Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor
In Reply: We thank Drs Paola and Walker for
their intriguing proposal that Reverend G's pacemaker should be regarded as
a biofixture that has become part of him, as opposed to something that remains
distinct such as an endotracheal tube or ventilator. Paola and Walker have
previously argued that "in cases where reasonable persons could disagree over
the ontologic status of a medical device, the patient or surrogate should
be permitted to determine its status as biofixture."1
That is, the resolution of disagreement over whether a medical device is a
biofixture should be based on respect for the patient's autonomy, as expressed
either in the informed consent process directly by the patient or indirectly
through a surrogate acting on the substituted judgment standard (a decision
based on the patient's values and beliefs). Paola and Walker, however, hold
that the surrogate should presume (without reference to the patient's actual
preferences or values) that the patient regarded the pacemaker as a biofixture.
This is an extension of their original position, which requires further support.
Given their own acknowledgment of the controversial nature of their proposal,
it faces a steep burden of proof.
Rhymes JA, McCullough LB, Luchi RJ, Teasdale TA, Wilson N. Is It Ethical to Withdraw Low-Burden Interventions in Chronically Ill Patients?—Reply. JAMA. 2000;284(11):1380-1382. doi:10.1001/jama.284.11.1378