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03/22/2018

BioethicsTV (March 19-23): The Good Doctor, The Resident, Chicago Med

by Craig Klugman, Ph.D.

The Good Doctor (Season 1; Episode 17): Cost of healthcare, stealing identities, dating patients; The Resident (Season 1; Episode 8): Patient Dumping; Chicago Med (Season 3; Episode 12): Pedophilia; Cherry-picking; ECMO; teenage pregnancy

The Good Doctor (Season 1; Episode 17): Cost of healthcare, stealing identities, dating patients

In the first storyline,  a patient, “Lucy,” comes to the ER with a post-op infection: She never filled her antibiotic prescription. When the doctors went to see her, she had disappeared. The case gets stranger when another woman named Lucy shows up to get her pain meds, but she can’t because her ID was stolen and the pharmacy says her prescription was filled too recently. We learn later that the first Lucy was uninsured and had stolen someone else’s health insurance identity card to get the medications that she could not afford. As hospital president Glassman said “We have a duty to treat. We have a right to get paid.” He says they have to call the police on the imposter. The first Lucy, whose real name is Beatrice shows up again: “I had to choose between premiums and tuition [for her son].” She continues to decline and is put on a vent. When her heart stops, the doctors let it stop and do not call a code.

In a second storyline, a teenager was born with a neurological condition that leaves her without control of her facial muscles: She cannot smile or express other emotions. There is a surgery where a nerve is taken from elsewhere and transplanted into her face that will eventually give her control over her facial muscles. Being on the spectrum, Murphy does not understand why one would need a smile, so he tells the patient that the surgery is too risky for a small benefit. The teenager changes her mind against the surgery in part because of Murphy’s statement, but also because insurance says the operation is not medically necessary so will not be covered. After pulling some strings using personal connections, the insurance company changes its mind and agrees to cover 85% of the cost. The girl’s father says he can afford the rest. After the surgery, Murphy is unable to wake her up, fearing she was braindead. The doctors even inform the father. However, the anesthesiologist posits that the girl has a rare condition where she does not break down the anesthetic. He says that she will just wake up at some point. She does and although the nerves won’t be fully function for 3 months, the careful application of electricity to her face activates the muscles. The story ends with the girl smiling.

In a third storyline, Kalu’s patient from a previous episode returns and he finds her attractive. He thinks she is into him, but thinks that her feelings toward him, if she has them, might be transference because she was in a vulnerable place. Murphy finds Kalu surfing online to see whether he could pursue a romance with his patient.  Kalu removes himself from her care and then asks her on a date. In reality, physicians should not date patients under their current or recent care. The UK General Medical Council unveiled guidelines in 2013 stated that it would be okay to date a former patient in certain circumstance if one is aware of the patient’s potential vulnerability. This ruling was met with suspicion by others who felt that one should never date a former patient. The power imbalance between a physician and patient lends doubt to the idea of a truly consensual relationship being possible. In the case of dating a former patient, there is wisdom in having a considerable period of time after the fiduciary relationship has ended before exploring a romantic one.

The Resident (Season 1; Episode 8): Patient Dumping

A homeless woman wanders into the hospital lobby in the middle of a fundraising gala. Hawkins and Nevins bring her into the ER. We can see how the higher-ups view the patient when we see Bell pull a bottle of hand sanitizer from his pocket and use it after touching the new patient. In order to get her admitted, Hawkins decides to lie and say that the patient was experiencing chest pain. Nevins find an EKG lead stuck to the patient’s back—another hospital dumped this patient at their door. Hunter and Bell tell Hawkins “We are not running a charity here. Treat her and street her.” Bell says they should call the other hospital and threaten to publicize the dumping if they do not take her back. Under EMTALA, patient dumping is illegal, though it does happen. Patient Doe coughs up blood clots and her lungs start filling with blood. She is intubated but needs more [expensive] tests: bronchoscopy and MRI.  Okafor recognizes Doe’s purse as a one-of-a-kind designer bag and finds a name embroidered in it—the woman is the estranged daughter of a wealthy family. Her mother says that a world expert has diagnosed her as schizophrenic so they should put her on a hold and treat her for that. Suddenly Bell wants to keep the patient in the hospital and move her to the VIP ward. Her parents arrive to take her home. While Bell stalls them, Hawkins and Nevins diagnose the patient with Wegener’s syndrome—a rare autoimmune disease but a treatable one. The condition explains all of her symptoms including the “schizophrenia.” Hawkins is happy to have saved a life and Bell sees an opportunity to raise funds.

