Posted on October 22, 2018 at 7:30 PM
by Craig Klugman, Ph.D.
“Exploring ethical issues in TV medical dramas”
Jump to The Resident (Season 2; Episode 4): Medical Lawsuits; Jump to The Good Doctor (Season 2; Episode 4): Inappropriate coercion to remove autonomy; Jump to New Amsterdam (Season 1; Episode 4): Conflicts of interest; Giving bad news; Jump to Chicago Med (Season 4: Episode 4): When medicine and immigration collide; tough choices
This episode is less about particular stories than the about the topic of malpractice lawsuits. The episode jumps between a deposition and the events that led up to it The main point occurs about 15 minutes in when Hawkins, Pravesh, Nevin and Feldman are having coffee in the cafeteria as they watch an attorney go from table-to-table, asking patients about their care. Pravesh says that their jobs are hard enough without these “vultures” hanging around. Hawkins says that patients need to be able to sue because it’s their only recourse against medical error. Feldman responds that malpractice is abused and leads to overtesting, CYA treatment, and the practice of defensive medicine. They are all correct.
In the case under review, Hawkins, as a senior resident, drills a burr hole to save a man’s life when a neurosurgeon is in surgery and unavailable. The patient ends up in a wheelchair (he had been an adventure guide). After the deposition, Hawkins’ father—the new owner and chairman of the board of the hospital—strongarms (through threats of neverending lawsuits) the patient into dropping the lawsuit and apologizing to Hawkins. And the patient does. While frivolous lawsuits can be a problem, using threats is not a good solution to any problem.
An 18-year-old woman is a free climber and she falls 150 feet from the summit of her current conquest. She has a broken neck and requires surgery. One option is to fuse her vertebrae which limit her range of motion and end her climbing career. Another procedure will leave her full range of motion but with a longer recovery. Her parents prefer the fusion, hoping that it will keep her from climbing and further injuries, or even death. However, she is over 18 years of age and thus has autonomy to make her own decisions. At least until Browne makes a suggestion to the patient’s parents that they have her declared incompetent. A therapist/social worker performs an evaluation by talking to the patient in front of her parents and then talking with three doctors (Lim, Browne, and Reznick). In her evaluation, the expert says she is concerned about reckless behavior and that “I have to err on the side of the preservation of life” meaning that the patient is not capacitated to make this decision, and the parents should choose. From a clinical ethics perspective, the patient should be interviewed by herself, without the influence of her parents or, in this case, her manipulative physician.
What is not clear in this case are the full risks and benefits of the proposed procedures. We are told that one will restrict her range of motion by as much as 50%, and this is usually the preferred surgery. However, we are also not given any of the risks of the motion-preserving surgery. The patient asks her doctors to relay to her parents that after the surgery, she never wants contact with her parents again. Browne relays the message, saying that she has pushed them to this decision because of her own baggage. The parents state that they may not be part of the patient’s life anymore, but at least she will be alive. Then they leave the hospital. We are left with the sense that they never will speak again.
Browne was unprofessional and inappropriate. It is made clear through the episode, that she is pushing the parents to act because of an incident in her past. She is repeatedly told by Lim to leave her personal opinions out of it and focus on the medicine; something that Browne is unable to do. A family is broken and a person’s dreams destroyed because when the patient chose an option different than the one Browne thought was best, Browne manipulated the situation. We are supposed to be left thinking how much she cares for her patientsbut the reality is quite the opposite—she does not care enough for her patients to value their opinions, values, and beliefs. The patient made it clear that being able to climb was her prime value, and Browne viewed that as a death wish. The social worker/therapist also needs to be called out, since only speaking with the patient in front of the very people who are going against her is inappropriate—the patient should have been spoke to without her adversaries in the room. This storyline is an example of how not to make medical decisions.
