Ethical frontiers of pediatric compassionate deactivation: exploring an emerging bioethical phenomenon

The increasing use of ventricular assist devices (VAD) in children with advanced heart failure, including as destination therapy, has brought compassionate deactivation (CD) into pediatric end-of-life care. While this practice is ethically recognized in adult medicine, its application in pediatrics remains underexamined and lacks specific guidelines. This paper argues that pediatric VAD deactivation represents a distinct bioethical phenomenon rather than a standard case of life-sustaining treatment withdrawal. The ethical specificity of pediatric CD arises from the hybrid nature of VADs as both therapeutic devices and functional cardiac substitutes, the active character of deactivation, the central role of parental proxy decision-making, and the possible awareness and involvement of the child. Drawing on the principles of proportionality and the best interests standard, the paper defends the ethical legitimacy of compassionate deactivation when treatment becomes disproportionate or futile. It then examines key moral challenges, including debates over the Equivalence and Non-equivalence Theses, clinicians’ moral discomfort, assessments of medical futility, and communication with caregivers and pediatric patients. The paper concludes that, although ethically permissible, pediatric CD requires clear, context-sensitive ethical guidance and a multidisciplinary approach to support children, families, and clinicians in these complex decisions.