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01/06/2017

BioethicsTV (January 2-6, 2017): Violating promises, coma v. PVS, transplant evaluation, and whether to abort

by Craig Klugman, Ph.D.

Pure Genius (Season1; Episode 10- 1/5). In this episode, Dr. Channarayapatra is working with a patient in lung failure. Due to exposure to toxins dumped in the ground beneath her neighborhood, the patient’s lung tissue is disintegrating. Bunker Hill hospital is attempting to build the world’s first implantable, artificial lung but has not had success. With her lung function decreasing, the patient may soon face one of two options: death or ECMO—a process where a machine oxygenates her blood outside of the body. The viewer is told that ECMO can only be used for a maximum of two weeks. The patient tells Channarayapatra in no uncertain terms that she does not want to be on ECMO. Channarayapatra promises that she will not put the patient on ECMO. However, when the crisis appears and the patient’s lungs fall apart, Dr. Channarayapatra goes back on her promise and begins ECMO.

There are three concerns with this scenario. First, a doctor should never make a promise to a patient that she or he cannot keep. Second, a doctor should keep promises made to patients. Third, if a competent and capacitated patient has clearly rejected an invasive medical treatment, then the patient’s right to refuse consent and to reject that intervention must be honored, even if it results in the patient’s death. Otherwise, the physician commits a battery by touching a patient without permission and also violates the patient’s autonomy.

Of course, this being a show where the ends always justify the means, an artificial lung is created and implanted in the patient (without any animal or preliminary human testing of course). Nor is she consented for that procedure and we are told that she is unbefriended, so who is consenting? It appears that walking into that hospital is viewed as consent for being a guinea pig. The patient does recover and scolds Channarayapatra for putting her on ECMO. The new lung operates perfectly. At the very end, Channarayapatra receives a distinguished award for her advances in medicine. Apparently the price of that award is breaking promises to patients and assaulting your patients.

Chicago Med (Season 2; Episode 9 – 1/5). The show makes its winter return with another trifecta of ethical dilemmas. As part of a continuing storyline, a nurse with TB is taking her prescribed treatment. However, she is pregnant and has been told that the meds could affect the fetus. At a regular exam, she is told that her 12-week old fetus is far smaller than it should be and displays traits that may indicate anencephaly. Is this caused by the meds? Is it a real problem or something that will resolve? The show tells us that if she decides to terminate the pregnancy, it needs to happen by 14 weeks to avoid complications. The father asks what will they do? Given the short time frame available he thinks they should consider termination. The mother says that she is Catholic and there is no circumstance under which she would abort. What if they abort and learn that the fetus was fine? What if they carry to term and have an anencephalic child that lives for only a few hours? The tension between the two characters and their positions is likely to end their relationship.

A second storyline concerns an MMA fighter who is brought in after a vicious cage fight. He falls unconscious at which time we learn he has a brain bleed. An emergency craniotomy gives him a chance to survive, but his pupil was fixed and dilated even before the first incision. Dr. Choi tells the family that the patient is in “a persistent vegetative state.” The patient’s mother then asks, “Is he in a coma?” To which Choi nods, yes. She then asks if he will wake up, and Choi says he did not know. This exchange perpetuates a misunderstanding that makes it harder for families to understand that a coma and a persistent vegetative state are two distinct things. In a coma, a person is neither aware nor awake. He or she is unresponsive to stimuli, lacks a wake-sleep cycle, and is incapable of taking voluntary action. A coma may be reversible or irreversible.

A persistent vegetative state is usually diagnosed after 4 weeks in an insentient state, and after 3 months the patient is said to be in a permanent vegetative state. Patients in PVS are awake but not aware. They have sleep-wake cycles but cannot initiate voluntary movement to stimuli. Recovery from PVS is highly unlikely and becomes even less likely the longer a person is in the state.

By not explaining this difference, Choi leads the family to believe that recovery might be possible when it is not. The family will eventually have to decide whether to withdraw life support or transfer the patient to a long-term care facility for patients in PVS. Or more likely, Choi (and the writers) simply do not understand. Where was the neurosurgery consult and why didn’t neuro speak to the family? Where was the discussion about options (other than prayer and hope, which is what are offered)? By not explaining the difference between coma and PVS, this show makes this conversation more difficult for those of us who may have them in the real world because the show feeds into a common misunderstanding.

The third storyline concerns a psychiatric evaluation for a patient in heart failure. The patient is a recovering addict, 3 years sober, but having done it on her own rather than through therapy or a 12-step program. From an ethics perspective, what’s interesting in this story is Dr. Charles’ discussion of the importance of the evaluation he has to make—whether the patient understands the surgery and what life will be like afterwards, that she has a sufficient support system, and that she will take care of this heart. He says that the decision is important because if she gets the heart, then someone else will not. Thus, he takes this role seriously. The question of justice—that a heart for transplant is a valuable public resource—was a good justice conversation in the episode. Charles’ speech also raises the issue that when one person gets a heart, others die who did not receive it. We should also consider that someone had to die for a heart to even be available.

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