Deactivating the implantable cardioverter-defibrillator: A biofixture analysis

Automatic implantable cardioverter-defibrillators (ICDs) are becoming incre asingly common, as is refusal of resuscitative efforts at the end of life, both by patients and surrogate decision-makers. While it is clear that a te rminally ill patient who lacks decisional capacity may, through a surrogate , refuse cardiopulmonary resuscitation (CPR), is it appropriate for physici ans to infer from such a refusal that the patient's ICD should be deactivat ed? A proper answer to this question requires consideration of the nature o f consent to a do-not-resuscitate (DNR) order, the context in which permiss ion is given for the writing of the DNR order, and the ontologic status of implantable devices in general and ICDs in particular. We introduce the con cept of "biofixtures" and suggest that a biofixture analysis is a novel way of approaching the difficult ethical issues that may confound the care of patients with implantable devices.