In the last decades, new technologies have improved the survival of patients affected by chronic illnesses. Among them, left ventricular assist device (LVAD) has represented a viable solution for patients with advanced heart failure (HF). Even though the LVAD prolongs life expectancy, patients’ vulnerability generally increases during follow up and patients’ request for the device withdrawal might occur. Such a request raises some ethical concerns in that it directly hastens the patient’s death. Hence, in order to assess the ethical acceptability of LVAD withdrawal, we analyse and examine an ethical argument, widely adopted in the literature, that we call the “descriptive approach”, which consists in giving a definition of life-sustaining treatment to evaluate the ethical acceptability of treatment withdrawal. Focusing attention on LVAD, we show criticisms of this perspective. Finally, we assess every patient’s request of LVAD withdrawal through a prescriptive approach, which finds its roots in the criterion of proportionality.
At times, clinical expertise may not be sufficient to find a way out of a moral impasse, especially in the context of end-of-life and organ transplantation decisions. Advances in medical knowledge and technology, and highly pluralistic and multicultural societies, have led to the emergence of new ethical problems in daily clinical practice along with the need to manage them in a prompt and effective manner. Clinical ethics developed in the late 1970s and early 1980s in North American health care contexts with the aim of identifying, analyzing, and attempting to resolve ethical conflicts and dilemmas at the patient's bedside. At present, only a few regions in Italy have established clinical ethics committees, and Italy may count on a very small number of clinical ethics services fully devoted to ethics case consultation, guidelines development, and the education of health care providers and citizens. Despite this situation, one has to acknowledge both the increasing request for ethics support coming from health care providers who experience an "ethical vacuum" in the Italian health care system and the cultural change that is affecting Italy nowadays. By highlighting clinical examples and sharing experiences, we show and encourage the potential benefits of establishing clinical ethics services in Italian health care contexts.