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BioethicsTV (November 12-17): Obligation to treat, assisting suicide, autonomy, and prejudice

Outlander (Season 3; Episode 9): Obligation to treat
In this time travel love story, Dr. Claire finds her ship crossing the Atlantic in the 1700s is stopped by a British Naval ship afflicted with “Ship’s Fever.” Her husband does not want her to go aboard the Navy vessel, fearing that she will be separated from him and be away from his protection. After listening to the symptoms, she thinks that the sailors suffer from typhoid fever. She explains to her husband that being from 1968, her inoculation makes her immune to that disease plus her oath as a physician requires her to help people in need.

In reality, physicians do have an obligation to assist those in need. However, the question is open as to whether the physician is obligated to put her or himself in danger in order to do so. If a physician sees an accident at which she or he can help, then the physician is supposed to stop and render assistance. Thus, Claire is correct in stating her duty, but since she would put herself in a position of likely bodily harm, the requirements of the obligation are not clear. And in fact, she is kidnapped by the Navy to help save their men.

The Good Doctor (Season 1; Episode 7): Assisting a medical suicide; Ignoring autonomy; Facing prejudice
Dr. Kalu’s patient has a malfunctioning pacemaker. A surgery to replace the device should leave him feeling better. However, his condition is progressive and he is in pain most of the time. When the patient runs away to the hospital basement, Kalu chases after him. The patient says, “I know my rights. The minute I catch my breath, I’m going to walk out of here. So you can just leave.”  As they sit in the basement, Kalu says that he is waiting for the patient to collapse so that he can take him upstairs and save his life. The patient talks about his life and what he has been through. The two share their life stories. They connect and the patient feels less alone. The patient changes his mind and chooses to permit Kalu to perform the surgery. However, before the surgery, the patient runs away a second time: This time to the roof to end his life. Again, the patient asks to be left alone; this time requesting a DNR. Back in the patient’s room, a DNR has been signed and the patient turns off his temporary pacemaker. Kalu sits with him and administers morphine to help with the pain while the man dies.

In reality, a resident would not likely help a patient die in this way. Assisting in a death is illegal in most states, and where it is legal, must follow a specified process. The resident making this decision on his own is acting illegally and most likely violating hospital policy. Though displaying compassion, he should be fired and may even face a murder charge. The other aspect of this case, is the doctor initially ignoring the patient’s wishes and then pushing him to get the surgery. House staff usually do not question a patient’s capacity to make decisions until the patient chooses other than what they recommend. A patient who has rationally explained his reasons and has clearly communicated his choices, should be permitted to exercise his autonomy, even if that is not what the doctor wants. In most cases, though, autonomy is not respected in these situations and doctors will push patients to undergo the surgery or the treatment. The irony is that if the patient had agreed up front, no one would have questioned whether he could make choices and no one would have taken the time to get to know the patient. The patient’s wish for death is a complication and in most situations, would result in a psychiatric evaluation and hold, rather than helping the patient to end his own life.

In a second storyline, Murphy connects with a patient who has the same autism condition that he does. He is able to calm the patient and make a diagnosis. Treating the patient requires surgery. The parents are thankful for that work, but are adamant that Murphy should have nothing to do with the actual surgery. Melendez, surgical attending, believes that the parents are prejudiced against a doctor with autism. Melendez is left with two choices: If he agrees with them, then do the surgery. If he does not agree, then he can tell them that they can’t exclude a member of his team and he can show them to another doctor. Melendez does confront the parents and tells them “I can tell you, he has my complete confidence.” The parents are not convinced and a transfer is arranged. However, the patient says that he wants Murphy to be his doctor. For the first time in this series, Melendez allows Murphy to touch a patient in surgery and to make the initial incision. The surgery is difficult but successful.

Grey’s Anatomy (Season 14; Episode 8): Right Decision-Maker?
This episode’s ethical moment was brief and a throwaway as far as storytelling goes. An adult woman has met her father for the first time during the last month. She is just getting to know him when he ends up unconscious in the hospital. The surgeons want to put him on ECMO treatment to allow his lungs a chance to heal. The hospital need someone to sign the informed consent and the daughter is legally the next decision-maker in the hierarchy list. She is reluctant to sign because she does not really know him, but with reassurance of the surgeons, she does sign. What bothered me is that no one really responded to the daughter’s concern that she does not know him enough to know what he would have wanted. I am sure that if she was refusing the treatment that there would have been questions about her suitability as a surrogate. However, in the bias shown in medicine everywhere, we only question appropriateness of a surrogate if they disagree with what the physician says. Likely, this is realistically how such a scenario would play out even though informed consent is most certainly not happening in this instance.

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