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12/01/2016

BioethicsTV (November 2016): Informed consent, HIV organ transplants, Forgiveness, Assisted Suicide, Treating Prisoners, Undue Influence in Consent, and Failure to Vaccinate

by Craig Klugman, Ph.D.

Grey’s Anatomy (Season 13, Episode 9). A building collapses when a landlord has failed to make necessary repairs a year after an earthquake. The landlord mistakes a resident for a priest and confesses that his neglect was the cause of the tragedy that has led to much morbidity and mortality. The resident wonders if he has to preserve confidentiality like a priest or if information told to a doctor is different. A fellow resident tells him that since it’s not medically related, he has no obligation to maintain this particular confidence. Later, after surgerty the landlord tells the resident that he knows there was never a priest, but he simply needs someone to forgive him. The question then is whether the physician can offer a patient forgiveness for causing mass casualties to others. Of course, a physician must treat every patient the same irrespective of anything the patient may or may not have done in life. Thus the serial killer is treated the same as the cop. Health care professionals must make no moral judgments about choosing who to treat and how. But what if a patient admits criminal neglect? If the physician is a mental health professional, then the therapeutic privilege of confidentiality may protect the patient’s secret (unless there is an admission of fraud or abuse). But to your surgeon or anesthesiologist there is no such promise of confidentiality. In fact, the non-therapist physician may be obligated to report knowledge of the crime.

Chicago Med (Season 2, Episode 7-11/3) The main story line consists of a female patient who presents with altered mental status. Turns out she has a heart infection that is causing micro strokes that have affected her cognition. Cardiac surgery fellow Rose takes her for surgery but not before Charles, the psychiatrist, stops him, asking how the patient was consented. Rose responds that he explained everything to her and she signed. Charles says he only sees scrawl and that she’s not capacitated to consent. Later Rose shows up with signatures from two attendings saying the surgery was necessary and most be done imminently, which is a stretch. Charles calls him on this to the administrator stating that it violates not only ethics but also the law. However, after watching her first love die, the administrator says that Rose should go ahead and tells ## that he can file a complaint. At the end, the patient is better and has no memory of meeting the psychiatrist or anything that happened before her surgery. Rose sees this good outcome as his proof that he did the right thing. Charles is not so sure, thinking that there was no informed consent for this surgery. The reality is that the two doctor rule only applies to imminent threats—a patient likely to die within about 2 hours. This case was urgent, but not that imminent. Why didn’t they call for an ethics consult? Because this show established ethics as merely policing doctors, looking for wrong doing in its premiere episode. Certainly a family member or surrogate could have been found or an emergency court order could have been sought. In this show as in most television dramas, the ends justifies the means even when it violates ethics and law.

Chicago Med (Season 2, Episode 8-11/10). A brother has end stage kidney disease and heart disease. He needs a kidney transplant, as he can no longer receive dialysis. Given his complicated health situation, he is unlikely to receive an organ off the UNOS list. His brother is a strong match but is gay and HIV positive, two facts that he has not shared with his sick brother who is homophobic. Such a transplant is illegal because the patient would become infected and the immune suppressant drugs would make the disease very difficult to treat. Dr. Halstead also states that such a transplant would be unethical because it would be harming the patient. However, the patient is willing to take the risk because the his current life span is days.. The doctors end up providing a syringe to the patient and explain that an HIV infected organ can only go to a patient already infected with HIV. The doctors say that they cannot infect him, but his brother could, and they walk out. While this storyline is not resolved, the implication is that the brothers will go through with it. The mere suggestion, nevermind making the means available is not only a violation of a physician’s fiduciary responsibility and nonmaleficence but is also illegal. Of course the viewer is supposed to see the physicians as noble, doing everything possible for their patients. The reality is these physicians should lose their licenses.

Code Black (Season 2, Episode 5 – 11/2). In this episode a mother brings in a troupe of campers with “poison ivy.” The grandmother soon faints with similar symptoms. The diagnosis is measles because the mother chose not to vaccinate her child. Her mother was susceptible because she last had the immunization decades earlier. The mother says she did her research on the internet and made the decision to protect her children from autism and other conditions. A first year resident offers her a lecture that the internet material is not scientific but the diseases the vaccinations protect against are very real. Indeed, there have been outbreaks of measles in public places (most notable DisneyLand). For some diseases, such as measles there has been such an epidemic of parents avoiding vaccines that herd immunity has been lost, meaning that vulnerable people who may have low immune systems (like the grandmother) or who cannot have immunizations for medical reasons are at greater risk. The resident was correct and even though his method of delivery was aggressive, he is correct that not a single legitimate study has shown a risk of autism from vaccines. The mother at that moment did not need a lecture, but compassion. A lecture, however, should have been delivered after the immediate danger was past. As a t-shirt my husband has says, “Your Google search is not the same as my MD.” At the end, grandma comes through fine and the daughter has an appointment to vaccinate her kids.

