In thinking about this debate, we recall a story that occurred to one of the editors (DMH): “I can remember the first time that I was confronted with the ethical issue of deactivating a cardiac implantable electrical device (CIED). I had just moved to a new job, and the palliative care physician at our hospital brought the question of whether or not it was ethically acceptable to have an CIED turned off, per a patient’s request. This was nearly 15 years ago, and not much had been published on the topic. My bioethics colleague and I discussed the issue at length, did a nominal literature search, and then pronounced that as a piece of medical technology used to supplant or support the function of a natural organ or physiological process, it could be consented-to or refused, implanted, or removed, as the patient (properly capacitated and informed) chose. For my colleague and me, this was not significantly unlike stopping a ventilator (which had become ethically commonplace) or even ceasing dialysis (at the time, a bit less commonly accepted). For the palliative care physician, this response was adequate and acceptable, and he went off to discuss these findings with the healthcare team.

However, when the cardiologist was told of our position on the issue, he was much less certain and more distressed by the argument. It was his original concerns that prompted the palliative care physician to call us, and our position, while not illogical, did not meet with his felt sensibilities about CIEDs and his role as a physician.”

* * *

For Thomas Huddle, the cardiologist’s reaction speaks to something morally significant about the deactivation of CIEDs, and it seems that this sensibility drives Huddle to attempt a carefully-nuanced argument about the moral status of CIEDs. In the first part of this debate, Huddle attempts a careful analysis of several conceptual distinctions, particularly that of “killing” versus “allowing-to-die” made by Daniel Sulmasy (and others). Huddle argues that Sulmasy predicates his argument for allowing deactivation of CIEDs on the “traditional” distinction of “killing” versus “allowing to die.” Huddle sees Sulmasy as accepting that deactivation is simply a form of allowing the patient to die, but Huddle is unconvinced. For his money, the distinction between killing and allowing to die must be seen as paralleling another distinction—namely, between processes that have been “completed” and those that are “ongoing.” Huddle’s argument turns on the idea that, once implanted, CIEDs become part of a physiological homeostasis, and as such, the process is “complete.” The moral relevance to this distinction is that “completed” processes, if directly impacted after-the-fact, result not in allowing a patient to die of natural causes but a direct form of killing. As a result, Huddle comes down firmly against deactivation as a morally acceptable act for healthcare providers to perform.

In response to this, Dan Sulmasy and Mariele Courtois counter that Huddle simply has misunderstood (or at least mischaracterized) Sulmasy’s previous arguments on this matter. For them, the killing versus allowing to die dichotomy is predicated on intentions in a way that Huddle does not acknowledge properly. Further, there are significant negative moral, prudential, and practical consequences to Huddle’s position, for which Sulmasy and Courtois attempt to account. Sulmasy and Courtois maintain that such consequences sway the argument in favor of accepting deactivation as a morally approvable option (with the usual caveats about valid informed consent, of course).

Through the debate, different sides of a complex issue are illuminated. Hopefully, by giving space for both sides to identify and articulate their respective positions, readers are left with a more robust understanding of the debate overall, and a recognition of some of the main points of contention. Even more, one may come away with an awareness of where there may be important points of agreement, on which the matter might ultimately be grounded.

As is our usual practice, the editors of “The Great Debates” in CQ wish to leave the substance of explanation of positions and interpretation of meaning in this debate to the authors of the debate themselves. This CQ department is dedicated to bringing “noted bioethicists [together in order to] debate…some of the most perplexing contemporary bioethics issues.” In that light, we hope you find the following a fruitful debate between respected colleagues who wish, like all of us, to reach better conceptual clarity for the sake of our moral attitudes and behaviors. And further, you are encouraged to contact “The Great Debates” department editors, D. Micah Hester (hesterdm@uams.ed) and Alissa Swota, PhD (Alissa.Swota@bmcjax.com)—with any suggestions for debate topics and interlocutors you would like to see published herein.