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09/29/2017

BIOETHICSTV: Gender-change surgery; coercing consent; conflict of interest and impaired judgement

by Craig Klugman, Ph.D.

Late September means the beginning of a new television year. This week saw the return for the 14th season of Grey’s Anatomy and the introduction of a new medical drama, The Good Doctor. However, the first major bioethical dilemma of the new season came from an unlikely place—a new science fiction show.

The Orville (Season 1; Episode 3): Forced Gender Surgery on a Newborn
The first significant BioethicsTV episode came from an unexpected place, a new science fiction show called The Orville. This show is an off-brand Star Trek and shares a creator with several of the franchises of that fictional universe. An officer on this new ship, Bortus, is a member of the Moclans—a single-sex species who identify as male. When he and his partner lay an egg, they hatch a female. In a species of only males this is seen as an abomination. The viewer learns that such a birth (what they call “a birth defect”) happens rarely and the infant is usually immediately given “gender correction” surgery. The parents request the ship’s doctor to perform the operation and she refuses, citing the Hippocratic Oath and that she would not operate on a healthy child when the reason is not life threatening. An appeal to the Captain has him supporting his doctor. The parents then call their home planet and a ship arrives to bring them to the homeworld for the operation. While awaiting the transport, Bortus changes his mind as a result of watching the children’s stop-action television special, Rudolph the Red-Nosed Reindeer, deciding that one cannot know what kind of life a child who is different will lead. His partner has not changed his mind. When the homeworld ship arrives, the Maclan captain explains that the state is required to support the parent in favor of the surgery. Bortus asks for a trial where the social consequences for being an outcast and an outsider are laid out.  Various issues are discussed including the rights of parents and the power of the state, stigma and social ostracism for being “different,” the right to be as one is born and to decide one’s own life, and whether one species (or culture) should judge or honor the practices of another.

The story is clearly a commentary on gender determination surgery imposed on children born intersex. In the U.S., at least, the tendency has been to perform such surgeries when the child is young and can grow up as a “normal” sex. Historically, many parents were never even told of the surgery. However, thanks to advocates and more visibility of the intersex community, the tide is turning and more parents are opting to raise an intersex child who can then make the choice for or against surgery when older.  This more transparent and autonomous approach is not universal yet and many intersex infants are still altered without their input. The Orville’s approach is simplistic and not logically consistent. The Maclans are presented as a single-sex species; however, we learn that they see themselves as male and actually can be born as female. This storyline is the only one in a one-hour episode that consists mostly of spoken dialogue–debates on the various sides of the issue. Even though the show sets up the viewer to sympathize with the child and Bortus, the court rules against him and the child has the surgery. At the end, the family is altogether and it as if all that has happened was forgotten.

The Good Doctor (Season 1; Episode 1): Coercing Consent and Civil Rights
This new series from the creator of House follows Dr. Shaun Murphy, a surgical resident living with autism. Through flashbacks, the viewer learns about his abusive father, and his running away from home with his brother to live in an abandoned bus. In the present, Murphy leaves his small town in rural Wyoming to begin his residency at San Jose (CA) St. Bonaventure Hospital, a fictional facility in Silicon Valley. Murphy is described as “high functioning” and his brilliance is that he thinks differently from most doctors, paying attention to details and with a savant’s ability to map the patient in front of him to his book learning to make rare and easily missed diagnoses. This opening episode presents two ethical issues in problematic ways.

