ADULT – Education|Articles in Press

Does Everyone Need High Technology Intervention Before They Die?

Published:October 25, 2022DOI:
      A persistent problem in cardiothoracic surgery, as in all of medicine, is when to offer or to withhold expensive technologies. The ethical requirement of balancing harms and benefits is often difficult to achieve. The use of LVADs is an example of such technologies, and when to offer it is explored in this paper.



      CHF (congestive heart failure), DT (destination therapy), ICU (intensive care unit), LVAD (left ventricular assist device), NCD (national coverage decision), VAD (ventricular assist device)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Seminars in Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Slutsky AS
        History of Mechanical Ventilation. From Vesalius to Ventilator-induced lung injury.
        Am J Respir Crit Care Med. 2015; 191: 1106-1115
        • Sade RM
        Profits and professionalism.
        J Thorac Cardiovasc Surg. 2002; 123: 403-405
        • Sade RM
        Should the use of transcatheter aortic valve implantation be rationed?.
        J Thorac Cardiovasc Surg. 2012; 143: 769-770
        • Schenck D
        Virtues, skills and the practice of surgery.
        J Thorac Cardiovasc Surg. 2017; 153: 1218-1219
        • Stone ML
        • Kern JA
        • Sade RM
        Transcatheter aortic valve replacements: Clinical aspects and ethical considerations.
        Ann Thorac Surg. 2012; 94: 1791-1795
        • McKneally MF
        • Sade RM
        The prisoner dilemma: Should convicted felons have the same access to heart transplantation as ordinary citizens? Opposing views.
        J Thorac Cardiovasc Surg. 2003; 25 (-3): 45
        • McCarthy PM
        • Lamm RD
        • Sade RM
        Medical ethics collides with public policy: LVAD for a patient with leukemia.
        Ann Thorac Surg. 2005; 80: 793-798
        • Hippen B
        • Friedman Ross L
        • Sade RM
        Saving lives is more important than abstract moral concerns: Financial incentives should be used to increase organ donation.
        Ann Thorac Surg. 2009; 88: 1053-1056
        • Entwistle JW
        • Sade RM
        • Petrucci RJ
        The ethics of mechanical support: the need for new guidelines.
        Ann Thorac Surg. 2011; 92: 1939-1942
        • Churchill LR
        The American Association for Thoracic Surgery 2016 ethics forum: Working virtues in surgical practice.
        J Thorac Cardiovasc Surg. 2017; 153: 1214-1217
        • Smedira NG
        Saying yes or saying no!.
        J Thorac Cardiovasc Surg. 2016; 151: 243-244
        • Brody B
        • Halevy A
        Is futility a futile concept?.
        J Med Philos. 1995; 20: 123-144
        • Coyle L
        • Yost G
        • Gallagher C
        • et al.
        Impact of morbid obesity after left ventricular assist device placement.
        J Heart Lung Transplant. 2017; 36: S182-S183
        • Kirklin JK
        • Naftel DC
        • Pagani FD
        • et al.
        Seventh INTERMACS annual report: 15,000 patients and counting.
        J Heart Lung Transplant. 2015; 34: 1495-1504
        • Kahneman D
        Thinking, Fast and Slow.
        Farrar, Straus and Giroux, New York2011
      1. National Health Expenditures 2017 Highlights. Available at: Accessed June 29, 2021.

        • Altman S
        • Shactman D
        Power, politics and universal health care: The inside story of a century-long battle.
        Prometheus Books, New York, NY2011: 39
      2. Nunn R, Parsons J, Shambaugh J. A dozen facts about the economics of the U.S. Health-care system. The Hamilton Project. 2020. Available at: Accessed June 29, 2021.

      3. Chart: Life Expectancy at birth and health care spending per capita. The Incidental Economist. 2013. Available at: Accessed June 29, 2021.

        • Shreibati JB
        • Goldhaber-Fiebert JD
        • Banerjee D
        • et al.
        Cost-effectiveness of left ventricular assist devices in ambulatory patients with advanced heart failure.
        J Am Coll Cardiol: Heart Failure. 2017; 5: 110-119
        • Lietz K
        • Long JW
        • Kfoury AG
        • et al.
        Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: Implications for patient selection.
        Circulation. 2007; 116: 497-505
        • Decision Memo for Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy (CAG-00432R)
        Medicare Coverage Database, Centers for Medicare and Medicaid Services.
        2021 (Available at) (Accessed June 29)
        • Mayer JE
        Is there a role for the medical profession in solving the problems of the American health care system.
        Ann Thorac Surg. 2009; 87: 1655-1661
        • MacDonald H
        The false ‘science’ of implicit bias.
        Wall Street J. 2017;