Posted on October 12, 2018 at 1:14 AM
by Craig Klugman, Ph.D.
“Exploring ethical issues in TV medical dramas”
Jump to The Resident (Season 2; Episode 3): Saline shortage, pressure to bill; Jump to The Good Doctor (Season 2; Episode 3): Structural discrimination against women; surrogate decision-making; Jump to Chicago Med (Season 4; Episode 3): Best interest of a child; faith versus science; Jump to Grey’s Anatomy (Season 15; Episode 4): Fraud, assault, lies, and the ethics police
Medical dramas this week seemed to focus on two themes: 1. The poor treatment of female physicians and 2. Doctors committing fraud to manipulate patients and insurance companies into doing what they want.
When no saline can be found in the ED, Hawkins finds that nurses are hoarding it. Bell tells the Board that there is a saline shortage because the plastic bags are hard to find—they were manufactured in Puerto Rico and the factory was crippled during the Hurricane (this is true). The solution ends up being to start their own company to get around a monopoly. The ethical issue in this case is that a few companies control the production and supply of a basic, simple resource to the detriment of affordability and patient access as well as limited supply lines that are easily disrupted by a disaster.
Bell tells Austin (triple-board certified CT surgeon) that he needs to use the robotic surgery tool because they can bill at a higher rate. Austin responds that he needs to see studies showing it works better in cardiac cases. Austin faces a dilemma: Not use the robot because he believes that his patients will do better without the machine or use the machine because it’s what the CEO wants. In the end, he decides to do what is best in his medical judgement and is told that he may be let go at any time.
The Good Doctor (Season 2; Episode 3): Structural discrimination against women; surrogate decision-making
This episode was about the treatment of women in medical culture. We see this in two scenarios. The first is Lim’s appearance before traffic court where she has to take a phone call (she is on call and the residents she left in charge have questions). In return, the judge makes her wait all day and then offers an extreme punishment. Lim believes her treatment was because she was a woman and that a male physician would have not received such a sentence.
The second storyline is about Browne’s role. Browne speaks with Andrews about his flex scheduling policy that can leave them short-handed and require residents to work long hours. He dismisses her out of hand. This is the same Andrews who two episodes ago told her to be more assertive. But, when she is more assertive, the male surgeons complain that she is overstepping. During a surgery meant to take 1 hour but taking more than 12, Brown questions Melendez when he sends her to talk to the patient’s husband instead of Park. Melendez says that Browne is better at talking to people. While she is away, Melendez asks why Brown is “more irritable than usual.” A female surgical nurse takes that to mean he was blaming her behavior on her menstrual cycle. After Browne apologizes for her behavior (even though she did nothing wrong), Melendez asks her to perform the next part of the surgery. Is this an example of a reward for bowing to his will? Or did she truly do something wrong?
One of the problems is long standing structural discrimination against women in medicine. This was recently seen in attempts to limit female admission into one medical school in Japan, underrepresentation in specialties, less autonomy given to female surgical residents, and fewer women are in positions of power in medical administration. As recent evidence shows that patients of female doctors have better outcomes, it is important that this discrimination be dealt with—a step that is long overdue.
In this episode, later in the surgery, the team discovers a tumor in this patient that will require a hysterectomy. The patient had said that her dream is to be a mother. There is a potential workaround but it would be dangerous. Browne volunteers to talk to the husband about the choices. The husband, however, is unable to make a decision and asks Browne to choose. In the OR, she chooses the hysterectomy. This is a problematic part of the episode. Yes, a surrogate decision-maker can choose not to choose, but, that person cannot appoint someone else to choose. If the designated surrogate does not make a decision, then one must go to a designated secondary decision-maker or the alternate system for deciding (in some states, there is a hierarchical list). But there is no situation in which the surrogate can appoint someone else, especially someone who admits she does not know the patient and what the patient would want.
A father comes into the ED with his son in abdominal pain. We learn that the boy has end-stage renal disease and that the father is recently released from prison and is now wanted for kidnapping his son. Sexton wants to not report the father, so he can stay with his son. Goodwin tells her that the law requires they report the father and Choi says that their first obligation is to protect the patient. When the father is a match for donating a kidney, the new CEO says “no” because he is a high risk patient (since he will be recovering in jail) and she does not want bad statistics to threaten their status as a transplant center. When Goodwin asks if she is willing to sacrifice a child’s life to protect the numbers, the CEO essentially says yes. Efforts to find another donor or another willing hospital fail, so the father grabs a guard’s gun and shoots himself in the head. The boy gets his kidney, but at the cost of losing his father, a man he never got to know. This case raises two questions—where was the boy’s mother? That is never discussed. If the boy was kidnapped from his mom, it would seem that she would want to be with as soon as he was found. And the second is a criticism that corporate medical care has lost sight of human lives over pursuit of statistics and dollars. At the end, the CEO holds that her decision was still the right one.
