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04/24/2018

BioethicsTV (April 16-20): #TheResident, #ChicagoMed, #GreysAnatomy

by Craig Klugman, Ph.D.

The Resident (Season 1; Episode 10): Self-doctoring; nonmaleficence; the problem with hospitals…; Chicago Med (Season 3; Episode 16): Compassionate lying; choosing gender; medical error; Grey’s Anatomy (Season 14; Episode 20): #METOO

The Resident (Season 1; Episode 10): Self-doctoring; nonmaleficence; the problem with hospitals…

After Conrad has a run-in with a skateboard while jogging, he hobbles into the hospital with a sprained ankle. He refuses a colleague’s offer to look at it, or at least to put him in a soft boot. Instead, he goes to the pharmacy and lies, stating that a bottle of cortisone ordered for a patient broke. When the pharmacist says he has to check the record first, Conrad talks him into not checking. Then Conrad goes into the resident’s lounge and injects himself with the cortisone. Over the episode his junior resident, Praves, repeatedly tries to get him to take care of the ankle, even talking about Conrad’s history of knee surgery—Praves looked up the record of a person who is not his patient. Looking at the chart of a colleague, family, friend, or yourself is a violation of most hospital’s confidentiality policies—you can only see the records of patient’s you are treating in most places (and following up on in some). Lying is almost never acceptable in the medical environment, and lying to access drugs is an egregious and illegal act. As for self-treating, Osler tells us, “A physician who treats himself, has a fool for a patient.”

With a season that has been showing that Bell is suffering from tremors and has a higher than average patient loss rate, a VIP patient is left in jeopardy. The patient is having a liver tumor removed. Bell is feeling confident with a new drug he is trying for his tremors and conducts a surgery with arrogance—refusing the recommendations of his resident and even rejecting standards of the surgery. The result is a patient who barely survives surgery and has internal bleeding (veins were not tied off and tissue was torn) that immediately requires going back into the OR with     Silva, another attending. When Bell learns of the problem, he leaves his press conference.  In the OR Silva calls Bell out on his increased error and death rate. The two have a shouting match in the middle of the second surgery. When they discover a  new intestinal mass, Bells pulls Silva away and removes the tumor. Bell never admits his mistake to the patient, just tells of how he found the second tumor and saved the patient’s life. Silva’s reward for saving the patient? “I’m done at this hospital.” Ideally, a physician would know when their skills wane, but there is also a responsibility to speak with, and, if necessary, report physicians who are dangers to patients. Thus, although all of the characters blame Bell, by not reporting him, they all are taking part in unethical behavior.

In a conversation between Hunter and Bell, they discuss how the problem is high administrative CEO salaries. Their solution, that a physician needs to be in charge—i.e. the money should go to them and not to a bureaucrat. They are also concerned that their CEO is obsessed with transparency of errors and actions; they would prefer more discretion and less light on their behavior. In most hospitals, the administrative class are the people who make the most money. Between 1970 and 2010, the number of physicians increased by 150%, but the number of administrators increased by 3,200%.Certainly, during that time, insurance has become more complicated and there are many more regulations with which to comply. But the average physician has had their paperwork responsibilitiesincreased during that time as well. Bell and Hunter are correct that there is a problem with a bloated bureaucratic class in medicine, but their reasoning—that money in the administrator’s pockets is money that is not in their pockets—is incorrect. After all, a professional is supposed to be altruistic—in the work to help others.

Chicago Med (Season 3; Episode 16): Compassionate lying; choosing gender; medical error

Story 1: An older man comes into the ED with shortness of breath. He has a history of malignancies and says he is done with further treatment. His only family is a son to whom he is estranged and he regrets not reaching out sooner to make amends. When the man goes into distress, Noah asks him “You have DNI and DNR orders in your chart. Now I need to confirm that you do not want us to intubate you or perform CPR should your heart stop.” The patient nods in agreement and Noah tells him that they will make him feel comfortable, starting with morphine. Nurse singleton locates the son and lets the patient know that he is coming. However, the son does not show up and is not answering his phone. Noah enters the patient’s room and pretends to be the son, so that he does not die alone. He dies within minutes, having waited for his son to appear. In reality, lying to a patient is wrong 99% of the time. But in this case, Noah’s lie was merciful and allowed the patient a good end.

