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12/01/2017

BioethicsTV (November 27-November 30): Apologizing & Autonomy

by Craig Klugman, Ph.D.

The Good Doctor (Season 1; Episode 9): How to Say I’m Sorry

A patient had a nodule removed from her vocal cord. Is it cancerous or benign? If cancerous, then her surgery will remove her vocal cords. If it’s benign then there is no surgery. The problem is that the sample is missing and time is running out. The hospital counsel tells the doctors that no matter what, they should not say “I’m sorry” to the patient. And of course, that is exactly what Browne does. Rather than calling her attorney, the patient is appreciative. Although “do not tell them you are sorry as it can be used as an admission of guilt in court” is traditional advice, the current literature actually suggests the opposite—saying “I’m sorry” can do more good than harm. Several states have even passed apology laws that allow one to apologize without that being used as evidence in court. The AMA recommends that physicians admit medical errors as to hide such information is a violation of professionalism and medical ethics (autonomy; nonmaleficence).  Attorney Lee Taft even offers a protocol for delivering apologies that includes one’s state of mind and intention: “There should be an unequivocal admission of error communicated by the physician or health care provider responsible for the error, so the healing dimension of the authentic expression of remorse can be fully experienced by patient and provider alike.” At the end of the episode, the nodule is found, having been put into a mislabeled specimen cup and it is benign. The patient sues anyway.

Chicago Med (Season 3; Episode 3): Autonomy

A young pregnant woman is brought to the ED with an irregular heartbeat. She tells her doctors that she does not want to be seen or treated because there’s too many chemicals and risks to her baby. Dr. Halstead does a quick ultrasound with complaints from the parents-to-be because the high energy waves can damage the baby. Halstead responds that there is no truth to that idea. He finds that they have a perfectly healthy 5th month pregnancy. The only problem is that this is the 8th month.  As a pregnant woman, she is eating only organic food, nothing from animals, and with restricted calories to maintain her baby’s health. She is, in short, starving her baby.

Halstead and Manning recommend artificial nutrition to help both the mother and the fetus. However, mom refuses concerned about the chemicals in the IV bags and the inorganic nature of the nutritional supplements. She refuses permission and she is both competent and capacitated. The doctors express their concerns for both lives—mother and fetus—to administrator Goodwin who says she can take the case to the ethics committee. In the next scene, Goodwin reports that the committee recommended following the patient’s wishes since she is capable of making them. To do otherwise would be a battery on the patient. Which is exactly what Manning does when she “sneaks” nutrition into the patient’s IV line. The patient pulls it out and has lost all trust. Goodwin and the husband are able to talk the patient down from taking legal action against Manning and the hospital.

Manning approaches the patient as a fellow new mother and explains her fears and concerns. When the patient’s heart problems worsen, a C-section is the only option to save the baby’s life. Reluctantly, the mother agrees. This storyline ends with the mother looking at her underweight child, being artificially fed and fighting for its life. She does not know whether the child will live but she wants only the best.

In reality, a doctor would not “sneak” nutrition to a patient who is competent and capacitated. Such an act would violate patient autonomy, would be an exercise of nonmaleficence to the patient’s trust and will, and would be illegal—administering treatment when consent has been expressly refused. One bright note in this case was seeing a referral to an ethics committee. While we do not know the deliberations, I can only imagine that the recommendation was based on balancing the patient’s state of mind, autonomy, nonmaleficence, and beneficence. One point not made in this episode is that an ethics committee makes a recommendation, not a medical order, and not a ruling.  Responsibility for taking care of the patient ultimately rests with the physician who should make decisions in partnership with the patient.

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