In a second storyline, a patient is 13-weeks pregnant and having pain. She explains that she has a tricuspid uterus and it was a miracle that they got pregnant. Med student Curry is evaluating the patient, but after learning about the patient’s “miracle”, she begins to lecture the patient about human anatomy. Manning stops her. Curry says that the patient needs to know the truth so she can make decisions. Manning says it is not their job to disabuse patients of their beliefs. An ultrasound shows an ectopic pregnancy and that the patient needs surgery to remove the fetus. The patient refuses surgery saying “You don’t understand. This baby is a miracle and God will take care of it.” The patient passes a psychiatric exam. Curry thinks they should force the patient to get the surgery, “Our job is to fix her, not argue about theology…This is ridiculous.” Charles offers her an accurate perspective, “Our Job in fact is to treat our patients to the best of our ability, while honoring their cultural, spiritual and religious beliefs.” As the patient’s condition worsens, the husband suggests they should listen to the doctors. Curry negotiates with the patient that if the fetus dies, they could do the surgery. Manning calls her out for terrifying the patient. When the patient’s BP falls, Curry finds that the fetal heartbeat has ceased at which point the patient reluctantly agrees to surgery. However, during surgery they find that while the fetus was not viable, it had a heartbeat. Charles accuses Curry of hacking the ultrasound to give a false reading. She denies it, but it is clear that she is lying. Curry says that the important thing is that the patient is alive (a utilitarian argument). Charles tells Curry that she doesn’t get it; she lacks compassion and temperament and he will be observing her closely.
Beside the lack of professionalism displayed by Curry, I was concerned with the move to call for a psych consult on a patient who believes differently than the doctors. Unless there is a reason to suspect psychiatric illness, calling for a mental health evaluation is a sure way to shut down physician-patient communication and trust. As Charles points out, believing in a supreme being may not be rational, but it is a trait shared by a large portion of humanity.
A food delivery person is brought to the ED after smoke inhalation in a house fire where he was dropping off an order. He has a “bleb” in his lung which could explode and cause his lung to collapse, leading to his death. He has had it since he was a child but the smoke inhalation makes it more dangerous now. However, he is a college student and his mother’s insurance only covers an ED visit, but not surgery. Weber tells Karev that if he calls the mother to tell her, then he’s breaking HIPAA. When the patient tries to leave AMA, Karev surreptitiously (spraying on lidocaine) cuts him with a scalpel and shows him blood, saying it is “a penetrating chest wound.” Karev continues “It’s emergency surgery so it’s covered; as is anything else we find there.” In surgery, Weber asks Karev how he plans to tell the mother or a medical ethics committee about what he did. He offers a song and dance about his childhood. Later, someone tells the patient about the false wound. The patient says his mom will be “crazy happy” about this, but won’t Karev get fired. Karev says no, because he’s the boss.
To start, Karev committed fraud. More than getting fired, he could go to jail and lose his license. His intention might have been good—to help a person in need who was avoiding surgery because of the cost. But fraud is illegal. From an ethical standpoint, Karev lied to his patient and to the insurance company. The act of cutting a patient to create a reason for surgery is a violation of nonmaleficence as well as a battery, since the patient did not consent; the patient was not even aware. Perhaps the show is setting us up for a reckless Chief Karev who is going to get in trouble by violating ethical norms and law. In regards to Weber stating that Karev would have to defend himself before the medical ethics committee—nothing could be further from reality. Karev might, and probably will, have to defend himself before a medical practice committee. An ethics committee, however, is not a police force; it has no power of physician oversight; and it has no ability to punish. An ethics committee exists to help health care providers, patients, and families to navigate the challenging ethical waters of health care. They make recommendations, which one can freely ignore. I find it frustrating when medical shows present ethics committees as a body that polices health care providers, because that is not their role and it simply causes obstacles to the real work of education and helping people to face difficult choices.
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