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04/07/2016

BioethicsTV: “Heartbeat” tackles therapeutic misconception

by Craig Klugman, Ph.D.

On episode 4 of Heartbeat, the heroine, Dr. Panttiere has received hospital funding to try an experimental cancer treatment on 5 patients. The intervention uses laparoscopic surgery to implant radioactive pellets directly into tumors. The show presents a good debate on the values of enrolling patients because the characters discuss the hope of more time versus providing patients with comfortable quality of life at the end of life. The side-by-side contrast is quite literal as the camera shows Panttiere sitting next to her paramour, Dr. Harrison. The camera pans between the two doctors and the patient/potential subject, sitting on the other side of the table.

Panttiere says that the study is about giving patients more time and would provide data that would allow them to help future patients have more time. She tells the potential subject that in the first [limited] trial, 90% of patients lived longer than would have been predicted without the experiment. She looks annoyed when Harrison tells the patient that there are risks and he should weigh the risks and benefits before making a decision. The patient then asks his personal physician, Harrison, what he would do. Harrison responds that he would take his [service] dog and go on a trip.

The patient leaves the room after deciding not to participate. Panttiere gives Harrison a look of betrayal. She takes the position that her job as a doctor is to help patients get more time, which she claims is what they all want. Harrison takes the position of “whatever happened to do no harm” and to help patients have a good death. He asks whether this was about helping patients or forwarding their careers. While Panttiere takes offense to the career statement, she does not fully deny it either. Harrison is not only recruiting for this research protocol, he is also this particular potential subject’s physician, a dual role that could either mean that he is being protective of his patient or he is in a conflict of interest. Panttiere is the researcher in this situation and seems to be phrasing her descriptions of the experiment to minimize the risks and emphasize benefits, thus coercing people into being part of the project.

In a second scene, Panttiere is expressing her outrage that a physician would want anything other than offering any medical hope, no matter how slim, to a patient. Dr. Shane, her former paramour, says to her “Prolonging your patient’s life at the expense of their well being isn’t the way to go.” The clear difference demonstrated here is viewing a person as a patient versus as a subject. These scenes also show that the language used and emphasis placed in a consent conversation can influence how people respond.

The potential subject soon returns saying as he was packing for his trip, he realized that he had to do everything possible to get extra time. He expresses a common refrain in treating ill patients at the end of life—there is an imperative to try everything. Quantity wins the quality argument in this case. But Panttiere needs 4 more subjects for the experiment so she puts an ad on Craigslist. The next scene shows a lobby filled with people desperate for any hope. The patients exemplify this medical imperative and sense of desperation. In a later scene, the potential subjects refuse to leave until they all receive the experimental treatment. What is happening here is known as the “therapeutic misconception”—that people do not understand the intention of research is to collect generalizable knowledge, not to provide benefit to the enrolled subjects. That is especially true for small, early phase trials.

From the large group, Panttiere winnows the list of candidates to 41 and asks how she is supposed to tell 5 people they are in and tell the rest they should go home to die? Even the physician in charge of the experiment seems to have lost perspective.

Instead of choosing the 5, she joins a sit-in among the potential subjects. When news cameras show up at the hospital and patients make personal appeals, the hospital board feels emotionally coerced into spending half a million dollars to offer the protocol to all of the potential subjects. The cost is compared to a million dollar art installation that a new character is installing in the hospital and is suggested to be a waste of money.

Between the money and the 20-hour marathon of surgeries requiring dozens of health care providers, one has to question whether this was the best use of limited resources. Consider how many immunizations could be given with that time and money. An adult flu vaccine retails for $60 per dose. That means the same amount of money could protect 8,333 people from the flu.

At the end, there are unforeseen complications. All subjects spike a fever and 3 subjects die—a moment that causes Panttiere to wonder if she had been wrong after all. However this is television and Panettiere’s character is the doctor as hero. The fevers subside quickly. After waking up from anesthesia, the subjects smile and are ready to move on with their “new found time,” even though they’ve taken a huge risk with very little potential for benefit.

One more ethical issue raised in this episode is a brief aside. During the experimental procedure, all health care personnel wear radiation detection rings. When the ring turns red, a person has reached his or her acceptable dose and must step out. In explaining how this works, Panttiere explains that they must step away and not cause themselves harm. However, when Panttiere’s ring turns red she takes it off and throws it away. As the hero, the rules do not apply to her and her altruism extends so far that she harms herself to help others. This is not noble, but rather hubris in a mistaken belief no one else can care as much or provide the same quality of care. It will be interesting to see if this move comes back to haunt her.

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