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02/03/2016

A Letter to Dick Wolf & Chicago Med

by Craig Klugman, Ph.D.

When I was a graduate student in my clinical bioethics masters program I was rotating through a pediatric subspecialty, following a physician. The first half of the day was great. The doctor introduced me to patients, explained what was going on with them, explained his plans and his hopes for each patient. About two-thirds through one particular day he asked me for my stethoscope. I thought “Uh-oh, He doesn’t understand.” When I responded that I did not have one, he said “What kind of medical student are you.” I shrugged my shoulders. When we left that patient’s room I re-explained to him (as I had in my email asking if I could shadow him) that I was a student in the medical school studying clinical ethics, but I was not a medical student.

For the next several hours, doors he would walk into an exam room and shut the door on me. I was not introduced to patients but did that myself. Nothing was explained. I was, in short, a tolerated nuisance that he probably wanted to go away. As we left the last patient of the day, the physician turned to me and addressed me directly for the first time in 3 hours: “Well, was I ethical?” Then he stormed off. I tried to explain I was there to learn, not to judge, but he was long gone.

Despite a growing history of ethics committees in hospitals, it seems that few people understand what such committees are and what clinical ethicists actually do. I was reminded of this while watching Chicago Med. Kayhan Parsi and Nanette Elster wrote about an episode of this show where the ethics committee was viewed as “nearly invisible and unresponsive.”

Now in episode 8 (February 2, 2016) titled “Choices,” the ethics committee makes a second appearance. A father has brought his sick daughter to the emergency department. Since the patient’s medical history made no sense, Dr. Daniel Charles, a psychiatrist, sets up a camera to spy on the patient. He suspects, and the video confirms, that the girls acts sick around the father but not when alone. When Dr. Charles shows the video to the chief administrator she responds tersely, “You know, I ought to haul your $%& before the ethics committee.” The meaning is clear: The ethics committee are the police, prosecutor and judge.

The mistaken notion that clinical ethics is about trying to catch doctors in wrongdoing is not a new one. In other professions such as law and even business, ethics and compliance are used interchangeably. In the legal profession ethics are actually encoded into the law. Most hospitals have a compliance office and often they offer an “ethics hotline” where one can anonymously report illegal and unprofessional behavior. It’s easy to see where the idea of “ethics” gets mixed up with a perception of a team playing “gotcha” with doctors.

George Agich wrote about the damage such a view can have on health care professionals wanting to call for a consult in a 2003 article. Ten years later he reiterated this problem, suggesting that one way around this was for clinical ethics to familiarize medical and nursing staff with its services. Robert Klitzman even named his latest book about research ethics and IRBs, The Ethics Police? At Johns Hopkins this perception is compounded by the fact that the ethics program is actually housed in the old Baltimore police department: As Gail Geller and Joseph Carresse wrote in the Berman Institute’s blog “But the perception of bioethicists as self-righteous scholars who go around telling researchers, practitioners, patients and their families what they ought to do is no laughing matter.”

Portraying medicine accurately on television is difficult. Writers and directors change things around for dramatic effect and shorten time so that an entire case can fit into an hour. And certainly most physicians have had the experience of a patient thinking he/she had a disease or unrealistic expectations because of what he/she saw on television. For example, at least two studies have shown that CPR on television shows are at least twice as effective as in real life. Seeing CPR magically work most of the time on TV certainly changes what patients and families think is possible and probable and makes DNR conversations more difficult.

Is there a risk of the public (i.e. current and future patients) asking for treatment they do not need or that is unlikely to help as a result of seeing ethics committee bad mouthed or incorrectly presented on a TV show? Probably not. The risk of treating the ethics committee as buffoons or a punitive police force (or both in the case of Chicago Med) is that health care providers will have an inaccurate idea. These portrayals reaffirm or create a view that can prevent health care providers reaching out to an ethics committee when the team could really help. And in the end, that means the health care team, patients, and their families will not benefit form the education, policy, and consultation services that ethics has to offer.

There is nothing wrong with making interesting television. Please try to get it right because for much of the public, these shows are what they think medicine really is. The administrator in this episode should have threatened to bring the physician before the credentialing board, the medical affairs committee, or even the compliance office.   But not the ethics committee, which in reality, has very little power and can really only offer recommendations.

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