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12/13/2017

BioethicsTV (12/11-13): Confidentiality, Cost, Religious Objection

Chicago Med (Season 3; Episode 4)

Confidentiality: A husband comes into the ER with his wife who is experiencing Braxton Hicks contractions. He does not look well so Dr. Halstead gives him an examination. Tests results are inconclusive for Zika virus. The patient says he was in Buffalo, NY and has not traveled anywhere known to have the virus. When Halstead says that he is going to have to test the wife for the virus because of its potential negative effects on the fetus, the husband informs Halstead that he was in Aruba with a “lady friend” and he’s not about to lose his marriage: “Did they teach you about patient confidentiality in medical school because they certainly did in law school. Shut up.”

In a later conversion, Halstead speaks with Manning who mentions that if the husband was HIV positive, then they could tell the wife and test her, “Doesn’t Zika get the same exemption?” she asks. Halstead’s research shows no exemption for HIPAA, “Zika’s so new there’s no legal precedent.”

Cut to the patient and husband leaving the hospital: Manning tries to detain them and suggests that they avoid sexual contact for the pregnancy. She comes close to violating the husband’s confidentiality when she interrupted by the CDC. Halstead learned that Zika is a CDC reportable disease. The story ends with a CDC officer taking the couple aside to discuss the test results.

High cost of health care: In a second story, a family member shows up complaining about a $16,000 bill for his brother-in-law who died in the waiting room. Goodwin approaches the ER chief, who has been billing for every single item and procedure because the ER has been costing the hospital too much money. The chief says that the patient’s insurance will pay for it. Goodwin says “What if he doesn’t have insurance?” The chief responds that he’ll cry poverty and the finance department will work on it. Goodwin goes to the board and makes a thinly veiled threat about what the publicity would look like if this got out. They forgive the debt but threaten her position. This brief story is a debate about the high cost of health care and the burden it places on families. The show is commenting about the problem of health care as a business and the challenges of providing care when the hospital (and the board) care more about the bottom line. Goodwin’s final lines of the episode include “The system’s broken.”

Designated Survivor (Season 2; Episode 10): Religious Objection in a Child’s Life

This show is a political thriller, but this episode had an intriguing medical dilemma. A newborn has tetraology of fallots, a condition that will lead to her death without surgery. Her mother is member of an unnamed fundamentalist religion that holds religious scripture to say that blood products are unacceptable. To make mattes more complicated, her pastor and members of the congregation have locked themselves inside a building in the Shenandoah Forest with an enormous forest fire bearing down on them. They refuse to leave until the baby is released from the hospital.  The mother is refusing consent, saying that the wellbeing of her child’s soul is most important.

President Kirkman meets with his staff, trying to find a way to save both the congregants and the baby. One person suggests that they do the surgery to save the life, but White House counsel says there is no legal way to do that because the surgery is risky with no guaranteed outcome. In order to solve this Gordian knot, Kirkman creates an even worse ethical dilemma.

He hires a physician known for his experimental work in artificial blood. Kirkman asks if he could do the surgery. The doctor says it is risky but he thinks he can do it. The one catch is that his license was pulled in D.C. for a previous experimental surgery. He also says that the AMA would never approve and he would lose his license. Kirkman says that he unilaterally reinstates the doctor’s license in the District (claiming that with Congress on break, he has that right). The mother gives consent.

In reality, the AMA has little say over licensing which is handled by state licensing boards. Neither does the AMA has no jurisdiction over approving experimental research—that power belongs to the FDA and local IRBs, neither of which are mentioned in this episode. Second, in D.C., medical licensing is managed by D.C. Board of Medicine not by Congress. Although all laws in the District come under Congress, medicine is a self-regulating profession. It is unlikely that a physician who has lost his license would be permitted to perform an experimental surgery on a newborn, that has never been done before on a person or even on animals in order to get around a belief concerning the use of blood. Creating a larger ethical dilemma to get around another one is simply not a way to deal with the original dilemma.

A snag during the surgery puts the baby at risk: The artificial blood is not carrying enough oxygen to meet the baby’s needs. Having the same blood type as the baby, the mother is gently convinced to donate her blood to save her baby. The surgery is successful.

In an attempt to resolve his original dilemma, the congregants blockading themselves in the middle of a fire, Kirkman chooses another questionable ethics move:  The President lies to the pastor, telling him that none of their beliefs were compromised in the baby’s surgery. Krikman may not have known of the use of real blood, but more likely his made a lie of expediency.

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