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05/02/2017

BioethicsTV: Boundary Crossings, Savior Children, and Euthanasia

by Craig Klugman, Ph.D.

In last week’s episode of Chicago Med (Season 2, Episode 21), Dr. Charles cannot separate his personal and professional roles. When his daughter (an epidemiologist in the hospital) is being evaluated by his resident, Dr. Charles is concerned that no one can evaluate his daughter as well as he can. Rather than trusting his resident and the system, he interferes at every step. First, he arranges to have his resident (rather than someone else’s) evaluate his daughter. Second, he logs onto the electronic medical record to look at the notes on his daughter’s case. Third, he consistently asks his resident questions about the case. Fourth, he steals his daughter’s keys and visits her home where he finds strong evidence of her psychological disorder. Fifth, he arranges an involuntary commitment for his daughter and watches as the guards catch her and take her to the inpatient psychiatric ward.

There are two major problems in this storyline. Consider first that Dr. Charles not only tries to diagnose but actually prescribes treatment (in the form of involuntary commitment) for his daughter. There is a reason that physicians are not supposed to treat their patients including loss of objectivity and clinical gaze. The results are seen in this episode when we learn that the resident was giving Dr. Charles (the daughter) the night to consider whether she wanted to voluntarily commit herself. By usurping the plan of his resident, Dr. Charles (senior) destroys trust between the patient and his resident; between himself and his daughter; and between himself and his resident. His actions have directly harmed multiple people. Dr. Charles’s (senior) viewing of his daughter’s records (which clearly violated hospital policy as well as HIPAA) results in concern from the administrator but no actual reprimands. He should have been reprimanded for that action.

The second major problem is that Dr. Charles had a conflict of interest: He had an obligation as a physician and as a parent. He could do one at a time, but not both and he chooses being a doctor over being a parent. The result, as he admits at the end of the hour, is that he has damaged his relationship with his daughter. Conflicts of interest are best avoided. If unavoidable, then you should remove yourself from the conflict as soon as possible. If not avoidable then they should be disclosed and reported. Since this conflict was clearly known (they both work in the same hospital), Dr. Charles was in the wrong for taking over his daughter’s assessment and treatment.

In another story line, a woman comes in with her family (husband, daughter and son). She is under 30 weeks pregnant and experiencing severe heart failure. She needs immediate surgery to save her life but she refuses any intervention that threatens her fetus. Her concern is that her oldest daughter has cancer and this is a savior baby. Even more concerning, this is the second savior baby as the first one (the son) ended up being born incompatible. The family pleaded with the mother to save her life and let the fetus go. The patient refuses saying she would gladly offer up her life to save her daughter. Dr. Rose attempts a very tricky surgery (open heart surgery without bypass) that fails. In the end she is on an LVAD and has lost the fetus. The family is happy to have their matriarch alive, but the patient is inconsolable, feeling like a failure for not birthing the savior baby.

The family members state that the son is treated as a second-class citizen in the family. All attention and efforts go toward the sick daughter and the son is pushed to the side, having failed to be the savior for his sister. All hope is on this new baby. Concerns about savior children include that they are created as a means of a cure, and not as ends in themselves. Usually, creating a savior child requires selecting an embryo that is compatible, using pre-implantation diagnosis. The selection of embryos is not without controversy. Another concern is that the savior child has constrained autonomy—he or she will be a forced donor for most of her/his life. The savior child will be donating tissues, blood and marrow to take care of a sibling, without the real ability to say no. After all, the parents who give consent for these medical procedures are the same ones who had the child to be a cure for their other sick child. On the other hand, this process offers a potential treatment for someone who otherwise would have little chance to survive.

Mary Kills People (Season 1; Episode 2) opens with an older woman on a beach thanking the consultants for meeting her there. Mary releases a stream of pentobarbital into a glass and fills the rest with wine. The woman drinks the mixture. Next we see the physicians walking away, the client’s body laying on a rock at the shore. This is the second death of this series and a pattern is that after the death, the physicians walk away, leaving the body where it is to be discovered. They most likely do so to avoid police attention and having to answer questions but the act of leaving diminishes the humanity that they are trying to preserve by offering assisted suicide.

In a second case, a woman with a neurodegenerative disease is in the hospital. She is barely able to speak, struggling for every breath. She and her son want her to go home. Grace, the nurse, says they can arrange a discharge plan and refer to palliative care. The son asks how much morphine she would need to die. Grace says that she can’t do that, but she does give them the number of the “Independent end of life counselors” who can give them options. Because the patient is unable to swallow, Mary injects the pento directly into the patient, crossing the line from aid-in-dying to euthanasia.

This episode’s philosophical conversation takes place between Mary and the cop, who tells her that she doesn’t “get to play god.” It wasn’t deep, but it provided another argument in the debate as represented in the show. In other scenes, the illegal nature of their enterprise is reinforced when Mary purchases pento from Des’s drug dealer and finds herself under his control since he could expose her extracurricular activities.

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