The contrast in this episode is between a patient who appears poor and thus no one wants; versus a patient who is rich, who gets special treatment and the hospital fights to keep as a patient. This show does not hide its main theme, that the drive for excess profit and wealth has corrupted the medical system, and that idea is in full display here.

Chicago Med (Season 3; Episode 12): Pedophilia; Cherry-picking; ECMO; teenage pregnancy

The theme of this episode is tough choices. In the first storyline, a 56-year-old male patient is found to have cancer of the larynx. The man refuses to see an oncologist and says he is ready to die. Halstead tries to inquire why he is ready to die and the man responds that he is a pedophile who has never acted on his desires but cannot hold back anymore: “I have an itch that I haven’t scratched. Cancer is my reward.” Halstead called for a psychiatric consult to have the man declared incompetent and start treatment. Sexton says that because he is a pedophile, they should let him die. Halstead believes that this action is suicide but as Charles explains, not wanting to be treated is not suicide. Charles goes on to say that the patient sounds rational, that he is trying to avoid hurting others and does not see a way out of his thinking. In a later scene, we see the patient with a purple DNR bracelet. Sexton asks Halstead why he wants to help the patient; Halstead replies that it’s not his job to judge. When the patient has ruptured blood vessels from the tumor and is bleeding out, Halstead says he has to help him. “No, you don’t” the patient replies. Halstead holds the man’s hand as he dies. In reality, patients who are competent and capacitated have the right to refuse treatment and to make decisions with which their health care providers do not agree. The patient was exercising his autonomy to make his own decisions. In this case to refuse care, knowing it would lead to his death. The tragedy is that it is the lack of strong options to control his urges that led him to crave death. I was surprised that Charles did not offer medication, chemical castration, or counseling.

My first job in my PhD program was working on a prison health project, specifically looking at sex offenders. For two years, I attended their group therapy sessions and even conducted 1-on-1 life history interviews with five of them. They ranged from an 18-year-old boy who had sex with his 16-year-old girlfriend, to a woman who made her daughters available for her boyfriend, to a middle-aged man who groomed his victims—the “classic pedophile.” This was a difficult project for a twenty-something grad student and even 20 years later, I never published my findings. Two things that are pertinent to this episode is that half of them did not see what they did was wrong, and those who did felt a compulsion that they controlled only with medication and frequent counseling.

In a second storyline, the hospital lawyer brings Goodman a lawsuit from a homeless patient who claims an ambulance passed him over to take another person who had insurance, on order of a nurse in the ED. An EMT states that the presence of a fancy lounge (the “pizza room”) for the EMTs was an unwritten statement to bring only paying patients to this hospital. Later, when the attorney comes to say they were settling the lawsuit, Goodwin informs him that she shut down the pizza room. The attorney says no, that the Board will not let her do that because the insured patients brought to them bring in too much money. As two other shows this week discussed, hospitals need to make money and yet they have an obligation to treat people in need—people who may not have money or insurance to pay for their care. The fiscal reality aside, cherry-picking patients is not ethical as it violates social justice.

A third storyline concerns a young boy with cystic fibrosis in need of a lung transplant. The lungs are available two hours away. His stats are falling and Rhodes puts him on ECMO. The risk of ECMO is possible infection and other organ failure that could make him unlikely to survive. When the boy begins experiencing liver failure, Bekker says they should remove him from ECMO. The two doctors explain to the boy’s parents that there is no clear best decision to make—there are risks and benefits to both choices. The parents ask Rhodes what he recommends and he says to stay on ECMO. Bekker later talks to the parents, without Rhodes, and explains that she may not agree but there is no way to know the best answer here. She reassures them that the disease is relentless and they should not second guess themselves because ever decision they made was made out of love. The lungs arrive and we leave this story in the OR, presuming a successful outcome.

A fourth storyline concerns a character from a prior episode who is a homeless, pregnant, 16-year-old. Choi and Manning visit her in the camp where she stays. She is having a troubled delivery but the patient refuses transport to the hospital where she would be put into foster care. She does successfully deliver, but the doctors say that she and the baby need to go to the hospital—her for follow up care and the baby because it will freeze if it stays outside on a winter night. The girl decides to give up her baby, knowing that a white newborn will be easily adopted by a family who can take care of her. But if they stay together, neither will have a good life. This tale shows the challenges of a system that is not set up to deal with teenage mothers and their children except through a foster system that does not serve them well. Only by giving up her child, can this young mother provide her with a chance at a good life, and she makes this sacrifice.

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