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05/20/2016

BioethicsTV: Week of May 20 – Assisted suicide, public health crisis management, and making promises

Chicago Med
In its first season finale (episode 18), Dr. Downey arrives in the emergency department in distress—he is bleeding from his liver as a side effect from his cancer treatment. When he does not awake from the anesthesia, Dr. Rhodes, his protégé, suspects a stroke during surgery. A CT scan shows that Downey did not have a stroke, but rather has a large, inoperable brain tumor—his cancer has metastasized. We are told that his future prognosis is grim and that he is in unrelievable pain. Instead, he asks Rhodes to help him die. This request is a reference back to episode 11 when Rhodes removed a patient’s LVAD at the patient’s request and Choi accuses him of performing an assisted suicide.

Rhodes tells Downey that he can’t help him die. In Illinois there is no legal assisted suicide and the AMA has come out against doctors being involved in that process. In a later scene, Rhodes brings a necklace of puka shells to Downey, a reminder of his love of all things Hawaiian. They have a touching moment of saying goodbye. Then Rhodes leaves the room and seconds later, Downey codes. As the staff rushes into the room, Rhodes yells that he is DNR. The episode ends without any questions. But the strange timing left me with the question of whether Rhodes did assist Downey in a suicide. One possibility is that some of the puka shells actually contained live organisms. The cone snail (which creates the puka shell) is venomous and some have venom that can kill a human. A more likely possibility is that there was something other than puka in the necklace. Consider that Downey mentions how much he loves the smell of jasmine when he first gets the gift. The thing is, puka shells have no real smell. But, yellow jasmine and Madagascar jasmine fruit are poisonous. When Rhodes leaves the room, Downey could have ingested jasmine placed in the necklace. Given that Downey was cremated and his ashes spread in the Hawaiian waters in the final scene, it is unlikely that anyone would find out.

Assisted suicide is legal in 5 states under very controlled and regulated circumstances. Assuming Rhodes did sneak something into the necklace, were his actions ethical? Under Illinois law, they were illegal. Under the AMA code, they were violations of the physician’s role. Downey made a competent and capacitated request that was in line with his long held beliefs, and even actions toward other patients. Rhodes may have made a means available, but ultimately it was Downey’s choice to consume the poison. This was less doctor-assisted suicide than it was aid-in-dying from one person (who happened to be a doctor) to another person (who also happened to be a doctor). But there was nothing involved (like medications) that only a doctor could have procured.

Containment
This show continues to get stranger and to ignore all good advice for crisis response. For the last 7 years, the Institute of Medicine has been urging states and large cities to prepare crisis response plans. Such plans are supposed to be based on ethical frameworks. This show has either never heard of such plans or is deliberately not following them (as is suggested since it seems this outbreak was not natural nor a terrorist operation as viewers were earlier led to believe). Consider that in a week’s time on the show there has been a near complete breakdown of civil order. Gangs are a strong force and seem to be controlling much of the cordoned area. One gang even stole government food rations that were quickly brought in and distributed with less than 24 hours of planning.

This begs the question as to why no one conceived that a cordoned off area where no one gets in or out, might use up its supplies? Shouldn’t food distribution be one of the first things established once the cordon was in place? (I also chuckle when I see people driving cars in the cordon, wondering where the gas is coming from).

The police major confronts the response leader about not having had enough time to set up the distribution procedure properly. The result of the lack of planning and subsequent robbery is that people are going hungry and gangs control the food for which they will charge a high amount. The leader’s response is chilling: (a) there is more food in the cordon today than yesterday and (b) haven’t there always been people who cannot afford food? When working on developing crisis plans, there is often a stated value that while a crisis situation cannot eliminate social and economic disparities, responses should not exacerbate it. Another value is that all lives are equal and no one should be discriminated against for age, sex, race, sexual orientation, disability, socioeconomics, immigration status, etc. But this show seems to be condoning an exacerbation of injustice. In fact, the message seems to be Nietzschean—might makes right.

Another common value to these response plans is transparency—the idea that there needs to be honest and open communication at all levels. However, in last week’s episode when unapproved images from inside the cordon were being sent into the world, internet, phones, and all forms of communication with the outside world (except for police and medical) are cut off. In this show, there is also a lack of information flowing from the top to the bottom of the response teams. This is likely for dramatic effect: There is some secret being kept from the viewer and characters alike. In the real world though, transparency and open communication are important. Yes, the message needs to be spun so as to avoid general panic—but truth and facts are important.

The last theme appearing in this show is that of racial tension. One gang is African-American, one is Caucasian. There is even a standoff between the cops—those who want to let a fellow “brother in blue” in the cordon who may have been infected to the outside world and those who are towing the line of “no one in or out.” The words come over a visual of the police standing in two separate groups, one black (for holding the line) and one white (let the infected cop out). One of the officers insinuates that the groups are divided not along ideas of holding the cordon, but rather along racial lines. Racial issues are even seen in the declaration that a Syrian immigrant was patient zero and that he brought this genetically engineered virus to Atlanta in an act of bioterrorism (this week’s episode put that theory into question). It is interesting to note that in this show, the people in positions of true power—the response leader, the lead doctor, the highest ranking cop in the cordon, are all white. With much of the season remaining, it will be interesting to see where this theme goes.

Heartbreak
Episode 9 finds a child with a congenital heart defect and HIV+ dying. A year earlier, Dr. Panttiere made a promise to the boy who wanted to know that his heart would live on in someone else after he died. Today, the boy is brought into the hospital after having coded in the ambulance. He was down for too long and is presumably brain dead. However, keeping her promise proves difficult, as no one wants such a diseased heart. The ethical issue is that Panttiere knew that there was no possibility of transplanting this child’s heart into someone else. If she made a “promise” as a little white lie to calm a scared child’s fears of dying, then this might have been an understandable statement. Except in this case, she made a true promise. Physicians should never make promises that they cannot keep—to do otherwise risks destroying trust.

The promise, however, is fulfilled by transplanting the heart into a chimpanzee with heart disease. The viewer is told that this is the first human-to-animal transplant. Besides the obvious challenge of getting the boy’s reluctant father willing to consent, the hospital administration is wary because of concerns over bad publicity. And everything turns upside-down when it’s discovered that the chimp was stolen (i.e. “liberated”) from a clinical research facility. The COO recognizes the animal’s tattoo code and calls the clinical research company. They commend her for doing the right thing in returning their property. Several surgeons, meanwhile, fake a death for the animal so that they can complete the surgery and won’t have to return her. This show often takes the perspective that the ends (keeping a promise, saving an animal’s life) justify the means when that is usually far from the best policy.

There is an interesting dialogue on the value of clinical testing on animals and the strides in human health that have been made. A preachy scene discusses how much more progress could be made if physicians and veterinarians collaborated more. There is also a discussion about how the humane treatment of such animals is essentially. The private lab in question had the chimp locked up in a cage for 32 years. We learn that St. Matthews hospital, where the show takes place, only uses humane methods in keeping and testing its animals. The viewer is left with the idea that there is value to animal testing but how the animals are treated is the difference between an excusable act of stealing an animal from the lab (ends justifies the means thinking), and knowing it will be treated well while helping science progress.

And that is this week in medical drama.

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