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05/11/2018

BioethicsTV (May 7-11): #ChicagoMed, #GreysAnatomy

by Craig Klugman, Ph.D.

Chicago Med (Season 3; Episode 19): Maternal-Fetal Conflict; Grey’s Anatomy (Season 14; Episode 23): Personal Disclosures of Illness

As the traditional television season comes to a close, many medical dramas have steered away from ethical dilemmas in medical care to heighten the drama among their characters in order to provide strong cliff hangers for the season finale.

Chicago Med (Season 3; Episode 19): Maternal-Fetal Conflict

Tracey Hermann is a 25-year-old pregnant woman (21 weeks) who comes into the ED with shortness of breath and fatigue. Scans show that she has a problem with her mitral valve—a condition she’s likely always had but has only manifested with the added pressure on her body of the fetus. The valve can be replaced, but the blood thinners used during the procedure have a high risk of causing vaginal bleeding in a pregnant woman. Zanetti recommends that Hermann terminate the pregnancy before the surgery. However, Hermann’s husband died 3 months before and the baby is the last connection to him that she has. She refuses the abortion. Without the surgery, she will likely die. Rhodes recommends an altered surgery that might work and honor the patient’s wishes. Zanetti points out that it is riskier than the standard procedure. During surgery, the doctors learn that the size pig valve she needs is on backorder. They can use a mechanical valve which requires her to be on blood thinners after surgery, or try another supplier which would take an hour, which prolongs the surgery and increases the risk of bleeding. The surgery goes well but soon after she begins to hemorrhage when the placenta begins to separate. Rhodes wants to stop heparin (which could clog the valve) and hope the placenta corrects, but Zanetti wants an immediate hysterectomy. The valve clots and Hermann’s heart stops. After about 1 minute (it is TV time) of attempting resuscitation, Zanetti declares the patient dead.

Rhodes usually tries to give patients what they want even if it means compromising the medicine. Usually, it works out because the ethical mantra in this show is that the ends justifies the means. However, in this episode, the tables have turned and such decisions led to a poor outcome. By trying to please the patient and suggesting a riskier approach, compounded with having to make a tough choice in the middle of the surgery, the patient died. Is the problem the recommendations he made? His attempt to find a way to fulfill the patient’s wish? Or was the problem a systemic one—the backlog. One could argue that the surgeons should have known that certain sizes of their replacement valve were not available before starting the surgery (especially since it would only have taken an hour to get additional sizes). Rhodes ends up doubting his skills and decision-making ability at the end.

Grey’s Anatomy (Season 14; Episode 23): Personal Disclosures of Illness

Set in an episode about personal trauma for one of the main characters, a secondary story line reunited Amelia Shepherd with a former patient. At that time, this particular patient had an insidious brain tumor that was declared inoperable, and Shepherd had thought she could remove it. She did so, saving the patient’s life, but taking away her sight. What no one knew at the time of this impossible surgery was that Shepherd herself had a large nonmalignant brain tumor that was affecting her judgement. Was she a brilliant surgeon because of her tumor or in spite of it? Shepherd’s concern is whether she needs to reveal to this patient that her surgeon was under the influence of a brain tumor. Shepherd fears that the patient may blame her for losing her sight.

The question is an interesting one: Does a physician who later learns of a personal health problem that could have impacted patient care have a duty to inform all patients treated during the time of the doctor’s illness? The literature has a few articles discussing how physicians are bad patients and whether doctors should keep seeing patients when the physician is ill (after all, doctors do not get sick days in many places) and studies show that most doctors see patients when sick.  The suggestions include that practices and hospitals need to have plans in place for when a doctor calls in sick. What I could not find much written about was the scenario offered in this episode.

Most of the characters felt that Shepherd should not tell—she saved the women’s life by completing an impossible surgery. Plus, the tumor is private health information: Like all patients, Shepherd has a right to confidentiality. Certainly many (if not most) risk managers and hospital attorneys would sway toward not telling. What if the patient had not been cured but had died on the table? Would Shepherd or her tumor be liable for the death? Only a court case would answer that.

What if Shepherd did not have a brain tumor, but had been under the influence (she is a recovering drug user)? The rules and ethics of that are better known since the drugs poses a direct threat to the patient. She would have to tell.

Despite the recommendations from her colleagues, Shepherd feels that ethically, she should inform the patient sitting in her hospital. She wants to err on the side of truth. What she should have done is spoken to her supervisor, risk management, and the hospital attorney for advice. While she struggles with telling the patient in her clinic, she does not ask whether she should inform all patients she treated when she was operating with her tumor. Does she ethically have an obligation to inform them? In general, this blog has favored truth telling in most circumstances,  but the brain tumor is not something that Shepherd knew about when she did the surgery and is not necessarily something that other people would have noticed (her behavior has always been erratic over two medical series).

The answer is not clear. Certainly if a physician has altered behavior and abilities (notice by themselves or others), then they should not treat patients until their own health is evaluated (and colleagues have an obligation to report such changes). Shepherd’s tumor, however, offered no symptoms (other than she was able to complete tricky surgeries). Her tumor was discovered as an artifact when taking part in a brain scan research study (yes, another ethical question). Ethically, she probably does not have an obligation to inform patients of a risk that existed when neither she nor anyone else had an awareness of it and it likely did not affect her skill. But, if there was a bad outcome with a patient, then revealing her situation may be ethically warranted.

In the end, the patient opens the door by saying she had heard through other people they mutually know about the tumor. There is no blame, no debate, no request for an apology. The patient knows and the matter is considered closed. But ethically, Shepherd has opened an ethically challenging door.

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