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Letters
September 20, 2000

Is It Ethical to Withdraw Low-Burden Interventions in Chronically Ill Patients?—Reply

Author Affiliations
 

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(11):1380-1382. doi:10.1001/jama.284.11.1378

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.

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