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12/19/2016

BioethicsTV: Pure Genius Proudly Ignores the Rules

by Craig Klugman, Ph.D.

“We’re Bunker Hill, since when do we follow the rules” sums up the attitude of this poor-performing medical drama that kicks ethics, law, and regulation to the curb on a weekly basis. Fictional Dr. Zoe Brockett uttered the above statement. In this fall finale episode, she breaks confidentiality, UNOS rules, and autonomous informed consent.

This episode (season 1; episode 8 – 12/15/2016) sees a patient with a rare blood type in need of a kidney transplant or face certain death in weeks. Her daughter, a world-class ballerina who was just offered her lifetime dream—a position with the Paris Opera Ballet—is willing to donate but is not a match. The hospital designs a new algorithm outside of UNOS to create an 8-pair transplant chain of international scope. The caveat is that the pairs will not learn of each other until after the surgeries and one pair will never be known. After all 8 pairs are flown to Northern California, we discover that mom’s donor is 1-month pregnant and thus cannot donate. However, if the daughter will still be a donor then the other 7 recipients can get their transplants.

The daughter chooses to withdraw, knowing that her mother will not get a kidney and in the recovery period she will not only lose her chance at the dream job, but she also won’t be able to be helpful during her mother’s dying. Another patient is concerned about the international representation in the donor pool, wanting only to get a kidney from a white person. The parents of a 10-year-old boy say that they will pay the daughter to stay in the chain, something that is clearly illegal in the U.S. and that is explained to them.

Chief of Staff Dr. Wallace understands the daughter’s reluctance and tells her there is no pressure and no obligation. However, Brockett feels a need to save the chain at all costs. Despite the ban on knowing donors and recipients, Brockett brings the daughter into the room of the 10-year-old boy who would have received her kidney. Brockett says that she is not coercing the daughter but wants her to see who won’t be getting a kidney based on her decision. In the closing shots of the scene, the little boy asks the daughter if she is a donor or a recipient because he’s a recipient. She hesitates but after this emotional assault says that she is a donor.

Brockett’s actions violate UNOS rules and the stated hospital policy. Wallace later “reams” Brockett, as she phrases it, but she defends herself by saying that she “saved the chain.” She says to Wallace, “I didn’t coerce her [the daughter]” and he responds that she most certainly “manipulated the donor.” Coercion is intimidating a person to perform an act through psychological or physical force or pressure. An agreement made under coercion is not ethically nor legally valid because the person was not free to make an autonomous choice. According to the Oxford English Dictionary, manipulation is “The action or an act of managing or directing a person, etc., especially in a skillful manner; the exercise of subtle, underhand, or devious influence or control over a person, organization, etc.; interference, tampering.” While the show might be making a distinction between two terms, in spirit they are the same thing in regards to forcibly pushing a patient to make a decision that she or he would not have made on his/her own.

Brockett’s punishment is being taken off of the transplant surgery on which she was scheduled to assist. Wallace tells her she was lucky not to have been fired. Realistically, she should have been fired and reported to the licensing board. By giving her a lesser penalty, she may repeat her actions in the future, causing harm to future patients.

The bigoted recipient is basically ignored. Once his wife is in her donation surgery he is told that since the chain is unbroken, if he wants to refuse the kidney being donated to him by a minority individual, he can but he would be the only person who suffers: The chain is maintained. He agrees and swallows his hatred.

The secretive pair turns out to involve a donor who is a prisoner for violent crimes. He declines meeting his recipient because he feels that he does not deserve to be thanked after all of the bad things he has done. As he states, one good deed does not make up for his past nor make him a good person. Such a sentiment comes directly from Aristotle who stated that a deed is moral if it fulfills three qualities, one of which is a consistent and established character. Dr. Verlaine tells the donor that may be true, but one act can help a person on a road to changing and making amends.

The deeper conversation from having this particular donor is that in general, prisoners cannot donate organs in the U.S. Much has been written on prohibitions against death row inmates donating, but far less from those serving life or shorter sentences. Certainly donating cannot lead to a reduction in sentence, rewards, better treatment by guards or warden, or earlier probation since this would be the equivalent of paying for an organ (getting a good in return for donating) and would also be highly coercive (get out early if you donate a kidney). Prisoners are considered a vulnerable population and their ability to freely consent can be (but is not necessarily) compromised. In addition, prisoners have a higher rate of hepatitis and HIV than the general population and thus are considered to be a higher risk pool for transplant. . However, in 2013, Utah became the first state to create a prisoner organ donor registry (joining Maricopa County, Arizona; New Jersey and Florida allow prisoners to donate if they were on the registry before incarceration or If the family decides to donate posthumously).

The moral theme of this show is that the ends justify the means. The daughter donates and all 7 recipients receive their new lives. They are all shown hugging and jumping and dancing at the end of the episode. There is no mention of a lifetime of anti-rejection drugs or any negative aspects of being a donor or a recipient. Even Brockett who coerced the daughter finds redemption when she is able to complete development of an artificial kidney that is surgically implanted into the mother to give her one additional year of life. Although we are told the device is experimental, nothing is said of a new device permit or FDA oversight. We are shown a 3-D printed model as proof the device works, but no animal testing is done. And the pregnant woman who could not donate signs a contract pledging to donate her kidney after she has given birth. Of course, she lives out of the U.S. and if she violated the contract, who is going to arrest her, extradite her, and forcibly remove her kidney? No one.

This show that flaunts its unethical, illegal actions has five more episodes in the bank. While it has not been cancelled, it has not been renewed either and no additional episodes have been ordered. Unlike Brockett, hopefully the show will bear the full consequences of its tragic actions.

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