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10/06/2017

BioethicsTV (October 2-6, 2017): Communication Issues and Assisting Suicide

by Craig Klugman, Ph.D.

The Good Doctor (Season 1; Episode 2); Communication (lying, stealing credit; keeping silent)

This week’s episode of this new drama was about communication, specifically on the topic of lying. In the first storyline, a patient arrives with stomach pain which turns out to be an invasive, advanced, and complicated tumor. The patient is concerned because she is the only parent to her son who is getting married in a week and she wants to be there. Resident surgeon Claire Brown tells the patient that they will take care of her and that if she has surgery, she promises the patient will not die and will be at the wedding. Jared Kalu, also a resident, tells her that she should not make promises that she cannot definitely keep. Browne says that she told the patient what she needed to hear in order not to be scared. Kalu says that legal has told them not to make promises and to be sure to tell patients all possible outcomes, especially the bad ones.

This storyline continues to the operating room where the surgeons cannot see the tumor which seems completely wrapped around the aorta and the kidneys. Dr. Murphy suggests that the problem is not being able to see the tumor, but if they removed the healthy left kidney, then they would be able to view it. A second ethical dilemma is whether a healthy organ should be removed (one only needs one kidney to live in order to save the patient’s life). A conversation takes place between Browne, Kalu and their attending, Neil Mendez. Browne says that they should wake up the patient and explain the situation to her. Kalu and Mendez suggest just taking out the kidney and doing the surgery first. They adopt a variation of pikua nefesh, that to save a life you do things you would not ordinarily do such as removing a healthy kidney. Another ethical perspective can be found in the principle of double effect where removing the organ is the unwanted outcome outweighed by the goal of removing the tumor and saving the patient’s life. The surgery happens successfully and as she awakes, Browne is prepared to tell her everything. However, the patient stops Browne from speaking and just wants to know if she is fine.

In an aside to this storyline, Kalu told his attending that the idea to remove the healthy kidney was his when in fact the idea came from Murphy. In a conversation between Kalu and Browne, Kalu says that coming up with the idea is one thing, fighting to support it and be able to carry through the idea is important. If the idea failed then it would have been his fault so shouldn’t it be his credit if it succeeds?

In reality, a patient should give informed consent which includes an honest assessment of the risks, benefits and alternatives. The patient initially asked for 2 weeks for the surgery so she could attend the wedding. She made her values known. However, complications do occur and sometimes decisions must be made quickly. Ideally, there would be a designated proxy decision-maker who could help make decisions: This patient had a son who could have been consulted on what his mother would have wanted. Removing a healthy kidney does impose limitations on her life: Contact sports are out of the picture and her risk of the remaining kidney failing increases.

In reality, one should not lie to patients to “make them feel better” as usually the one who is having trouble with the information is the speaker, not the patient. Patients should be told the truth unless that truth would cause them harm (in which case the truth might be told at a different time) and one must never make promises to a patient that cannot be kept are or are not guaranteed. The patient will need to be told about what happened at some point in the near future. As far as credit goes, there is no reason why the idea could not be credited to Murphy and the push for it from Kalu—he is lying to himself in his justification.

A second storyline consists of a nurse being placed in charge of Murphy to make sure that his decisions made sense after he ordered unnecessary tests on a patient. When Mendez reprimands Murphy for ordering the test, the nurse responds that she knew that the test was unnecessary. Mendez then turns to her and asks her why should did not speak her mind at the time; it’s her job to speak up when she knows better and disagrees with the doctor’s plan. Her response is “doctors don’t listen to nurses and they only talk to us to lecture us when they figure we screwed something up.” The nurse points out to another problem in communication, that health care providers from different professions may not respect one another (especially if lower on the food chain) and thus have a tendency not to listen to one another. In reality, she is right—many doctors do not do well when a nurse points out a disagreement. However, Mendez is also right that everyone on the health care team has a duty to care for the patient and protect her/him from harm: The nurse should have said something.

Bull (Season 2, Episode 2): Ethics of assisting a suicide/mercy killing

A reader brought this particular episode to my attention. In this court-based drama, Adam is an 18-year-old boy charged with murdering his 17-year-old ex-girlfriend, Emily, who has a terminal brain cancer. She called him after several months of silence and asked him to take her out of the hospital. Emily brought Adam to a hotel room (for which she paid) for a rendezvous. As he says that they should be getting back to the hospital, she informs him that she is never going back and then removes a syringe and a bottle of fentanyl from her bag. She explains to him that she is supposed to have surgery tomorrow to cut out part of her brain and she will lose her personality. Not wanting that, she has arranged the evening to end her life. He objects and she tells him to go if he can’t handle it. As she plunges the syringe into her arm, she loses her nerve and asks him to stay and help—Adam presses the plunger.

As the case moves forward, the viewer learns that Emily had an aggressive glioblastoma and she lives in New York, so aid-in-dying is not an option. We learn that she had visited Eva, a member of her online support group, who had the surgery Emily was about to undergo. The viewer sees Eva wearing a helmet, staring at nothing and her mom says that she does not communicate often. Clearly, seeing the dramatic change in this person affected Emily’s thinking and the viewer is shown this image as a way of saying this is what Emily would become.

When her surgical oncologist takes the stand, he explains that surgery could give her 6 more months of life. The surgery, however, would affect her language, communication, and memory centers. The prosecution asks if there was a possibility that a cure could be developed in that time and he answers it was not out of the question. The defense has him admit that such a cure that would come out of the blue and no one had ever heard of (even in clinical trials) was highly unlikely and even if there was a cure, there would be no way to replace the excised parts of the brain. The doctor is asked if Emily ever mentioned not wanting the surgery and he replies that she did so that on multiple occasions. However, since she was a minor, he dismissed her sentiments. In reality, this is a complicated case of competency and capacity. Yes, legally she lacks competency because she is under the age of majority. But as a patient who battled her disease for a long time, who was on the cusp of turning 18, and who displayed adult-like reasoning, she may have had capacity to at least assent to surgery. Her say in the matter was dismissed, relying solely on who could legally consent. Such a dismissal is unlikely in the real world, but there are cases: In Connecticut, a 17-year-old who did not want radiation therapy was court-ordered to have it. Of course, in that case there was a very high remission rate and for Emily, there was no cure, only buying time.

The viewer learns that dad was a vet and that he was taking Emily to see an end-of-life therapist. He was sympathetic to her position and wanted to help, but could not. Her mother, however, was religious and prayed for the miracle. The boy’s attorney is Catholic and he mentions several times that he has problems with this case because he believes that suicide is a mortal sin. To the attorney, Adam is guilty of murder. Thus, the viewer is shown one argument against suicide/mercy killing which is brought forward in the form of divine command theory. Deontology also makes an appearance—by the letter of the law, what the boyfriend did violated statute.

However, the spirit of the law is what the defense rests upon—that Emily took all of the steps to arrange the situation for her action—she called up an ex-boyfriend, paid for the hotel, secured the needle, and stole the fentanyl from her father’s veterinary office. Thus, her actions are presented as an exercise in autonomy and the ex-boyfriend bravely supported her when her doctors and her family could not. Like most real cases of “mercy killing,” the young man was found innocent by a sympathetic jury. Thus, the case presents a national debate on assisted suicide by showing how this young woman had to make her arrangements in secret, not even saying goodbye to her parents, by examining the debate through several ethical lenses.

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