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10/05/2018

BioethicsTV (October 1-5)

by Craig Klugman, Ph.D.

Jump to The Resident (Season 2; Episode 2): Rising drug costs Jump to New Amsterdam (Season 1; Episode 2): Cultural accommodation; medicating schoolkids Jump to Chicago Med (Season 4; Episode 2): Withholding support; withdrawing support

The Resident (Season 2; Episode 2): Rising drug costs

In its sophomore year, this show seems to be shying away from ethical issues and the gross incompetence of its fictional hospital and exchanging it for hope; hope that hospitals can cover their costs and meet patient needs.

One storyline begins with a nurse saying, “Because you’re a minor, we have to wait on your mom” to a teenage patient in the ED. The patient appears to be in distress. The nurse walks the patient to the waiting area with instructions to come back when her mom arrives. We are not told her primary complaint nor whether she has been evaluated for any emergent issues. We later see her stealing drugs from a cart and giving herself an insulin injection in a closet. She is too late and ends up DKA, in a coma. Her mom works two jobs and can’t afford the $2,000 a month insulin cost. Now that she is unconscious, the cost of caring for a patient on a vent and a feeding tube is far higher than even the exorbitant cost of insulin now. This is a commentary on the increasing cost of drugs not because they are more expensive, but because drug companies and the supply chain want bigger profits. On the show, Conrad cites a price increase from $21 to $2,000, which is close to the increases being seen in the real world.

The other important factor here is the original nurse who would do no more than take a temperature and blood pressure of a minor patient. While consent of a parent is necessary to treat a patient, that does not apply if the patient is emergent. Had a health care provider taken a history, it would have been clear that she was in a diabetic crisis. In fact, this was an emergent situation and a health care provider should have caught it rather than just turfing the patient to the waiting room.

The Good Doctor (Season 2; Episode 2): Truth-telling; Assault and cultural traditions

The theme of this episode is truth telling—Murphy has recently gained the ability to lie. He is wondering when he should lie to a patient and when he should tell the truth. A custodian, who becomes a patient, tells him that he should lie to a patient when there’s nothing one can do. In a one storyline, Murphy diagnoses a custodian as having pancreatic cancer. After offering the options—palliative care and a year of life or a dangerous surgery that might kill him or might save him, the patient asks Murphy, “What should I do?” Murphy says, “All we can do is present you with the facts.” This is not quite accurate. Murphy can offer a medical opinion of the best option. In fact, just delivering facts is no different than handing the patient a set of information sheets and telling them to decide. A health care provider can and should guide the patient in decision-making.  The patient makes the decision that his family wants—to have the surgery to have a chance, even a small chance, at being with them longer. He makes the choice his family wants, not the choice he wants. This would seem to go against self-interested autonomy, but it does align with how people actually make decisions, coerced by the feelings and interests of their loved ones. The patient dies of complications from his Whipple. The family begins blaming themselves for pushing him into the surgery, “We killed our father” the youngest daughter says. Murphy tells them that the patient told him he wanted the surgery, a falsehood, in order to make them feel better. He lies in probably the only circumstance when a doctor should.

In a second storyline, a 16-year-old girl in the ER asks Dr. Lim for vaginoplasty. Lim asks the patient “who did this to you.” The patient was circumcised at 2 years of age. She begs for help and Lim says she will. Lim can do a female genital mutilation reversal (not the nerves, but it will “look like other girls”) in one day so the parents do not know. The patient does not want her parents to know because she will be rejecting their cultural traditions. Lim and two residents (Park and Reznick) debate whether they need a court order, parental permission, or reporting child abuse. The patient presented an ID saying she is 18, but it is clearly a fake ID. Lim says she is doing the surgery and can legally do it because she believes the ID is real or she’ll call child protective services and in the time it takes them to examine the situation, she can have it done.

The patient awakens from surgery in severe pain. She needs to be sedated and cannot come home. The parents are brought in. Lim says the pain means she can probably reconstruct the clitoris. The parents want a second opinion and believe that their teenage daughter should not be making these choices. In the meantime, CPS appears, having been called by new hospital president Andrews. We learn that the FGM was done by relatives visiting from Africa while the parents were out of town. There are two options at this point to deal with the pain: a clitoral reconstruction surgery or an ablation of the nerves—one could allow sexual pleasure and one would forever remove it. The CPS social worker says she thinks the patient is mature enough to make these decisions. When they wake her up, in front of her parents, the patient says to remove what’s left of her clitoris. Lim talks to the patient without the parents present, and the patient wants the removal to honor her past. Lim pressures her again about the future and her happiness and the patient asks to go back to sleep.

In surgery, Lim lies saying that the patient verbally consented even though there is no paperwork. Park immediately backs her up because he wants to believe that this is true even though it clearly is not. At this point, Lim is assaulting a patient who has stated she does not want reconstruction and whose parents do not want the procedure either. She operates without consent or assent. When the patient awakes she notices her cheek is sore and thanks Lim. As with most medical shows, the ends justifies the means here, and so Lim is a hero to this girl. In reality, Lim should be up on assault charges and lose her license. There is no ends justifies in the means when it comes to ignoring patient wishes because a doctor thinks they know better what a patient truly wants. If the doctor feels that way, then the doctor should talk to the patient and not act based on a feeling.

