being the case, clinicians adhering to the usual ethical analysis of withdrawal of support are correct to be uncomfortable with pacemaker deactivation at the end of life.
尽管伦理分析将心脏起搏器姑息性去激活等同于普遍接受的停止生命支持治疗，但许多临床医生在生命末期仍对心脏起搏器去激活感到伦理上的不适。对于这种不适感，提出了各种原因。一些心脏病专家认为，不愿意去激活心脏起搏器可能源于一种感觉，即心脏起搏器已成为患者“自我”的一部分。作者认为，Daniel Sulmasy 认为任何这种对心脏起搏器的认同都是有误导性的是正确的。作者认为，尽管临床医生对心脏起搏器去激活感到不舒服，但他们认为这与传统的停止支持的医学伦理是不相容的，这是正确的。传统的医学伦理目前被许多人认为在心脏起搏器去激活时是合理的，只要这种去激活尊重患者拒绝治疗的权利。作者认为，拒绝治疗的权利适用于涉及医生持续代理的治疗。这一权利不能支持患者要求医生逆转先前给予的治疗的效果，因为这不再涉及持续的医生代理。永久性内置心脏起搏器最好被视为这样一种治疗。因此，在依赖起搏器的患者中，心脏起搏器的去激活最好被视为主动结束生命，而不是停止支持。在这种情况下，坚持通常的停止支持伦理分析的临床医生对生命末期的心脏起搏器去激活感到不舒服是正确的。
