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01/13/2017

BioethicsTV: Violating confidentialty, ethical decision-making, unapproved human experimentation

by Craig Klugman, Ph.D.

Chicago Med (Season 2; Episode 10): In this episode a heart patient returns from a previous episode when a heart is found for a transplant. However, the patient who is 3 years sober had a couple of alcohol shots that morning upon learning that her friend had died. At a meeting of the transplant committee Dr. Latham—the cardiothoracic attending—says that the rules are clear, she must be sober for 18 months before a transplant. Dr. Charles—the psychiatrist—is conflicted, concerned that he misread the patient but also knowing, as he states, that often it takes a slip before a person with an addiction takes recovery seriously. This meeting shows a contrast between deontological ethics—following the standard without concern for consequences—and ethics of care—focusing on caring and nurturing. After the committee votes against the transplant, Latham seems concerned that he may have missed something and asks Charles why he is conflicted. The response is that the patient seemed to have true regret for her slip. But when the only other matching patient is in San Diego and there is not enough time to get her and the heart together, the decision is made to go ahead with the transplant anyway, rather than let the organ die. Thus, this is a case of having your cake and eating it too: The committee gets to follow the rules, but also gets to be compassionate and caring.

The more concerning ethical challenge in this episode revolves around a jockey who is brought to the ED after collapsing. He suffers from dehydration and malnutrition likely brought on my bulimia and the use of diuretics. The patient has a mitral valve relapse, which we are told could reverse if he hydrates and eats a healthy diet. As a jockey his concern is riding in a big race and to do that, he needs to make weight. He becomes irate after he gains 2 pounds from IV saline. The patient insists on leaving. Charles and Halstead are concerned that the jockey will further harm his health. The administrator, Goodwin, says that he has to sign paperwork that he is leaving against medical advice, which the patient willingly does. This all seems proper and appropriate. But then, we learn that Charles has called the trace rack and informs it that the patient has been taking drugs, specifically diuretics, and is not fit to ride. Charles has violated patient confidentiality. The patient was not at risk of imminent harm and was not a real danger to others. The only excuse is the strong paternalism and arrogance that this character holds. In reality, if the jockey finds out, he would be in the right to bring legal action against the hospital and Charles for this action, and should report Charles to the medical board. We cannot save patients from themselves. Patients have the right to make what the health care provide might see as a poor choice. Charles is unprofessional in his actions.

 

Pure Genius (Season 1; Episode 13): This show only had one egregious ethical (and legal) violation this week. In this episode, Bell—the billionaire tech genius—and nurse Cooper talk about Louis Keating, a patient dying of a rare degenerative nerve disease. Bell’s research group has been working on a potential treatment for the disease but it was denied FDA approval for testing. The FDA believes they need 6 to 12 more months before human use can even be considered. The patient does not have that much time. Cooper says that she could not believe that someone with Bell’s money and connections finds himself victim to the bureaucracy. These two characters present the FDA as a hindrance to progress, rather than an agency committed to protecting lives. This brief conversation reminded me of Ronald Reagan’s quip that government is not the solution; it is the problem. Bell states that he can’t risk the hospital and other patients to save one person if it means the FDA would sanction them.

As the episode progresses, Bell appeals the FDA decision which is upheld “from the highest levels.” A brief conversation leads him to realize think that there may be an emergency exemption if the patient will die soon without treatment. However, giving a unique new drug to a patient would require FDA approval, even for an emergency. If the drug were approved for another use or disease, then this might be an option, since it would have already been tested for safety. But in the case of this treatment, it has never been tested nor approved for any use. For an FDA expanded access (compassionate use) for an individual, the requirement is that the risk of the disease be higher than the risks of the drug itself. Given that there was an off screen conversation with the FDA during the episode, we must assume that all such access was denied.

In a disturbing, and perhaps foretelling, scene, Bell says “What the FDA doesn’t know won’t hurt the FDA or him.” At the very end, the viewer sees Bell handing a syringe to Cooper who injects the experimental medication into an IV bag and then the screen fades to black. Is Bell practicing medicine without a license? He certainly seems to be as he increasingly dictates what treatments patients should get. Most likely, the patient will have a bad reaction and die, bringing down the full force of the FDA and the Joint Commission. However, in this show where the ends always justify the means, the patient will probably recover. Given how this show flaunts reality, the process of scientific progress, ethics, law, and regulation, it would be satisfying to see the bad outcome.

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