Code Black (Season 2, Episode 6). A young woman is brought to the ER suffering from metastic cancer that has infiltrated into her brain. She has frequent seizures and loses the ability to speak on occasion (though she can communicate by writing). The 22-year-old woman wants to die and has asked Dr. Campbell (surgeon and ER chief) to help her die under California’s new End of Life Option Act. When she regains the ability to speak, she says that she wants his help and the ten days between first and second asking under the law have passed (the real law requires 15 days between oral requests plus a third, written request). Campbell refuses to help her, saying that the job of a doctor is to save life, not end it. The patient’s mother also is against an assisted suicide, urging her daughter to try more chemo and fight on. The mother soon learns that her daughter is an adult and gets to make her own decisions now. Dr. Willis (semi-permanently visiting military trauma surgeon), however, feels compassion for the patient, especially since his own mother died of ALS and wanted to have the option to end her life sooner. He provides the patient with a large pill (in reality, it’s a lot of pills, not a single big one) and a bottle of wine. The patient’s mother holds her hand and finally crawls into bed with her, holding her child as the drugs kill her.

 Code Black (Season 2, Episode 7). After a prison fight, a number of prisoners are sent to the ER. The doctors have to work hard to save a patient after a guard was killed. A surgical resident asks why they worked so hard to save a murderer. Rorish’s response is the correct one, “Because he’s a patient.” I say correct because patients should be treated as human beings irrespective of what they may have done in the world. In fact, in the United States, prisoners are the only population with a Constitutional right to health care (according to the Supreme Court).

Code Black (Season 2, Episode 8 – 11/23). A cult is brought to the ER after attempted mass suicide in an attempt to live forever in a virtual world. Led by their prophet, each cult member states that he or she does not want any medical treatment and refuses all attempts at medical intervention. Willis wants to treat them anway, saying that they lack capacity to consent or to refuse treatment. A psychologist says that they cannot treat the patients since each patient clearly stated a refusal of treatment. Willis is the final arbiter, deciding that they would treat all the patients despite what their words. The notion of undue influence may come into play here. This is a notion that a person is so influenced by another person that agreements made by the first person should be set aside. In other words, another person is such a coercive force that a person is unable to make a truly autonomous choice. In this case, the leader of the cult who leads his followers in a call and response refusal of treatment is such a coercive influence, that the patients are not actually legally or ethically able to refuse life sustaining treatment (in this case treatment needed as a result of their attempt to poison themselves).

Pure Genius (Season 1, Episode 4 – 11/17); The genius administrator of this futuristic hospital, who has no medical training, continues to dictate medical practice—telling his chief of surgery that he must repair a torn knee meniscus using a robotic surgery tool “because it’s cool” even if not medically indicated. Of course, like most medical shows where the ends justify the means, this unwarranted technique discovers a cancerous mass. The genius suggests that they pre-program a robot to automatically perform multiple complex surgeries at the same time, doing what a surgeon cannot do. However, it certainly is not more than a team of surgeons could do or a single surgeon could do over multiple surgeries (since each surgery is a distinct part of the body). The chief expresses his concern by saying, “Just because a patient is going to die, doesn’t mean you turn them into a guinea pig. This is a human being we’re talking about here.” The genius responds, “We have no other recourse.” And in the hubris of this show, the attempt is successful. I take issue with a surgeon who consistently tells his boss “no” when it comes to crazy procedure ideas and then always does them, even though they are medically not indicated. Every procedure done on this show is experimental and yet there is little conversation with patients about the risks or benefits and no conversations about FDA trials. The idea is that to truly innovate, medicine has to look less like a safety-conscious, conservative enterprise and more like a tech start-up. The difference is that in a start up failure means something doesn’t work and money is lost. But in medicine, if there’s failure a person could die or be permanently injured. Such a hospital in real life would be shut down very quickly. Also consider that this is a hospital where money is no object—no one ever asks what the cost is, or what the long term cost to a patient will be, or even whether creating an entire new technology to save a single life is the best use of resources. Or perhaps this show is what happens when corporate interests practice medicine—ignoring safety, ignoring the law and ethics, and ignoring that patients are vulnerable people who need help not to be used to further other goals (profit, fame, stock price, etc.).

Pure Genius (Season 1, Episode 5 – 11/24). A patient with facial disfigurement is set to receive an experimental treatment of printing skin directly onto her wounds. The only problem is that the FDA has just banned the use of bioprinted body parts. As usual chief of surgery Wallace says that if the FDA has a ban, then you don’t do it. Tech genius and hospital owner Bell plans to woo the FDA (the representative happens to be Wallace’s wife). The FDA nails the problem with a genius running a hospital, “He thinks he can get whatever he wants.” Wallace uses emotion to sway his wife’s opinion by introducing her to the patient and the patient’s daughter. The wife caves and grants a one-time, first in human permit. Coercion? Conflict of interest? No mention is raised. The ends justify the means in this show.

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