The other challenge here is the way the family’s beliefs are treated. The parents are presented as abusers and no one ever questions that. Their cultural beliefs and values are dismissed. The parents are stigmatized as “bad people”. Lim calls FGM “butchering” and the CPS social worker says the FGM was an “abomination.”  This approach shuts down the opportunity for dialogue and sets up an adversarial relationship, with the patient the one who loses.

New Amsterdam (Season 1; Episode 2): Cultural accommodation; medicating schoolkids

The first storyline is a case of cultural accommodation. A 32-year-old woman seizes and falls down before she is brought to the ED. She is diagnosed with mitral regurgitation from broken heart syndrome: As a global aid worker, she saw her home island destroyed by a mudslide. The family is from the Caribbean and practices an Afro-Caribbean religion. The patient and her father  want to perform a healing ceremony. Reynolds says “no” because the ritual requires cutting the skin and he fears infection. The patient crashes when they go to take her to the OR—every time her bed is moved, she crashes. Bloom tries to convince Reynolds to allow the ritual because it’s about what the patient needs. After the ritual, the patient is stable and able to be transferred. Goodwin says, “The ritual worked.”

The second storyline revolves around a school system that finds medicating children to be easier than treating their issues. An 8-year-old boy is on four medications for acting out but is now lethargic and unresponsive. Frome wants to take him off all medications to diagnose his problems. A psychiatrist from the NYC schools visits and informs Frome that if the boy comes off the meds, he will not be permitted to attend a public school. Under the law, if the mother agrees to the medication, then he can’t be in school without it. Goodwin suggests he take the schools to court and interestingly there is a courtroom in the hospital. That sounds unrealistic to expect , but remember that this show is based on a memoir about Bellevue Hospital, which does indeed have a small courtroom. The school psychologist shows a video of the boy beating up another child in a school hallway and says she is responsible for 3,000 students and to protect them, she needs the boy medicated. To prove that the fight was a situational case of rage in the middle of the trial, Frome and Kapoor perform rapid detox, to show the judge that the child does not need medication. Once off drugs, the kid explains his dad died from a heart attack and the boy he beat was tormenting him, saying he should be dead like his dad. The judge permits him to return to school without meds as long as he is in therapy.

Chicago Med (Season 4; Episode 2): Withholding support; withdrawing support

After a massive fire, the ED is inundated and out of ventilators and space. Goodwin transforms the doctors’ lounge and cafeteria into treatment areas.

A young woman who lived in the building has suffered burns over 80% of her body (very low chance of survival) and has a damaged carotid artery. She needs to be stabilized before she is taken to the OR. The parents learn about the months of being in the ICU followed by more months of physical and occupational therapy that she will need. When an OR opens, the parents say “no,” that the kind of life she would have is not one that she would want. The woman has struggled with body issues and they believe would not want this life. Manning says “People react differently to trauma. Surviving this might actually make your daughter more resilient.” The parents are firm, “We have to let her go.” Goodwin brings the parents a consent form to remove the ventilator, which both parents sign and Manning removes the vent. The patient breathes on her own and her mother then decides that the daughter wants to live. They inform Manning they’ve changed their mind, take her to surgery. Later, Manning wonders if she did the right thing, “Maybe we just gave her a life of suffering.”

When Halstead’s dad codes (he lived in the building) Halstead starts running the code. A nurse stops him, asking “He’s your dad, shouldn’t someone else run the code.” He responds “Do you see another doctor?” In general, a physician should not treat their own family members, however, if no one else is around in an emergency, then treatment is acceptable as long as the intervention is noted in the medical record.  Continuing the drama, though, the father is diagnosed as brain dead and the neurologist suggests that the bed could be used to help others given the emergency. Halstead’s brother, Jay, who is a cop, becomes incensed and does not understand that “brain dead” means “dead.”  The new CEO visits the brothers and says “we take care of our own” and offers any and all services they may want for their dad. As it turns out, the father had bypass surgery 29 days ago. If they can keep him alive past 30 days then his death would not reflect on the hospital’s survival scores—the CEO’s offer is a business decision to boost its stats. Jay sits with his dad and says that the father is communicating—squeezing his hand. Halstead says it’s just a reflex and means nothing. We then learn the real reason Jay is holding on is that his last words to his father were cross and he doesn’t want those to be the last words he ever said to his father. The brothers come together and choose to remove the vent, acknowledging that their father is dead. A sudden death is difficult for the survivors to process and accept and they may require some time to grieve and reach the point where they can let go. As for the CEO, making offers of help are compassionate but doing it for business reasons is not so compassionate, but rather self-serving. As Kant teaches, the intent matters. Most likely, once day 30 was reached, she would withdraw the offer.

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