Posted on October 26, 2018 at 12:58 PM
by Craig Klugman, Ph.D.
“Exploring ethical issues in TV medical dramas”
Jump to The Resident (Season 2; Episode 5): Buying Thought Leaders and Handsy Docs; Jump to New Amsterdam (Season 1; Episode 5): Gun shootings; Jump to Chicago Med (Season 4; Episode 5): Genetic secrets and duty to inform
Bell negotiates a deal with a new start-up medical device company: For a substantial discount, he will make the company the sole source of medical devices at the hospital. The device company ultimately offers Bell $200,000 in consulting fees and an ownership stake. In other words, the choice of devices used in the hospital is all based on the hospital CEO’s personal gain.
Sadly, this is not an unusual situation. Drug and device manufacturers look to “thought leaders” to influence the use practices of other doctors and hospitals. To encourage the use of their products, companies give incentivesto thought leaders including lucrative speaker feesin exotic locations. While new regulations require companies to report all payments to physicians, the practice continues.
The surgeons are in uproar since they can no longer use the devices they know and trust. Their response is to get the patients to demand the beloved devices instead of the new ones. Voss’s patient is reluctant, saying that newer must be better. Voss explains that the FDA does not do a thorough review, “The FDA approves new devices that have literally never been tested inside a human, not only do we not know if they’re better; we don’t know if they’re safe.” Voss says she would rather use a device with a strong track record than something that could be recalled. The patient is unwilling to believe that the hospital would put something dangerous in her. Voss says that doctors would not, but that administrators choose devices that offer the greatest profit margin. Austin talks to his patient in a different manner, saying that he must sign the request and there’s no discussion.
As dramatic as this is presented, what Voss says is true. As long as a device is substantially similar to something that already exists, the FDA does not require testing. Through this approval pathway, ninety-five percent of medical devices are not FDA reviewed for safety or efficacy before they go to market.
When Voss’s patient’s tumor compresses her spine, giving her temporary paralysis, she needs immediate surgery before the paralysis is permanent. However, only the new company’s screws are available. Voss has to use them even though she convinced her patient to refuse them. As for Austin’s patient, the drug rep (who seems to be a permanent fixture at the hospital), convinces the patient to use her company’s products or he will transfer to another hospital where Austin’s mentor will perform the procedure. Austin talks to his mentor asking him why he is changing devices after decades of using another. He gives a reasonable answer but later, we learn that the mentor too is a “thought leader,” getting money and a free trip to Cabo for his reference.
Voss later confronts Bell about his device deal: “I’ll never be a shill for a device company, even a reputable one. It’s not in the best interest of my patients.” And that sums up the problem with pay-for-play, thought leaders, and other conflicts of interests: Instead of putting the best interest of the patient first, decisions are first influenced by the financial rewards. My guess is that in future episodes, we will see these patients return with bad outcomes.
The other concern I saw in this episode is that Hawkins is very handsy. He is a physician that will touch patients, sometimes in a healing way and sometimes it is just plain creepy. He touches the chest of a dying child, but also touches the arms, back, shoulders, and neck of the patient’s mother. I am sure that this is supposed to be viewed as comforting, hands-on medicine, but when Hawkins is grabbing the back of the mother’s neck it looks like he is shoving her head toward her son. Even though there is such a thing as a healing touch, one person should never touch another without permission. Hawkins could have said something like, “I have found most parents in this situation need a hug, is it okay if I hug you?” Instead, he just seems to put his hands on her, a lot.
This episode is a message against the increasing gun violence in cities, especially police shootings of brown and black people. The ethical issues here is that shootings are taking a toll on children, families, health care providers and society and yet nothing real is done to change the situation. The response to shootings is “hopes and prayers,” loosening gun restrictions, and suggestions from industry that put more guns on the street. In other words, not to let death interfere with gun sale profits.
Two young man come into the ED, victims of police shooting. In one, blood is leaking around his heart and might kill him, but cardiology is understaffed and no one is available. Even though Bloom is not trained and her actions violate protocol, she inserts a needle to relieve the pressure, but seemingly pushes it too deep into the heart (turns out that she did the procedure perfectly). Sims hopes that he can repair the damage (he does and the boy survives). A second gunshot victim, Jalen, dies.
The other problem is that a reporter is visiting the hospital, invited to spread some good PR. However, he gets wind of this medical error and the story appears on the first page of the paper. As I teach in my bioethics classes, one way to discern if a situation may be an ethical dilemma is to consider whether it would be a problem if the situation appeared on the front page of the newspaper.
Repeatedly, Goodwin tells the reporter that the story is not this one shooting, or the bullets that expand inside a body to tear apart flesh and bone, but rather the truth of what is going on. As the reporter writes, “Although the hardworking doctors of New Amsterdam couldn’t save Jalen’s life, they all did their job. Except the bullet did its job better.”
Sharpe, who is from the UK, says to Reynolds, “This is no way to live.” He responds, “It’s not, but yet we do. So if it takes a million camera phones and protests and knees to make that point, so be it.” The ethical issue is that the more gun shootings, the less we actually seem to do: We have become blasé about violence.
A 49-year-old man is brought into the ED after ramming his car into a stanchion. He was not wearing a seatbelt and the airbags did not go off. As the man awakens, he is upset at being alive, grabs a scalpel off a tray, and slices his wrist. The man is in need of surgery to repair his internal bleeding but he refuses. Goodwin reminds the doctors that operating on him without consent is assault. He is also refusing permission to hang any blood. When Charles examines him he discovers the man suffers from Huntington’s Chorea. When the diagnosis is confirmed, the hospital agrees not to intervene any further to save him (issuing a DNR and a DNI). His son arrives, but the patient has stated that he does not want any visitors. His chest tube clots off and Zanetti moves to put in a second tube saying “DNR does not mean do not treat.” (She is correct, since a DNR refers only to resuscitation.) The man also states that he wants no visitors and no one to know. But Zanetti wants to convince him otherwise when the man’s son shows up. She says that if the patient won’t tell the son, then the doctors should tell the son themselves. Charles reminds her that violating a patient’s confidentiality is a federal offense. We learn that the father had his son (secretly) tested when he was 7 and that he carries the gene: He is avoiding his son find out so that he can live his life instead of having his life shaped by knowledge of the disease. At this point though, the son forces his way into the room as the patient dies. We learn that the father had his medical records sealed for 50 years. However, when the son explains his desire to have children, Charles suggests that he has the right to ask for an autopsy, the results of which would not be sealed but would reveal the disease: “Despite [the patient’s] good intentions, maybe some secrets you just don’t get to keep” he says.
This story raises a host of ethical challenges: Can a patient keep people from visiting them (yes); Can a patient refuse treatment when they are competent and capacitated (yes); Can a patient demand that their records are kept secret from family members (yes); Does a father get to keep the results of a child’s DNA test from the mother (no, unless mother poses a danger to the child or has had parental rights revoked); Should parents keep secrets from their children about their own health (ethically, no); Does a physician get to use a loophole to get around a patient’s wishes because the doctor thinks it is the right thing to do? To the last, the answer is not really since this is violating the patient’s confidentiality wishes. In general, confidentiality continues after death, but in some circumstances disclosure might be acceptable in the interest of a third party, solving a crime, or affecting the health of a relative. In the U.S., some courts have even said there is an obligationfor a parent to inform a child of a genetic risk. Thus, while Charles’ actions seem like a get-around, in fact his interest in the son’s health probably outweigh his ethical (and perhaps legal) obligation to the deceased patient. But, if there was no knowledge of the son’s positive Huntington’s test, then the need would not outweigh confidentiality.