by Craig Klugman, Ph.D.
- Mary Kills People (Season 2; Episode 1): Helping the healthy to die
This season picks up where the last season left off, with Desmond in prison and Mary carrying on helping people die. In many ways, this show has lost its edge since assisted suicide is now legal in California (where the show appears to take place) and Canada (since we see Mary with a Canadian passport). Desmond quickly is paroled and Mary brings him on a case. A middle-aged man has mesothelioma and wants help dying. I wondered why he just simply did not ask his physician for help, especially when his wife passed an envelope filled with $20,000 over. Assisted suicide through the law would be a lot cheaper. Then we learn that his wife, who is healthy, plans to die with him because she does not want to live without him—so maybe that’s why they need Mary’s help. While Desmond was away, Mary has broadened out the business by apparently helping healthy people die who wish to. Desmond refuses to prepare their cocktail—phenobarbital in champagne—for her. When Desmond and Mary turn away, she jumps over a railing on the high-rise apartment, plunging to the pavement.
Although it is romantic for a couple to want to die together, the law is quite clear that ending a healthy person’s life, even with their consent, is murder. Ethically, this act is also problematic. There are few philosophical theories that would accept ending one’s own life or ending a life for another person when they are healthy and simply do not want to face mourning. Mary is a physician and assisting a healthy person to die would violate her professional duties and oaths. With the wife’s choice to take her own life, Mary and Desmond avoid the ethical morass of helping a healthy person to die. Desmond draws a physical line made out of sugar at the counter of a bar and says to Mary, “There’s a line. There’s killing people who are terminal and killing people who are healthy. I don’t want to go on this side [killing healthy people].” Mary disagrees saying they should help people when they want it, not just when it’s easy. Desmond replies that they also need to sleep at night, suggesting that there is a morality involved that they need to acknowledge and honor.
Of course the wife does not die, but ends up in Mary’s ED. The woman says that as soon as she can, she will try again. Mary takes the safeguards off of the patient administered pain pump so that the patient can end her own life.
- The Good Doctor (Season 1; Episode 16): Walking again; Fountain of youth
A patient is in a wheelchair as a result of a motorcycle crash many years before. He has been having some pain that is radiating to his legs, which should not be able to happen. Melendez discovers that the patient’s spinal cord may have regenerated, but it is completely covered in a tumor that reaches up into the brain stem. Because the patient was unable to feel, he did not have any symptoms from the tumor. Surgery to remove the tumor is long (9 hours) and complicated with a 15% chance of death. His wife is against the surgery: She says they have a great life and she doesn’t want to lose him. However, he wants the possibility of walking again. Melendez wants to do the surgery because there is something he can do to help the patient and as he points out to the wife, “There are never guarantees.” The wife changes her mind and supports her husband’s decision. The complicated surgery is difficult but successful. However, he has a long road of recovery ahead of him. The question this story raises is whether there are some risks that are too high for a physician to offer and a patient to choose? The privilege given to autonomy suggests that if a treatment is medical appropriate and offered to a patient, that the decision whether to go forward and to decide the risk/benefit ratio, is up to the patient. There is, however, a deeper question of whether a physician should offer a treatment with a high likelihood of failure and if so, what would that failure rate be: 15%, 50% 75%?
In a second storyline, a 50-year-old woman has an infected cheek implant. She had extensive cosmetic surgery over her whole body to recapture her youth to make herself attractive to her husband who she says cheated on her with a younger woman. The implant is removed, the tissue cleaned, and a new implant inserted. Then the infection is found in another implant. Andrews says that she needs to have all of the implants removed and there likely will be scarring. They try a cycle of high dose antibiotics which does nothing. Without the surgery, she will likely die of sepsis. The patient refuses saying she can’t go back to what she looked like before the surgeries. After some impromptu marriage counseling, she agrees to the surgery. However, during the time it took to convince her to have the surgery, the infection spread and she died on the table.
- The Resident (Season 1; Episode 7): “Patients Don’t Know What They Want”
We are introduced to the VIP ward which looks like a fancy resort. The patient is a baseball pitcher with a swollen leg from a DVT. He is arrogant and demanding. When Nevin comes in to ask him to sign some baseballs for the kids in the hospital, he offers to donate some hats and jerseys as well. She gives him her phone number to arrange the gifts and he quickly sends her a picture of his genitals. Hawkins is upset at this harassment and confronts the patient. As a result, Hawkins is banished from working with VIPs. Bell delivers the news of the banishment and says that it was Nevins’ fault for giving out her phone number (i.e. blaming the victim). As Hawkins states, while they may have an obligation to treat people in need, there is no requirement that they put up with sexual harassment. Nevins chews out Hawkins for trying to “take care of her” saying that she can take care of herself. Later, she confronts the VIP with blackmail, saying that if he ever sends her or someone a picture like that again, she’ll send it to every gossip website. While harassment is wrong, using blackmail to stop it, especially from a health care provider to a patient, is unprofessional.
In a second storyline, a patient with likely small cell lung cancer and mets to the liver tells Hawkins that he does not want treatment nor a diagnostic biopsy. Instead he wants to be with his wife and put his affairs in order. When Hawkins reports this to Hunter, the oncologist, during a tumor board meeting, the doctors in the room act as if he didn’t speak. When Hawkins explains his solid reasons for thinking the patient is terminal, the board members agree and then go ahead and order the biopsy anyway. Hawkins tells them, again, that the patient does not want the biopsy and he is again ignored. He then asks if the patient’s wishes factor into any decisions at which point Hawkins is told to keep quiet and the biopsy is scheduled. All season we have been led to believe that Hunter is running her patients through high cost treatments in order to increase billings and how much money can be earned from each patient.
Hunter brings Hawkins to talk the patient so that they are on the same page. She tells the patient: “Cancer is a relentless enemy. You have to fight it with extreme prejudice. You have to fight it with fire and fury. You can’t just give up.” She admits the chances are not good but he could be the miracle. The patient agrees to the biopsy. Hunter uses problematic military analogies in describing cancer. I say problematic because it places the patient in the position of being a good soldier who fights, or a deserter who just gives up. Such language turns a personal decision into a moral judgement.
The biopsy shows the worst case scenario and Hawkins prescribes very aggressive treatment: radiation twice a day plus chemotherapy. Hawkins tells her that the patient doesn’t want it. She responds, “Patients don’t know what they want. It’s up to doctors to frame their care in a way so they understand what’s best for them.” And as Hawkins points out, “hides the downside.” So much for autonomy, or partnering with the patient. Hunter is a full on paternalist.
On the way to his first radiation session, Hawkins tells the patient how little time he has left and that even with the treatment, he might get at most, an extra few weeks. At that, the patient and his wife ask why no one told them all this. Hawkins and Nevins tell the patient that they are a hospital, not a prison and can’t keep him there. The couple simply walk out of the hospital. In this case, when he had enough information, the patient made a decision to enjoy his time left rather than pursue aggressive and costly treatment. He asks a good question, why wasn’t he told the full information before he was asked to consent? The answer, is that in the world of this hospital, getting the maximum amount of money per patient is most important and what patient’s want or need come second.