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10/27/2017

BioethicsTV (October 16-27, 2017): Maternal-Fetal Conflict, Trolley Car Dilemma & Lying

by Craig Klugman, Ph.D.

The Good Doctor (Season 1; Episode 4): Maternal-Fetal Conflict

Although the focus of this show is supposedly the neuro-different resident, what it does very well is pose and debate ethical issues. In this week’s episode, a fetus has a tumor that is 50% of his size. His mother desperately wants extra-uterine surgery to remove the tumor as this pregnancy follows 3 miscarriages. However, she has a clotting disorder and the surgery poses a very real risk of causing a heart attack or stroke. Her husband does not want her to have the surgery because he values having his wife alive and in his life. Without the surgery, the fetus will die leaving the alternative of terminating the pregnancy. However, the mother refuses this option, not for religious reasons but saying that emotionally, losing another child would drive her over the edge.  If nothing is done, the tumor will kill the fetus and both son and mother will die. The attending surgeon believes he can save both mother and child. The chief of surgery challenges the attending in this case, explaining that if the case does not go well, that the hospital’s ratings could go down which leads to less money and less opportunities to do amazing surgeries. In a conversation with the Board (taking place in the board room, which is quickly become the ethics cave), a vigorous debate occurs: Is the decision solely that of the mother since to perform surgery on the fetus necessitates doing surgery on her? Or does she decide about having surgery for her, and the decision to perform surgery on the fetus a joint decision along with the father? If the latter, then the father could refuse to consent for surgery on the fetus. Ultimately, the board decides that the decision is the mother’s alone and the board approves the surgery.

Once in the OR, the first incision leads to a heart attack and the surgeons close the mother back up. She is extremely disappointed and wants to try again. The husband realizes that with the surgery he risks his wife’s life but without it, she is likely to die when the fetus dies or because she takes her own life. Back in the ethics cave, the conversation asks whether she is capacitated to make this decision given her clear disregard for her own well-being. The hospital attorney is concerned that with the parents on the same side, if something goes wrong, there is more likely to be a lawsuit. The risk to the hospital seems strong. However, if they refuse to do the surgery, the hospital may be open to claims of abandonment. Surgical resident Kalu has an idea that the mother could be put onto bypass and her heart stopped, a step that would reduce the risk of a clot harming her heart. This is a risk that the parents are willing to take. The surgeon is confident. And the board decides that the complicated risk/benefit picture falls on the side going ahead.

The surgery goes perfectly and mom awakes with instructions for hard bed rest for the next 4 months.

In reality, this show does a good job at having vigorous debate on the ethical challenges it raises. Watching the diverse people involved in the ethics debates in the board room (i.e. ethics cave) is a brief, but fairly accurate view into how an ethics committee would discuss an issue. This committee composed of the hospital president, a member of the foundation board, an attorney, chief of medicine, and surgical attending may be smaller than most ethics committee (that would also likely include nursing, social work, other specialties and perhaps an ethicist). Given the confines of the medium, the first four episodes have treated the ethical issues well, debating various sides and perspectives, raising both ethical and legal points, and reaching reasonable conclusions. The only difference is that an ethics committee usually only has the power to recommend, and the board in this show has the power to stop procedures and give permission for them to take place. I’m not loving this show for entertainment value, but it does have a strong record, so far, for its ethics content.

The Good Place (Season 2; Episode 5): The Trolley Car Dilemma

Every philosopher’s favorite show delved in the Trolley Car Dilemma this week. When chief demon, Michael, has problems understanding this classic thought experiment, Chidi (his ethics instructor) wonders how to make the dilemma seem important. He experiments with the idea of a rap about Kierkegaard:

My name is Kierkegaard and my writing is impeccable

Check out my teleological suspension of the ethical

Eleanor shuts him down. They decide that the answer is to try and make the dilemma less theoretical and more applied. Chidi suggests thinking about who the people are on the tracks and trying variations such as a doctor with five dying patients needing organs and one healthy donor. Michael decides to have some fun and makes the Dilemma real. Michael puts himself, Chidi and Eleanor into a real trolley facing a real dilemma. When Chidi flips the switch to move the car onto the sidetrack, thus only killing one person; he finds that one person is his best friend. Running over a person results in a messy death with gore and blood splashing on everyone. We learn that Michael runs this problem 7 times including one variation where Chidi lets five William Shakespeare’s die so as not to harm a single Santa Claus. The name of the trolley on which they ride is “The Ethics Express.”

