The ethics of mechanical support: the need for new guidelines.

Each generation of physicians has been faced with new therapies or technologies that have dramatically changed the way medicine is practiced. Usually, mainstream adoption of such medical advances has been an uncomplicated process. Occasionally, these advances require a thorough reexamination of the way that we approach medical care because they represent such a change in patient management that our conventional assumptions no longer apply. New-generation ventricular assist devices (VADs) represent such a technology. VADs have been used in humans for nearly 50 years, but they have only recently seen widespread adoption to the point that they present today's clinicians with ethical challenges on a large scale. In many cases, these issues arise from patient non-compliance or other disruptive behaviors. Similar issues have been seen with organ transplantation, but guidelines and protocols for patient selection and organ allocation have been established, making psychosocial considerations, such as non-compliance and anti-social behavior, part of the selection process. In this way, the ethical issues surrounding organ transplantation have been mitigated, if not solved. To address the growing ethical problems generated by VAD implantation, similar guidelines are necessary. In the 1990s, VADs were used primarily in patients awaiting transplantation who needed interim support until a suitable organ could be identified. For the most part, they were implanted only in transplant centers as a bridge to transplantation (BTT), and VAD candidates were judged by the same criteria used to evaluate patients for transplantation. Thus, if patients were not candidates for transplantation, they were not candidates for VAD insertion. The decision to exclude certain candidates from VAD therapy was made easier because of the linkage of VADs to organs for transplantation, which are a scarce resource, was widely believed to justify limiting their use to situations in which the chance of success was good.