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12/20/2016

BioethicsTV (November 2016) Continued: Further commentary on Informed Consent

by Abhimanyu Amarnani

Chicago Med (Season 2, Episode 8, 11/10/16).

A December 1st BIOETHICSTV blog post briefly mentioned, Season 2, Episode 8 of Chicago Med. The post notes that the episode dealt with the issues of informed consent in brief. I felt that a more in-depth discussion of these issues was warranted. Consider the storylines in the episode: A young girl with a developmental disorder needs cardiac surgery. Her condition forces her mother to question whether the girl can make decisions for surgery. Second, Nurse April was coughing at the end of episode 7, and viewers learned that she is diagnosed with multidrug resistant tuberculosis (TB). Adding to this challenge is a confirmation of pregnancy. Her colleagues question her personal autonomy when she considers refusing treatment. Third, a patient dying from kidney disease is not allowed by hospital policy and law to accept a transplant from his HIV+ brother. The message is that death from organ failure is preferable to a longer life with HIV. By the end of the episode, Dr. Manning leaves a syringe on the table stating: “If you already had HIV, the procedure would be legal,” insinuating a workaround – that if the patient infects himself with his brother’s blood, then the transplant can happen. The donor and recipient acknowledge fully informed consent that receiving an HIV positive organ will infect him, but here the informed consent consideration comes up against the “do no harm” principle of medicine and United Network for Organ Sharing (UNOS) policy.

In the first storyline, a friendly, bubbly and trusting teenage girl, Karina, enters the hospital with cardiac issues. She has Williams syndrome, a genetic condition where patients frequently have cardiovascular disease (aortic stenosis) and social-emotional behaviors that make them more trusting and more willing to approach strangers. Karina needs heart surgery, and while she expresses that she wants the surgery, her mother asks to speak with Dr. Rhodes alone. Karina’s mother has more concerns about the surgery than her daughter, and notes that Karina is potentially saying yes only to please Dr. Rhodes, a side effect of her condition. Informed consent is based on the basis that the patient has a right to self-determination, however in the case of children under the age of 18, the parents (or legal guardians) are looked at as the decision-makers. Competency to make decisions, by law, is not independently attributed to those under the age of 18. In this case especially, Karina’s mother must play the decision-making role because with Williams syndrome, Karina also does not have the capacity to make a rational choice. Dr. Rhodes however still consistently tries to pull Karina into the discussion. Why? It has been understood that the informed decision should be “with the assent of the child whenever possible” and that even though parental consent is key, the highest goal is providing appropriate care (American Academy of Pediatrics, Committee on Bioethics). Doctors are even recommended to seek legal intervention if parental refusal puts pediatric patients in a clear and substantial risk. In this episode, these ethical nuances of informed consent were underscored by the discussions between Dr. Rhodes and Karina’s mother: Dr. Rhodes maintained that he was convinced by Karina’s assent, regardless of her capacity to make an informed decision, and Karina’s mother highlights that she has the decision making competency even though her daughter is the patient. In the end, after several scenes of discussions, the mother came to the decision to operate when weighing the severity of Karina’s cardiac disease. Of course had the mother decided against the doctor’s preference, then given his character, Dr. Rose might have proceeded anyway or might have sought the hospital attorney to pursue a judicial override of the parental decision.

The second storyline concerns a nurse, Alex, who started coughing at the end of episode 7. By episode 8, she was diagnosed with multidrug resistant TB. Although she had been previously exposed to TB, she was on her initial treatment regimen to prevent the disease from becoming full blown. As it turns out, she was also taking birth control. Accurately portrayed in the episode, the patient’s medication regimen (which could have been isoniazid with rifampin) can lead to drug interactions with birth control (decreased ethinylestradiol levels) because of increased drug metabolism. Her newly discovered pregnancy led to decreased immune system function. This perfect storm allowed the latent TB to activate. Unfortunately, the only drug that would work to treat her TB now is known to cause neural defects in the fetus. She considers not taking the medication, but Dr. Halstead already put in the order and the first dose was coming up. Why did he already order the medication? Does she not have the option to refuse treatment under the ethical guidelines of autonomy and informed consent? In a later scene, Alex and Dr. Halstead discuss that if she doesn’t take the medication there is a very high chance she and the baby will die. What they don’t discuss is the underlying truth that they both know as healthcare providers – the fact that she has to be treated for TB for her health and the health of others. In other words, TB is not only a personal issue, it’s a public health issue. Drawing on Mills’ harm principle, a patient’s freedom to choose cannot infringe on the rights of others or cause harm to others. An option to opt out of TB treatment inappropriately prioritizes individual autonomy over the public health interest in controlling a highly transmissible infection. In fact, The Centers for Disease Control and Prevention note that “an undiagnosed, untreated person with active pulmonary TB disease can infect an estimated 10-14 people in a year.” The CDC also highlight the practices for TB control. This case, which I’m sure will continue in further episodes, notes the important ethics of public harm vs. individual autonomy.

Near the end of the episode, a third story appears: Dr. Manning has tried everything to get approval for Jim, a patient dying from end stage kidney disease to receive a kidney donation from his HIV+ brother. Under UNOS guidelines, HIV+ individuals can only donate organs to other HIV+ individuals. Manning is ready to go tell the patient that “the one thing that he needs [his brother’s kidney] more than anything else in the world is right in front of him and he can’t have it and he doesn’t have a choice.” Dr. Halstead says there is one thing they can do to make the transplant legal: “He already said he is willing to deal with HIV infection, let’s give him the option.” The December 1st post pointed out Drs. Manning and Halstead suggesting and providing their patient with a means of infecting himself with HIV is both illegal and unethical. They broke the most basic patient care principle of nonmaleficence, even though the patient was fully informed and ready to accept the risk of now having HIV. Given that in 2013 the HIV Organ Policy Equity (HOPE) Act was passed removing a 1988 prohibition on transplantation of HIV-infected organs, and some of the first HIV+ to HIV+ patient transplants occurred in 2016, Chicago Med brings up a complex issue that goes beyond legal practice: Could some healthcare providers in the future try to justify the means of giving a patient the know-how to become infected with HIV/AIDS, with the ends that the patient could then receive an HIV+ organ transplant?

As this episode was the fall finale of the series, perhaps upcoming episodes will dive into the legal/ethical ramifications that may come when the patient returns to the hospital HIV+, and ready for a transplant.

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