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10/13/2017

BioethicsTV (October 9-13, 2017): Drinking on transplant list; big pharma in pandemics; mortality forces morality

The Good Doctor (Season 1; Episode 3): A Patient Takes A Drink While on the Transplant List

This week, a patient is finally at the top of the list for a heart transplant. The heart is at a hospital on the other side of the Bay and through a series of obstacles, getting the liver to the hospital while still viable becomes a challenge. At the same time, a final series of blood tests shows that the patient had a drink. The viewer is told that to be eligible for the transplant, the patient cannot have had alcohol for the prior 6 months. In this case, the patient had a small glass of champagne to celebrate his daughter’s college graduation. Dr. Mendez determines that the amount of alcohol was minimal and argues that these were extenuating circumstances: The patient should still get the liver. In the board room—that is quickly becoming a set for ethical debates—there is a conversation on the fairness of the current UNOS system. However, the committee agrees rules are the rules and the liver goes to the next person on the list. The patient’s condition is critical and he is going to die in a few weeks.

In reality, transplant committees have a lot of power to decide whether to list a patient or not. The six-month rule is not a UNOS rule, but rather is one held by 85% of transplant programs. An article by Bramstedt and Jabbour suggests that in cases like the one on this show, the committee should err on the side of life. The context and situation should be considered, not just hard and fast guidelines. Since the innocuous and understandable drink did not represent a return to drinking for this patient, the transplant should have gone ahead. If the patient was not critical, then Bramstedt and Jabbour suggest the patient be kept on the list but also seen by a chemical dependency counselor. By admitting the one drink instead of hiding it, the patient was demonstrating a commitment and trustworthiness.

Designated Survivor (Season 2; Episode 2): Does Big Pharma Have Obligations in Pandemics?

In this episode, an outbreak of virulent flu has appeared in a poor, minority parish in Louisiana. Concerned about the spread of infection, the CDC imposes a quarantine on that and surround parishes: Airports and roads within 200 miles are closed. As luck would have it, a new drug under clinical trials has a side effect that may makes it helpful for combating certain viruses and this one fits the profile. The President approaches the CEO of this company who is reluctant to release this unapproved drug: One bad outcome or if the drug does not work for this disease, then not only is the drug done but his company fails. What if someone dies from the drug; he has an obligation to his stockholders. The President offers him liability immunity and appeals to human decency. The CEO offers 10,000 doses. However, the CEO soon changes his mind when a wealthier parish offers to pay $2000 a dose. The President’s counsel brings a motion before court to shut down this contract. She claims that (a) there was a handshake contract which supersedes this one and (b) that in a national emergency, the federal government needs this resource to save lives. The judge agrees and says that a public emergency overrides their deal—they are ordered to deliver the drugs.

In order to determine dosing, the head of the CDC response team test the drug on herself, only to learn that 2mg is too high and she destroys her kidneys. One milligram turns out to be the right dose and indeed is working to save patients. Given the delay caused by the need to go to court, the disease spread further than the 10,000 doses will cover. The CDC leader suspects that there are more doses available because to produce only 10,000 would not be cost effective. As it turns out, there are 30,000 doses sitting in a warehouse. The CEO says, he’s a capitalist and giving away drugs is not lucrative. He also states that since this is an experimental drug whose patent is pending, the fact that anyone has the drug is hurting his business. He figures that a dozen manufacturers were reverse engineering his new drug as they spoke. The threat is not just the loss of this drug, but that if the company goes down, other promising drugs for other diseases that they are in testing will be lost and no one will ever benefit from them.

There’s a lot ethically to examine in this story. One element of this plotline that seemed inconsistent was the company turning around and selling the doses. After all, this was an unapproved drug, so how could he sell it? The CEO is correct in that his legal obligations are to his stockholders and he is correct that in a humanitarian gesture of offering compassionate use, he could doom the drug and the company. Ethically, though, we should want companies to offer their resources to help, especially when nothing in hand is effective. For example, during the Ebola outbreak, a few doses of ZMapp, a potential antiviral, were offered to Western volunteers. In a public health emergency, the federal government can offer immunity from liability and can enter into contracts to purchase whatever it deems necessary to deal with the disaster. By seeking a higher bidder than the government, the CEO acted poorly, putting profits (which is his highest obligation) before people (which is the highest public health value). The challenge is that there are two high level prima facie values in direct competition.

In the end, the CEO is encouraged to give the drugs and is touted as a hero in a Rose Garden press conference. The outbreak is stopped in its tracks and the CDC leader recovers.

The Good Place (Season 2; Episode 4): Does Mortality Force Morality?

This is the show that everyone interested in philosophy should be watching. In this week’s episode, Michael, the head demon (though we are informed demon is considered a racist term), has agreed to learn about human ethics in order to understand how humans are motivated to make decisions and to understand the idea of good. Michael informs his teacher, Chidi (a philosopher who on earth who never managed to publish anything) that all moral philosophy is human “bullshirt” (there is no swearing in the afterlife). Chidi comes to understand that for an immortal being, morality has no meaning: If you do something wrong, it will be forgotten in a few trillion years. Thus, in order to help Michael understand human morality, Chidi first has to help Michael contemplate the end of his own existence. The show suggests that morality and ethics are important because humans have brief lifespans and have to face the consequences of our decisions. Even from a biblical perspective, the idea of right and wrong only appears after Adam and Eve have eaten the fruit of the Tree of Knowledge (of good and evil). While not directly related to health, this is an intriguing idea and should be taken into consideration when discussing life prolongation.

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