Ethics and Cardiology

Characteristics of bioethical contexts

The emergence of bioethics involved four central factors. The first was increased capability – being capable of, say, keeping a dying patient alive, discovering fetal characteristics before birth or transplanting body organs – forced the question: ought this be done? This had been irrelevant to practice when there was no capability. The second was increased knowledge of the unforeseen consequences of actions, which compelled unanticipated moral decisions. The third was, as a result of increased capability and knowledge, an increase in benefits, raising the question of the fairness of their distribution. Lastly, there was a broad cultural emphasis on individuality and autonomy. This found particular expression in challenges to the authority of experts and specialists, to whom responsibility had been assigned for advice and decision-making. The challenge rose from the realisation that any expert judgment involved values and not merely facts – values that were strongly held by citizens.

These were the characteristic features of the first decade of the emergence of bioethics, essentially the 1970s. However, as bioethics has come to be applied in succeeding decades to the capabilities and knowledge, similar patterns of factors can be traced. The recent technological development in cardiology coupled with the broadening and deepening knowledge of the complex causation of heart disease is another opportunity for this same ethical conversation.

Capability

The technological advances in cardiology not only include an expanding collection of thrombolytic medications but an expanded battery of devices that include implantable cardioverter defibrillators (ICDs), cardiac resynchronisation therapy (CRT), implantable monitors, ventricular assist devices (VADs) and the artificial heart.

The complications that have emerged from the use of all of these devices typically prompts the question of whether they should all and always be used. While ICDs may prolong life, their frequent shocks can be traumatic and the unpredictability of these can cause patients fear and anxiety. CRT devices are riskier than normal pacemakers and are not always effective. VADs can improve the length and quality of life but at the risk of complications that include bleeding, infection and stroke.

The technological capability also supports a trend to treat acute coronary disease as tertiary centres as the new standard of care. With this trend come additional ethical considerations: interventional cardiology that relies so heavily on technological devices is competitive and highly remunerative, as cardiac device manufacturers are astute to realise. Their involvement necessitates the engagement of practitioners, preferably opinion leaders, which can present those professionals with complex questions of conflicts of interest.

Knowledge

As before, with new capability comes increased knowledge. A recurrent consequence the use of these devices is that patients who would, in the past have died from acute heart attacks, now survive the initial acute episode but with weakened hearts – they survive to live with a chronic condition of limitation of function and recurrent and unpredictable episodes met by rescue treatment but with an overall steady decline. However, this knowledge is not always understood. The successful technological treatment may mask, for patients, the causative link with the ensuing long-term debilitating illness so that they may not understand that treatment will be more complex than merely unblocking an artery.

Benefits

Enjoyment of the benefits of successful management of acute coronary disease will be directly affected by the financial structure and the limits of a health system. A trend to tertiary management can apply significant financial pressure on a health system as costs increase with the introduction of more sophisticated technology. This trend may redirect resources from the prevention of coronary disease – a benefit that would be more enjoyed, although,because of new knowledge of the complexity of the causation of coronary disease, effective preventive measures may be difficult to design.

Individuality and autonomy

Patient expectations and choices are likely to be directly influenced by the success of the technological devices. The immediate capability of such devices is at once demonstrable to and intelligible by patients. The threat of their acute coronary condition appears to have been removed by a clever technological fix. They are the beneficiaries of aggressive, rather than conservative therapy, grateful for the courageous intervention that cardiology has made possible.

The equation of a functioning heart with life – and a non-functioning one with death – is popular – and powerful – imagery. It is a value that is quickly espoused. However, the very devices that, in this sense, prolong life may come to be a source of distress to patients who succumb to other illnesses. Whether to maintain the function of these devices at a time when palliative care is indicated can be a troubling issue for these patients and their families.

Cardiology’s technological capability, advancing knowledge, demonstrable benefits and appeal to patient choice thus follow a characteristic pathway of ethical dilemmas. Past experience, albeit in different medical specialist areas, is likely to offer guidance to the recognition, analysis and resolution of these.

Colin Thomson

BA, LLB, LLM (Sydney)

Colin Thomson is Professor in the Graduate School of Medicine at the University of Wollongong and is Academic Leader for Health Law and Ethics. He also works as a consultant.

He has held positions at the Faculty of Law, Australian National University (1972-1988), where he introduced teaching in medicine and law, and the Faculty of Law, University of Wollongong (1991-2002).

From 1988-91, he was a member of the Medical Research Ethics Committee of the National Health and Medical Research Council and, from 1998-2002, a member of its successor, the Australian Health Ethics Committee, and Chair of that committee from 2006-2009.

He is Associate Editor of the Journal of Bioethical Inquiry and is a joint author of Good Medical Practice: professionalism, ethics and law, 2010, Cambridge University Press.