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03/01/2016

Code Black Ends the Season on Bioethics

BioethicsTV is an occasional bioethics.net feature where we examine bioethical issues raised in televised medical dramas.

by Craig Klugman, Ph.D.

The season finale of Code Black (season 1; episode 18 – February 24, 2016) presented a plethora of ethical challenges for the hard working doctors and nurses of Angels Memorial Hospital’s emergency department. The conceit for this show is that this is the busiest emergency room in the country, entering “code black” on over 300 days a year. The show defines a code black as overwhelmed, understaffed, overcrowded. But oddly, they never go on diversion status.

This season closer raised four disturbing ethical issues, most of which were only dealt with in passing.

First: Whom do we treat? After an explosion at the site of a Presidential debate, patients start coming into the ED. Mrs. Wesley, the wife of one Presidential candidate, Governor Wesley. She seems to have a concussion but is initially fine, until she decompensates. Juan is the janitor who was brought in last, having been overlooked by rescuers and because he lacks ID. Juan is refused a phone call to his wife and child because the Secret Service has external communications on lockdown. He has a bleed in his brainstem and after being on observation he also decelerates rapidly. Both need surgery now. As the two patients are side by side, there is only one available surgeon and thus, only one patient can get surgery. A physician says that both are equal in regards to medical need and chances of survival. The surgeon must decide who to take: Juan—the poor, minority janitor—or Mrs. Stringer—the wife of the potential next President of the United States who also started a medical mission program to Haiti. After a brief moment, the surgeon chooses to take the wife. The janitor is sentenced to death, which we assume happens since his story does not make another appearance. This quick scene is a demonstration on having to make tough choices in a limited resource situation.

Most professionals would look first at who is medically neediest, an option that the setting removes from consideration. Other options would be egalitarian—treating everyone as equal (e.g. first come, first serve; a lottery). But it seems clear that the choice was made on the social standing of the patient and her potential to contribute to the hospital’s future. After all, while the janitor’s death is unlikely to make a headline, saving or allowing a future President’s wife to do is headline-making. Though there is a part of it that hopes the surgeon will choose to save the underdog. A theme in this series is the balance between patient care and business interests, which was a factor in this choice.

A second story line is a continuing saga of a resident, Angus, who feels second best to other residents and to his brother who was just hired as an attending physician. To compensate, one of his colleagues introduces him to Adderall. On the pill, Angus finds he has become “superdoc” able to make amazing saves and be more productive. And then the pills start compromising his ability—he racks up mistakes but feels no remorse or concern. Mario, a fellow resident and a former addict, recognizes the signs and tries to intervene. Finally, Mario reports Angus to an attending (Angus’s brother), who removes Angus from a critical case. His future will likely be dealt with if there is a future season.

The issue of impaired physicians is a challenging one. Much of medicine is high stress and high stakes. A 2012 survey reported in JAMA Internal Medicine, that 46% of physicians reported symptoms of burnout. A 1996 study showed that physicians were twice as likely to committee suicide as non-physicians. Physicians have a higher risk of substance abuse during their careers than the general population (10-12% of all doctors). Impairment poses a direct risk to patient care and safety, a liability risk for the institution, and causes problems for peers and the medical profession as a whole. According to the American Medical Association, Opinion 9.031, “physicians have an ethical obligation to report impaired, incompetent, and or/unethical colleagues.” Mario tried to intervene with Angus and when that failed, reported to his superior, all of which was appropriate. That the superior was Angus’s brother probably was not the best choice of attending since there is clearly a potential conflict of brotherly interest.

A third issue occurred during a press conference with two physician-administrators sharing information about the injured Presidential candidates with the press. They shared names of patients, their diagnoses, procedures, and prognoses. While the previous two issues at least had a nod toward questioning what is the right thing, there was not even a blink here. Did the patients and families give consent for this information to be shared? HIPAA is quite clear that sharing any medical information without a patient’s (or surrogate’s) consent is a violation of privacy. Being a celebrity does not diminish one’s protections under HIPAA. They should have secured consent first.

A final issue dealt with organizational ethics in the institution. A resident and attending are dating and their relationship starts affecting their interactions with other colleagues in the hospital. Certainly this issue has been dealt with extensively in other shows (almost weekly in Grey’s Anatomy). Both physicians had signed disclosure statements with human resources. If the attending has supervisory capacity over the resident—evaluation, assigning cases, teaching, etc.—then such a relationship is compromising. If the relationship should end, the potential for disaster on both sides is strong (great for TV, not so great for real life) and thus, such relations should be avoided. If the attending is on another service, and there is no supervisory connection, then that argument is far weaker. We learn that this fictional institution requires disclosure of such a relationship but does not forbid it (and clearly allows an older sibling to supervise a younger one). Even with disclosure, since the attending in this scenario does supervise on many occasions the resident (and as is pointed out, the relationship appears to influence some of his choices), the relationship is a problem.

At the moment there is no word on whether Code Black will be renewed for a second season, but rest assured there are many other medical dramas in the pipeline.

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