Balancing Security and Safety: A Look at Emergency Access Solutions for Implantable Medical Devices (IMDs)

Abstract

Wireless implantable medical devices (IMDs) have transformed clinical care but have also created a cyber-physical attack surface in which security failures can cause direct physiological harm. This tension is most acute in emergency access: clinicians must rapidly interrogate or reprogram devices under conditions that invalidate normal authentication. Security measures can delay critical care; mechanisms guaranteeing rapid access introduce vulnerabilities. This paper offers a critical review treating IMD emergency access as a safety-critical socio-technical exception regime, not merely a technical backdoor. We synthesise major access mechanisms—proximity triggers, break-glass credentials, external mediators, and manufacturer-mediated approaches—and analyse them through threat models, safety failure modes, human factors, and governance structures. We emphasise how cognitive load, workflow disruption, and long device lifecycles amplify risk during urgent interventions. The analysis shows that these mechanisms redistribute risk among patients, clinicians, manufacturers, and regulators, and that both security and safety failures can be catastrophic. We argue that no single mechanism can simultaneously maximise safety, security, and accountability across diverse contexts. We conclude by specifying the governance interventions required to make emergency access defensible in practice.