If you receive an implanted pacemaker for your heart, does it become your property? When it is no longer any use to you (because you have died), do you have to give it back?
There was a story earlier in the week on the BBC news website about recycling pacemakers. Pacemakers are a wonderful life-saving technology for people whose own heart is unable to maintain a regular heart-beat. They are usually only used once. If someone who has a pacemaker dies, it is buried with them. If they are cremated, the pacemaker is removed first to prevent it exploding in the crematorium, and then it is disposed of.
There has been a move in recent years to allow recycling of pacemakers. In many parts of the world this technology is simply too expensive. Programs have been developed to encourage patients and families to donate pacemakers after death. The pacemakers can be sterilized, checked to make sure they are working and sent on to people in developing countries who would otherwise be unable to receive this treatment (and likely to die prematurely).
There are a variety of ethical issues with recycling pacemakers. But, here I am going to focus on the question of consent. The standard view is that as long as the patient or their family consent to donating the pacemaker, it is ethical for the pacemaker to be recycled after they have died.
But why is consent necessary? It seems that at least in some circumstances it is unnecessary and indeed unethical to seek consent to donate a pacemaker.
The most straightforward case is where a patient has received a pacemaker through a public health system and is being cremated. In that case, the pacemaker is going to be removed anyway. It is of no conceivable further use to the patient or their family. It seems that the state would be fully justified in reclaiming and recycling the pacemaker.
It may depend on whether we think that the pacemaker becomes someone’s property when it is surgically implanted. If so, then perhaps, as with the rest of their property, we would grant the individual the right to decide what happens with it after their death. They could choose to have it destroyed (though this seems a terrible and senseless waste), or to donate it. But why should we think of pacemakers in this way? We could equally think of the pacemaker as being provided on loan. There are many pieces of equipment or technology provided within a public health system that are given to patients conditionally, or temporarily, with the expectation that they are returned when no longer used. It would be deeply unethical for patients to hold on to that equipment or to destroy it after they had died since doing so would deprive someone else of treatment. If we are worried about those patients who currently have pacemakers and who didn’t realize that post-mortem recycling was a possibility, we could always apply this only to future pacemaker patients, with an explanation at the time of implantation.
This argument wouldn’t work for patients who had received their pacemakers privately, funded out of their own pocket, or through their health insurance. In that case it might make more sense to think that they do own the pacemaker. There would still be an ethical obligation for them to donate their pacemaker. After all, doing so helps another person in a very significant way at no personal cost. But it might be a little harder to justify recycling without consent.
What about patients who aren’t going to be cremated? Can the state still reclaim publicly funded pacemakers? Removal of a pacemaker involves a very quick simple surgical procedure. A small incision is made in the skin overlying the pacemaker, and the device and wires are carefully extracted. The skin is stitched afterwards. Because it takes place after death there is no risk with the procedure, nor any chance of the patient suffering. Do we require consent for this to take place? Should patients have a say in what happens to their body after they have died?
In general we think that they do. People get to choose whether they are buried or cremated. They get to choose (or their family does on their behalf) whether they donate their organs or have an autopsy. We might think that decisions about whether or not a pacemaker is removed should be treated similarly. However, in fact our choices about what happens with our body after we die are quite limited. The state sets very strict limits on how and where bodies are disposed of. In certain circumstances an autopsy will be performed regardless of the patient or family’s wishes. The procedure involved in pacemaker recycling is much smaller than coronial autopsy. And the benefit (for someone else) is much clearer. Again, the fact that pacemakers will be recycled after death could be made available at the time of implantation.
Many of the arguments above are themselves recycled. The issues are very similar to those about consent and organ donation.* But as I have argued, the current emphasis on this being a voluntary donation is overstated. Recycling has become an everyday part of our lives. It should be part of our deaths too.
* One difference (though it shouldn’t make a difference) is that the beneficiary in pacemaker recycling is from another part of the world.
I would argue that a pacemaker *does* become part of the patient. It is not that it is implanted that makes it a part, but that it becomes integrated into their physiological systems. In fact, pacemakers may be more part of people than passive implants.
Whether that makes consent necessary, however, is less clear. If one thinks that consent is necessary for removing parts of the body, then yes. But as you point out our control over our bodies after our death is limited. I am not entirely sure this lack of control is legitimate: it is not obvious why the state should be able to claim my body when I am dead if I wish to donate it to some institution or have a relative inherit it (if I own it while alive, it is my possession to donate). The problem seems to be that treatment of the resources of a dead body is controlled more by customs and fairly arbitrary laws rather than clear ethical principles, and some of these customary laws are based on rather worrying ideas of citizen bodies being merely on loan from the almighty state.
Any procedure (before or after death) ethically requires consent. The ends (donation) don’t justify the means without consent. Do not crush autonomy but, do encourage and educate people about donation. Physicians need to interact with the community more as apposed to working in concealed shrines.
A solution to publicly funded pacemakers is to have the patient consent to the donation before the pacemaker surgery. At that time, the patient is consenting for the surgical removal procedure (not for donation) after death.
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