On one unremarkable day, an 80 year old patient quietly told me that he had no idea why he was having an operation to insert an artificial pacemaker into his chest. He did not understand that the permanent cardiac device would correct his slow beating heart, laying in the chest of his ailing body, already firmly in the grip of cancer. This lack of informed consent is alarming, and presents us with important issues, such as, in whose interest are such medical devices inserted.
Dr Mohamed Khadra, Professor of Surgery at the University of Sydney and the author of The Patient: One Man's Journey Through the Australian Health-Care System, believes that there should be more discussion around the conflict of interest, that arises in the day to day consultations between doctor and patient. Khadra explains that in the case of his advising a patient to undertake surgery, he has a duty to inform, that only if the surgery goes ahead, will he be paid. Should his advice go unheeded, and the patient decline the surgery, there will be no payment.
I support the ethical stance taken by this good doctor and only wish that it was more widely adopted by the medical profession today. Was my patient told that his cardiologist would receive a very handsome monetary sum for his short afternoon’s work? Did my patient understand that pacemakers are not problem free? Will my patient regret the dependence that comes with such permanent technology? In whose interests are these very common heart stimulating devices inserted ? Does anyone but me care?
The rate at which our heart beats is controlled by a natural pacemaker called the sino-atrial node. This node is a mass of cells, producing electrical impulses which cause the heart to beat. Our cardiac conducting tissues are not exempt from the rigors of ageing, often resulting in altered impulse conduction, and the occurrence of heart arrhythmias, such as bradycardia or slow heart rate. When our heart rates are slow we can feel tired, even faint, and sometimes short of breath. Cardiac medicine overcomes the problem of a slow beating heart by the insertion of an artificial pacemaker into the chest, prompting the heart to beat faster.
The pacemaker industry is part of the huge Medical Supplies and Devices U.S. industry that includes 12,000 companies with combined annual revenue of about $50 billion. Modern medicine is increasingly obsessed with technology, intended to extend a person's quantity and quality of life. More than 1 million persons in the United States have implantable pacemakers, and the majority of this population, is older than 65 years. In 2005, a survey revealed that the total new pacemakers implanted in Australia was 11,850, up from 9498 in 2001.
Humans are living longer than ever before and the number of old hearts requiring attention and repair is set to escalate. As we age, all the many and intricate parts of our anatomy deteriorate, but in this instance, the heart is our focus. Should we be inserting pacemakers and other medical devices whilst denying the inevitable decline and death of our ageing bodies? How will we care for the increasing numbers of old people sitting in nursing homes, with implanted artificial devices keeping them alive? Do we discuss these issues? Are patients and their families encouraged to make an informed decision regarding this one aspect of life extension?
My other patient, on that very same day also being prepared for insertion of a pacemaker, was an 85 year old woman, the much loved mother of three middle aged children and the grandmother of several. However, the woman had many major health issues and was incontinent and wore nappies day and night. Was this woman fully aware of what the insertion of a permanent pacemaker would mean for her in terms of her increased longevity? What if her disabilities became too much for her? Would her family continue to care for her or would she spend her extended days alone in a nursing home? How might she find a doctor to turn off her pacemaker and let her die in peace?
Grant La Farge wrote Please, doctor. Turn off my pacemaker, where he describes his experience with a 92-year-old heart patient who wanted his pacemaker turned off so that he could die in peace. The author complied with the patient's wishes. "Ninety-two years is enough," said his patient. "When you get this far, you've really seen it all, or at least enough of it. Isn't it better to die with all your faculties than wait for the erosion of time?"
I would imagine that before the age of medical intervention, a deteriorating heart conduction system would have resulted in a quick death, preceded by dizziness and collapse, and this to me still seems a reasonable end to the life cycle. Why then are so many people amenable to the technological fix and extended duration of the mortal existence?
In The Postmodern Heart: a discourse analysis of a booklet on pacemaker implantation, Carole Anderson from The School of Nursing, Griffith University, provides some explanation that is worthy of comment. She describes the pacemaker booklet given to patients and published by the global leader in pacemaker manufacture. A well-looking attractive male of 65 years is featured, as the recipient of the device. There is a profound difference between the number of men and women who receive pacemakers, with ageing males the most likely contenders. The booklet describes the male as a loving grandfather surrounded by family and friends; indeed the portrait of a person with a life worth living. But nowhere in the pamphlet is a list of the problems, pacemaker technology may present; such as dependence on technology, and issues that may occur due to feelings of disfigurement, and the ever present fear and concern that the device might fail. The author of The Postmodern Heart also explores the idea of the cyborg in reference to the pacemaker, with the fusion of machine and human blurring the reality of life and death.
To understand this predilection for the pacemaker fix, Anderson explains that potential pacemaker recipients, are encouraged to believe that this is the only way to solve the problem of the altered heart beat, and that there are other choices which are not explained to the patient. Those who read the manufacturer- sponsored pacemaker booklets are convinced that the members of the medical profession are the keepers of all pacemaker knowledge, providing all the answers to their cardiac problems, leaving the readers seemingly powerless. Such a strong patriarchal view is reinforced by our general society which regards technology as progress, in all things medical, and beyond. Anderson says, that when nurses fail to question the unremitting usage of the pacemaker technology, we continue that nasty stranglehold, exerted by the powerful bodies, such as the medical profession, and the pacemaker manufacturers over authentic human lives.