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10/18/2016

BioethicsTV: 10/11-10/17 – Assaulting demented patients, sex trafficking, and surrogate decision-making

by Craig Klugman, Ph.D.

An occasional column examining the ethical issues raised in television medical dramas.

On Code Black (Season 2; Episode 3) the most important ethical issue was very brief, not taking more than about 2 minutes of screen time. Dr. Angus Leighton is a resident whose brother is unconscious and connected to life supporting technology after falling out of a helicopter (it is a drama after all). Angus is the named medical power of attorney. However, his father has had his attorney draw up papers that transferred the power of attorney from Angus to the father. The odd thing about this is that no such mechanism exists. In reality, a patient appoints someone to be her/his medical power of attorney in order to make decisions when he or she is no longer able to. There is usually a primary appointee and then secondary (even tertiary) persons named. An appointed proxy can choose not to take on that role, but he or she cannot assign that role to anyone else.

Chicago Med (Season 2, Episode 4). An 82-year-old demented man in distress is brought into the ER by his young girlfriend. He suffers from a large cancerous mass and his son wants no aggressive measures but the girlfriend wants to do everything. The son claims that when his dad was first diagnosed and was not yet demented they discussed his future health care wishes. A family meeting is held consisting of the son, girlfriend, Choi (an ER chief resident), Latham (an attending surgeon), Rose (a surgical fellow), and the hospital attorney (who in the pilot episode said that ethics was useless).. The son is adamant that his dad made his decision not to pursue aggressive treatment. The girlfriend denies that. The ER doc says that supportive care would help him die in a few weeks but excision surgery could buy him longer time. The surgeon says that an operation is an option. The surgical fellow offers that surgery has risks but could be a cure. The administrator asks who can legally make decisions. The hospital attorney says that absent an advance directive, the son is the legal decision-maker, a statement which has the ER doctor say “My job is to keep my patient alive.”

Choi approaches the patient and asks him if he wants surgery. The patient inquires several of him several times if he’s a doctor and displays other signs of dementia. Choi immediately goes to the surgeons and suggests presenting a “united front” against the son to convince him to allow his dad to have the surgery. The surgeon says, “Our job is to fix ailments and until [the family] asks us to do that, there will be no surgery.”

When the patient’s stats drop from a hemorrhage, he is making incoherent noises. Choi says, to a nurse and Rose, “He says save me.” Of course the audience hears no such thing. The son says he’s demented and can’t express his wishes. The doctors wheel the patient off to surgery. The doctors later question if the patient did indeed say “save me.” Choi even asks the nurse who was in the patient’s room and she admits that she did not hear the statement but it’s okay because “We’re here to save patient’s lives.”

After surgery, the patient awakes and appears to no longer be demented. He points out that the girlfriend is using him and he knows it. Not only was his cancer “cured” but so was his dementia—the ends justified the means in this show’s philosophy. The nurse tells Choi “you made the right decision.” Choi says that when he was in the military, combat medicine made decisions easy—you always try to save, but the nuances and ambiguities in civilian practice are harder to know.

Yes, medicine has a goal of saving patient’s lives, but not over the rational refusals of patients or their legal surrogates. This was not a surrogate acting against the patient’s interest or ignoring the patient’s previously stated wishes—this was a son following his father’s instructions. There is also a goal in medicine of respecting patients and their (or their surrogates) rational wishes. . Another goal is to always provide comfort. This does not mean hearing what one wants to instead of what the patient (or surrogate) actually says or wants. In a case such as this, why wasn’t palliative care or hospice consulted? Why wasn’t an ethics consult requested, especially in light of the family meeting—after all, the department administrator likely is not the right person to run that gathering. The fact that no one questions these actions, or the battery of doing surgery without consent is never raised because “a life was saved.” The temple of the MDeity is alive and well in Chicago Med. This show takes a purely consequential perspective to the practice of medicine, even when it violates patient autonomy and rights to self determination. .

However, the main storyline in this episode concerned an immunocompromised girl with a superbug that may kill her. When several other patients show up infected, infectious disease traces the outbreak to an endoscopy tube that has a small area that is impossible to clean and may harbor bacteria. The FDA knows about this, we are told, but doesn’t pull the device because they don’t want to cause a shortage. “So the agency created to protect patients…made a cost-benefit analysis.” Of course, this is a pulled from the headlines moment and the viewer is supposed to be appalled that money drives these decisions, perhaps over patient safety.

A third storyline concerns a young man who comes in for stomach pain. We learn that he is the subject of sex trafficking when the team discovers an implanted tracking chip. As we are told, he’s an adult and he has to want to leave his pimp before anyone can help. A fourth narrative ends a previous storyline about a nurse whose sister is on a ventilator. After the hospital receives court orders from the family, the patient is disconnected from the ventilator and quickly dies.

Reports on bioethics issues in non-medical shows

Jane the Virgin (Season 3, Episode 1). In the season premiere of this American telenovela, Michael, the husband of the main character—Jane, has been shot. Unconscious and in critical condition, his wife of a few hours must decide whether to (a) wait and see, which will likely result in paralysis or (b) surgery to remove the bone fragments, a procedure that may kill him. His mother does not want to take the risk. But his new bride is unsure. Her grandmother offers her advice, “You know him best. What would Michael want to do.” This helps Jane to recall a prior conversation where he talked about being a risk taker. She declares that he would want the surgery, a decision supported by her father-in-law. In reality, even though they were only married a few hours, indeed the new wife legally is the decision-maker. Her grandmother offers the perfect ethics consultant advice, that her job as the decision-maker is to choose what the patient would want, not what she or his mother would want.

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