Chidi then finds himself transported to an operating room facing the doctor’s variation that he had laid out earlier. Michael says, that he could kill Eleanor and take her organs to save these five lives. Chidi says, no because as a doctor, the Hippocratic Oath requires that he not harm a person. He cannot kill one healthy person to save five sick ones. Michael then tells him to explain the decision to the dying patients’ families when a little girl walks in and asks if Chidi was able to save her daddy.

As it turns out, Michael could not overcome his demon nature and was torturing Chidi through his attempts to teach to someone who simply cannot learn human ethics.

The Good Doctor (Season 1; Episode 5): Truth-telling, Clinical Objectivity, Consent

In this episode, a boy is admitted after breaking his arm. The boy looks a lot like Murphy’s brother who died at that same young age. As a result, Murphy pays him a lot of attention and discovers that the boy has osteosarcoma. He comes to learn that the parents know and have chosen not to tell their son. They want to spare him the pain of knowing. However, Murphy feels the boy should know. He then asks fellow resident Browne to lie to the patient for him—since Murphy is a bad liar—that he needs surgery to repair the break in order to keep the boy in the hospital. When they have a moment alone, Murphy tells him that he has cancer. The boy says that he knows—he googled some of the terms he heard and figured out that he was dying. He explained that he was okay with dying and that he believes there is no heaven but simply that everything will cease. This gives him comfort.

Murphy, his judgement clouded, realizes that the boy’s symptoms are sometimes misdiagnosed as osteosarcoma and a bone marrow test would tell for sure. The problem is that two previous bone marrow biopsies were positive for cancer. He sneaks into the boy’s room when the parents are out, so as not to give them false hope, and tells the boy that he is taking a biopsy and his parents do not know. When the parents walk in, Murphy stops and tells them what he was doing. They throw him out of the room as the boy has a pulmonary embolism. During surgery, the team finds lesions on his ribs. In recovery, the boy tells his parents that he’s known for a long time and that he is okay with dying. Then he lies to them, by saying he would be in heaven with other loved ones—a lie that he tells them to make them feel better.

This episode deals with several professional and ethical issues: truth telling, asking someone to lie, losing clinical objectivity, and performing an invasive procedure on a minor without parental consent. Unless there is reason to suspect harm from the action, a health care practitioner should not lie to an adult patient. Children are a different matter, since the parents have authority to make decisions for their kids. As Glassman tells Murphy, parents get to decide for their kids and that is that. However, as is often the case, a child living with a serious disease for a while, usually figures it out. And the children are usually more okay with it than the parents. The fact that the boy lied to his parents about “heaven” reinforces this point. In dealing with the issue of truth-telling/lying, this episode showed that it is not straightforward since there are the little lies (“I’ll be in heaven”) that make people feel better and the bigger lies that keep people apart and in the dark. Despite the law and codes of ethics saying lying is always wrong, there may indeed be times when not sharing the full truth at the moment benefits the patient. However, knowing whether the lack of truth/lie benefits the patient or the practitioner can be difficult to judge and thus, lying should be used sparingly, if at all.

Professionally, Murphy lost his objectivity by identifying this boy with his own brother. Via this surrogate, he was trying to save his own brother from dying (from a falling accident) and thus was making decisions to correct his past rather than in the best interest or even substituted interest of the child. Lastly, invasive procedures require the patient’s consent and in the case of a child, requires the consent of the parents. Lacking such permission, Murphy committed a battery of his patient and should be reprimanded for this actions. As his attending tells him, he indeed is in trouble for lying, sharing information against parent wishes, and performing an invasive procedure without informing the parents (nevermind asking for consent).

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