Story 2: Emma is a 9-year-old child who arrives in the ED wearing her ballet outfit. The girl has stomach pain and an ultrasound shows she has a testicular torsion. Genetically, the child is a male but has not expressed male characteristics. She needs surgery to fix the torsion. The girl’s mother arrives and Dr. Charles explains that if the torsion would not have happened, then no one would have seen anything wrong until she reached puberty, at which point she would have developed secondary, and also primary, male characteristics. The mother is in denial, asking the testes to be removed. Manning said that given the nature of the surgery (gender altering) that they would need Emma’s assent. The mother believes that asking would traumatize her daughter, if she could understand. Charles says, “The truth is that the dominant thinking among medical ethicists is that children should be afforded gender autonomy regardless of their age.”

Manning and Charles explain to the child what is going on in age appropriate language and understanding. The mother is saying to her child, that the boy partinside of her is causing pain and will cause her to change and then asks her if the doctors can take those parts out. The mother is clearly directing the daughter’s response. The doctors call out the mother, away from the child, but the mother insists that the daughter cannot understand. Later, Manning is speaking to Halstead and she explains that the mother is insisting on the invasive surgery: “Unless the ethics committee intervenes, I don’t think I’ll be able to stop it.” Then the testicle becomes ischemic and surgery is emergent. Manning tries to convince the mother who agrees not to have the testicles removed as her daughter is rolled into surgery.

The fact that bioethics and ethics committees are mentioned on the show is exciting, since appearances have been rare. But we do not have the power that is ascribed to bioethics. In a clinic, bioethicists and ethics committees can make recommendations, not dictate treatment. Charles may be accurate in his statement. A 2013 article in Gender Dysphoria and Disorders of Sex Developmentsays, “The conclusion is not only that there is nothing unethical with providing transgender children and adolescents with early medical treatment but that it may be unethical not to do so.” Certainly consensus has moved in this direction. Manning is also correct in that Illinois courts have held not only assent, but a mature minor consent exception can exist to parental consent.

Story 3: In a cardiac surgery, an instrument is left inside the patient. Scans do not show what it is or where it is. Latham says this is a sentinel (reportable) action and that they have to go back into the patient’s chest to find and remove the instrument. Rose and Zanetti discover that it is a suction tip that came off of an instrument that Zanetti was using. She tries to blame it on Rose until the nurses recall that it was her fault. Zanetti leaves in the middle of the surgery in a huff, leaving Rose to close and deal with the mess. Zanetti is inconsolable about the mistake because the patient might have died. When they go to Latham, both claim responsibility for the error. In a sense, both are because a team is responsible for counting equipment and making sure that everything goes well. However, by not accurately representing the reality and not being open with an investigation, steps cannot be taken to prevent similar errors in the future.

Grey’s Anatomy (Season 14; Episode 20): #METOO
Grey’s Anatomy is having its own  #METOO moment. This episode saw the release of information that Catherine Avery has been hiding for decades—she paid off 13 women whom her father had sexually assaulted and harassed.  This news will have significant consequences since the foundation her father, Harper Avery, founded owns many hospitals including Grey-Sloan. The foundation also awards the most prestigious [fictional] award  in surgery: The Harper Avery. Meredith is a winner of this award, as is her mother, who we have learned left a partner off of her paper that won her the award. This episode told us why: The other collaborator was one of Harper’s victims and part of the settlement Catherine arranged forbid these women from  working at an Avery hospital or being eligible for the award. Future episodes this season will likely deal with the impact on individuals, institutions, and reputations. My guess is that Meredith returns her award, she gives her mother’s partner credit, and the hospital becomes involved in a major lawsuit of the foundation.

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