by Craig Klugman, Ph.D.
As many of our favorite medical dramas head to their fall finales, they focused more on sentimental stories in the personal lives of characters, or feel good cases that did not raise any ethical issues.
The ethical issue in this week’s episode is located in a storyline about a man who comes to the ED after injuring himself with a nailgun. One nail punctures his kidney which has to be removed but, by a genetic fluke, the man was only born with one kidney. He has a rare tissue type and is unlikely to find a match through UNOS. His brother is a match and can be a living donor. During the consent process, Murphy talks about the risks. The brother says he will donate his kidney but only if the brother-in-need will sell the family business. He is holding his kidney hostage. The debate is whether the request is asking for compensation for the kidney (since selling organs is illegal in the U.S.) or is it just leveraging a business deal that he has requested before (which would not be organ selling). Things take a turn for the worse when his graft fails, meaning that hemodialysis is no longer an option—suddenly the need for an organ becomes acute. Still, no actions or words can bridge the divide between the two, until the donor signs the form, choosing saving his brother’s life over his business deal and personal gain.
In the U.S., live donation is considered giving a gift, donating, rather than a transaction. Thus, it is illegal to buy or sell an organ to protect all parties. Not all agree with this, suggesting that the donor (or the donor’s family in the case of cadaveric donation) should benefit since everyone else in the transplant system (hospitals, doctors, transplant organizations) make money on the surgery. The risk is social injustice; the rich (who can afford to buy organs) buying from the poor (who need the money to survive, pay debts, or to follow a dream). A monetary transaction can be coercive, encouraging the poor to sell an organ that they might not have in different circumstances and who might not have all the knowledge about the risk, and the required lifelong behavior changes required (no contact sports, no activities that could endanger the remaining kidney; regular check-ups because giving away one organ increases the likelihood of the second failing). Thus the idea of trying to get a concession from a close relative violates law and ethics of organ donation in the U.S.
After a driver crashes into a car while texting, the victims—a father and daughter—are brought to the ED. Abigail is 2 years old and unresponsive. She has fluid in her chest that requires intubation and a chest tube. In this case, Manning plans to push air and wait and see. When Abigail crashes, the doctors determine that she will not make it. Manning is sad because the girl could be an organ donor but there is no family to consent.
Her father, Mark, arrives with a GCS of 3 (deep coma or death). He is intubated and nonresponsive. His pupils are equal and reactive. He has lots of tattoos. As they cut off his shirt, the nurse finds a giant “Do not resuscitate” tattoo down his torso. Halstead asks Goodwin, “Is this do not resuscitate a legitimate a legitimate advance directive?” A DNR order has to be issued by a physician during a hospital stay. We learn that his wife died last year of cancer, so Mark may have gotten the tattoo after his wife died. Halstead asks whether this is how the patient feels now. There is no way to know. However, a DNR order is usually only given when a patient has a life threatening disease or irreversible condition. Before the car accident, this patient had neither.
Goodwin responds that the lawyers are looking at the issue; there seems to be no other family. Goodwin says that while the hospital figures this out, Halstead should “err on the side of life.” An MRI shows no brain damage, but his spinal cord is dissected meaning that he is paralyzed from the neck down. He goes into asystole and Halstead performs mechanical CPR for 10 minutes. (after he was down for 5 minutes) The nurse says she doesn’t know what Halstead was thinking; “This guy isn’t waking up.” Halstead believes that they won’t know the damage until the patient wakes up. Halstead and Manning talk about the validity of the DNR tattoo. Halstead holds that it’s not a legal document, “I have a responsibility to my patients to save their lives. Anything less and I am failing them.” In reality, while doctors are trained to think and often believe that saving lives is the only thing they are supposed to do, their job is more nuanced than that: Cure when possible, treat when available, and comfort always. Sometimes the best thing a doctor can do is admit when further care would be inappropriate (physiologically nonbeneficial) and provide comfort for the patient’s remaining time.
Manning says the tattoo indicates his wishes and there might also be an advance directive at home or in a safety deposit box. Manning has an underlying reason—if the father dies, then the hospital can petition the courts to be Abigail’s guardian and then they can donate her organs (What is not clear is why they can’t petition for temporary medical guardianship? And if Mark dies, wouldn’t they want his organs for donation also?). Manning goes to Goodwin to go around Halstead, in order to secure the organs. Goodwin later approaches Halstead to inform him that an “emergency ethics committee met” to evaluate the patient’s condition and concluded with “reasonable medical certainty” that the patient has no quality of life and the hospital will honor the tattoo as an advance directive. She orders Halstead to not resuscitate if he codes again. In reality, ethics committees do not make medical decisions. An ethics committee would appropriately weigh in on the question of the tattoo, an advance directive, and recommend whether there should be further resuscitative efforts. But, it is not the committee’s role to make a medical determination. Instead, his treating physicians and neurosurgery would explain to the committee their diagnosis and prognosis as facts that would be considered in discussion and deliberation. Also, ethics committees are not in the business of determining what is and is not a good quality of life for a patient—that decision is up to the patient and their family. However, given the lack of family to speak for him, and the presence of the “do not resuscitate tattoo” the conclusion to issue a DNR order seems appropriate and reasonable. They are not recommending withdrawal of any body supporting technologies, just issuing a DNR (in Illinois, without a designated medical power of attorney, removing life sustaining technologies are only permitted if the patient has one of a number of conditions laid out in law). However, the ultimate decision of whether to issue a DNR would rest with the attending (or perhaps the medical director), as ethics committees do not make medical orders or medical decisions for patients. Thus, Halstead’s disagreement with the committee’s findings is fine—he can choose to ignore them if in his medical opinion, that is best. The hospital could choose to take him off the case which is what seems to happen: When the patient codes again, another physician calls his death.
Abigail’s organs are donated for transplant.