Frome receives a grant from the NY Health & Hospital corporation (HHC) to create a community garden as part of his plan for horticulture therapy. However, the money for his project comes from Volt cola who sends him a large amount of swag. HHC tells Frome that he can either take the money from the sponsor or not get any money at all. Bloom tells him that the beverage company has lobbied hard to get soda bans overturned and that their product is a leading cause of obesity in children; he can’t take the money. Kapoor shares that in India that same company builds playgrounds and gardens. At the end of the episode, Frome has rejected the money but has recruited the hospital staff to build a garden. This storyline is about conflicts of interest and corporate “charity” that is merely self-interested marketing. Accepting a “gift” with strings attached—introducing kids to marketing for a product that is dangerous to their health; requirements for who to hire and who to treat; or following requirements dictated by the “donor” is ethically problematic and as this show demonstrated are best avoided even if it means giving the money back. The ethical choice is not always the pragmatic one.
In a second storyline, young girl comes into the ED with pain. As Sharpe is conducting a spinal tap to determine if the girl’s cancer has returned, the patient asks her parents “What’s it like when you die?” Rather than engaging her they tell her she does not need to know because “that’s not going to happen for a long, long time.” The girl complains, “Nobody tells me anything.” Her cancer is back and it is very aggressive. Her parents grasp at straws for clinical trials or even experimental treatments in other countries. Sharpe recommends considering palliative care. The mother wants to know how they tell their daughter. The father says, “We don’t; we can’t.” Sharpe says the patient is smart and wants answers. With the parents gathered around the girl’s bed, Sharpe tells her the diagnosis and tries to answer her question about what happens when you die. “When it happens, you won’t be able to see your mom and dad and they won’t be able to see you. But they will always be there.” Sharpe’s explanation is one about memories and about thinking of each other. Sharpe’s answer is not a fairy tale, it is not placing her own beliefs on someone else, and it is not refusing to answer. Instead, what she describes is mourning and the answer was a good one. The patient accepts this explanation, I don’t know if anyone in real life would.
The main ethical concern in this episode regards the difficult choices made by people living in the US without documentation. Seeking health careor other assistance can trigger a system flag that brings ICE to their door, sometimes waiting for them when they leave the hospital.
A 28-year-old mother passes out while holding her 18 month-old-baby presenting with a fractured arm. We are immediately shown that the mother is covered with bruises and petechiae. While in the ED she begins to bleed internally. The diagnosis is leukemia and the only treatment is a stem cell transplant. When the family is worried about the length of time being on a transplant list requires, Manning explains that stem cells come from living donors and the registry works differently. The patient is not a legal citizen (even though she is married to one, but she hasn’t applied for permanent residency yet) and thus the husband’s insurance does not cover her care. Goodwin suggests they do a direct donation and pay cash, if they can. A close family member is best, but her brother repeatedly says that he can’t donate. We learn that if he donates his name goes into the system and he and his pregnant wife could be deported. Goodwin promises him that they will keep his name private; that no one will know. “You don’t understand,” he says. “They come to your work, they tear apart families. I might never see my wife again.” (What is strange is that no one said anything about putting the patient on the registry even though she’s not documented; isn’t the risk of being apprehended the same?).
When the only option turns out to be her son, which puts him at great risk for developing the same disease later in life, her brother changes his mind—to protect her son and save her sister’s life. As the brother feared, he is arrested upon leaving the hospital, before he has a chance to donate. We learn that ICE knew because the upper administration asked the feds about what their requirements were and then gave permission for ICE to come to the hospital and grab him. The brother was being deported for stealing $8 worth of goods over 14 years ago. The patient has lost her only chance at survival. This episode is about, in Manning’s words, telling people “Be afraid to go to the doctor.” These actions turn doctors into an extension of immigration enforcement, or, forces health care providers to keep immigration away to do their duty of protecting patients from harm.
A 30-year-old woman presents having had flu like symptoms for a month. She feels worse and she develops a drooping eye. She seems to be having a rare reaction to a cancerous cyst in an ovary. But she has cysts in both ovaries—its’ hard to know which one is causing the problem. When her condition declines, Halstead orders for both of her ovaries to be removed (who gave consent? Was it emergent? Was there a second doctor agreeing?) He later states that was the hardest decision he ever had to make. His resident does not understand why since this way protected her life. Clearly she does not realize that the choice took away the patient’s ability to procreate and did so without informing her or getting her consent.
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