In an early sequence, Dr. Claire Brown is a resident who volunteers to consent a patient for bypass surgery. She enters his room full of bluster, which the viewer soon discovers is a form of tough love. She pushes the patient to admit his fear of the surgery and facing his change of life: Yesterday he was strong and healthy and today his life hangs in the balance. Brown arranges for him to talk to psychiatry after which she will discuss consent with him again, permitting the surgery to occur the following day. When she shares this plan with her no-nonsense attending, Dr. Neil Melendez, he asks if she passed anatomy because “his problem is in his heart, not his head.” She explains that the patient is physically able to consent but is not psychologically ready to consent—he needs time. An arrogant Melendez responds that since the patient is physically ready, the consent should be signed. Brown cites “17” studies showing that patients do better when they are psychologically prepared. Brown pulls rank, talking down to her and asking another resident to get consent. Brown’s approach is the more empathic and ideal, but unfortunately in real life, the Melendez approach is the one I have seen more often. Brown considers not just whether the patient is capable of giving consent nor even whether he can understand the procedure, but rather whether he is also emotionally ready to consent. This would seem to be a more ideal measure of true informed consent.
The problematic presentation of this ethical challenge of informed consent is that the empathic character is the only female physician on the show. This reinforces a cultural stereotype that women are emotional and compassionate when in reality, all physicians—irrespective or sex or gender—should be compassionate, empathic, and concerned with the whole patient. This old-fashioned trope is particularly disturbing given the second ethical focus of this episode: Expanding notions of social justice. This second line takes place almost completely in the board room, where the hospital board is voting on whether Murphy should be signed as a new resident. This may be the most diverse group ever seen on television when looking at sex, race, and ethnicity. However, the argument here is whether people living with autism is an issue of civil rights. On the side of those who are against signing Murphy are the foundation, the administration, and the medical staff who feel that Murphy’s communication problems as well as his unpredictable behavior and actions (because he thinks differently) make him a potential danger to the hospital (i.e. potential for lawsuits). On the other side is the hospital president, Dr. Aaron Glassman, who makes a speech about providing opportunities to all people. He says that living with autism is the same in terms of civil rights as being black or female. Glassman argues that hiring Murphy “give[s] hope to people with limitations that those limitations are not what they think they are. That they do have a shot.” Glassman makes an argument for break glass ceilings and giving others living with autism a role model. At the same time, Glassman refers to Murphy only by his first name, rather than his title and last name: This action lends an air that Murphy is lesser than the “doctors,” undercutting his speech.

Where this show goes is likely predictable: Like House, Murphy will be an amazing diagnostician. And like House, Murphy will have problems with communicating with his patients and being a social person. I would not be surprised if both sides of the board debate are proven correct.

Grey’s Anatomy (Seasons 14; Episode 1): Conflict of Interest; Impaired Judgement
In the premiere of this long-running medical drama, two ethical issues play a small role. In the first, there is a question of a conflict of interest. Meredith had been dating Riggs—another surgeon—until his fiancée, Megan Hunt (whom everyone thought died in a war), is discovered alive and brought to the hospital. Meredith is Megan’s surgeon. She and Riggs decide they do not want the patient to know about their dating history. Teddy, who makes a surprise return—remarks that hiding this connection is inappropriate and that it marks Meredith as “family.” Thus, Meredith should not be the surgeon given this conflict of interest. After some debate, Meredith reveals the history to Megan who chooses to stick with her surgeon. The reason for this policy is that when treating a family member, one’s objectivity and clinical detachment might be compromised. In general, doctors are advised not to have intimate relations with former patients if knowledge of the person may influence the relationship. For example, dating former patients is not advised by the American Psychiatric Association and most certainly not permitted for two years after treatment has ceased. Meredith did not date or have a relationship with this patient. Thus, claiming she is “family” may be a stretch. If she felt hurt by Riggs and might take that out on Megan then that would be a violation, but as the episode makes clear, that is not the case. Thus, the concern in this particular case seems unfounded though transparency is always a good choice.

In the second issue, Amelia—head of neurosurgery—decides to perform a jaw dissection in a teenager who has a benign tumor causing pain. She is advised, repeatedly not to do the surgery. The viewer is told that Amelia is becoming manic—not having eaten and slept for several days. She claims she is working hard to save her patient, but the viewer knows she is avoiding personal issues. Despite the warnings, she goes ahead with the surgery and then needs Jackson’s help when she finds herself in over her head. The case turns out fine because “she is very lucky.” Jackson lets her know that she was reckless and deserves to have her license suspended for what she did. At the end, we learn that Amelia has a huge brain tumor, which is what has been causing her unusual behavior. In reality, the doctor who is impaired due to actions (drinking) or mental status or an illness that may interfere with her ability to doctor should have not been permitted to operate: Clinical objectivity was compromised and the patient was put in harm’s way.

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