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11/02/2018

BioethicsTV (October 29-November 2): #TheGoodDoctor; #ChicagoMed

by Craig Klugman, Ph.D.

 “Exploring ethical issues in TV medical dramas”
Jump to The Good Doctor (Episode 2; Episode 5): “No, Dr. Melendez that is not an IRB”; Physicians cannot be compelled to maintain a patient’s lie; Jump to Chicago Med (Season 4; Episode 6): Saving an abused non-resident spouse; stolen children; medical error blame

The Good Doctor (Episode 2; Episode 5): “No, Dr. Melendez that is not an IRB”; Physicians cannot be compelled to maintain a patient’s lie

A 42 year old female with intermittent PVT (an irregular heart beat) is brought to the hospital. She is frail because of her anorexia. The heart problem is mitral regurgitation that requires surgical repair and is often an effect of her disease. However, her frailty makes her a poor candidate for the surgery—she’s too easily subject to post-op infection among other concerns. The patient can’t seem to consume enough calories and agrees to tube feeding. When she thinks about how many calories are being put into her, the patient pulls out her NG tube. Melendez suggests going through the surgery before she loses any more weight. Browne finds a small study (6 subjects; 50% success) where a DBS (deep brain stimulation) device was inserted into the brain to treat anorexia. Melendez says the procedure isn’t approved in the U.S. Browne says, “We call an emergency IRB ethics hearing and argue emergent use approval.”

There’s so much wrong with that statement. First, IRBs do not approve surgeries, they approve research protocols. Second, IRBs and Ethics Committees are two different entities with different charges and functions. Third, there could be a hospital policy that requires a review before experimental use of a procedure, but compassionate use (using an unapproved FDA drug) requires an application to the FDA and if approved, the agreement of the manufacturer to this particular use. And fourth, when Browne finally speaks to this committee, it is composed of three people—the hospital president, the head of the foundation, and her attending. We hear Melendez state, “This is an IRB.’ No, Dr. Melendez, that was not an IRB.” An IRB is composed of individuals who are dedicated to protecting research subjects and making sure that protocols meet high ethical standards. An IRB is composed of a larger number of people who come from all across the institution and represent a diversity of disciplines. An IRB consists of people who are educated in the subtle legal and ethical requirements of human subjects research.

In this show, the patient meets the IRB and begs for their assistance. I never heard of an IRB doing the consent process either, which is what happened in this episode. Fifth, it is not clear that any of the three had the scientific expertise to review the proposal—an IRB is required to have an expert in the subject matter (even if someone is brought on ad hoc).  Sixth, the committee voted “2-to-1” to allow the surgery. An IRB would vote to allow a research protocol to be carried out; it would not vote to allow a particular surgery to happen. “No Dr. Melendez, that was a medical review board, not an IRB.”

The husband visit Melendez and says they want the brain surgery before the valve replacement. Apparently, Browne has done what she does best, ignored her attendings and spoken to the patient and family to manipulate them to do what she wants. Why this resident has not been fired and been arrested is beyond a willing suspension of disbelief. However, at the end of this episode, she is reprimanded, fired from Melendez’s service for her disobedience of going to the patient after he said no. He is absolutely right.

One of the side effects of the DBS is personality change and because, as Chekov said when you see a gun in the first act, it must go off by the third, that story ends with the mother hugging her son and not feeling the same maternal warmth that she once had toward him.

In a second storyline, a healthy male comes in to be assessed for knee surgery. We learn that he had bypass surgery 15 years earlier. Murphy is concerned that the urine sample is “fizzy” and orders a cystoscopy. The test shows that the patient has a fistula connecting the bladder and the small intestines. They also diagnose him with Crohn’s disease. The solution is bladder repair and reversing the bypass, two procedures that require two incisions. The patient doesn’t want his husband to know and asks the doctors to just inform the husband that there was a complication. Park says, “our obligation to protect your privacy doesn’t include lying”. Murphy suggests a single abdominal umbilical port that could allow both surgeries with a single incision: “We can help you deceive your husband.” The husband is told that the surgery is for the Crohn’s disease.  Just before surgery, the patient starts projectile vomiting—he may have an obstruction.

Later in the cafeteria, the husband approaches Parke and offers the results of his internet searches, which could avoid surgery. Parke tries to get away, but ultimately tells the husband that they aren’t treating the Crohns, “Go talk to your husband.” While he did not lie and offered a good response to talk to the patient, Parke may have dented confidentiality when he contradicted what the patient had said. Lim calls him out on this, “You violated our patient’s confidentiality.” Parke tries to cut hairs “I told him what we weren’t treating. That’s not a violation and their marriage is better off.” No patient can ask a health care provider to lie for them, but the patient can request that they not share information. The question is whether a physician has an obligation to help maintain the perception of a lie, even if they did not state the lie. The answer to that is likely no, a physician cannot be compelled to maintain the illusion of a lie. To say anything other than what Parke said would have been to become a collaborator in the lie, and that is not something a physician should do. This is a scenario where the duties of confidentiality and truth-telling butt against each and leave no good response.

Lim informs us that the patient has fired them and is requesting a transfer to another hospital. Before the transfer can happen, in the middle of a domestic argument, the patient starts bleeding and needs immediate surgery. He comes through okay, but as the husband sees pictures of the patient before the bypass, our fears that he is bigoted against overweight people  becomes evident. Perhaps, the marriage won’t last after all.

Chicago Med (Season 4; Episode 6): Saving an abused non-resident spouse; stolen children; medical error blame

A 29 year old female, Daria, is brought into the ED after a motor vehicle crash. Her husband was driving and will not let anyone check him nor will he leave her side. She has old contusions on her abdomen that appear to match the pattern on the bottom of her husband’s boot. When in the MRI room Manning asks the patient is anyone is hurting her and emphasizes that there is confidentiality of what they say. We learn that the her now-husband came to the Ukraine and charmed her but when she arrived in the US he was different—getting mad all the time, and beating her. She begs Manning not to report the incident to the police because she has no papers and they never filed for a green card. While Manning and Halstead are talking to the patient about an aneurysm, the husband gets angry when the doctors speak to the patient rather than to him; he also resists their efforts to have her alone in the room without any visitors. Goodwin learns that an exception to the Violence Against Women Act is that a battered spouse can apply for residency without the US-citizen spouse knowing. The husband requests that they leave against medical advice. Halstead says it is the patient’s decision and she agrees with her husband. Later, Halstead and Manning inform the husband that they are convening an emergency hospital ethics committee meeting. At that moment, the patient codes as her aneurysm blows. Manning and Halstead tell the husband that all traumatic deaths, by law, must be autopsied (this is mostly true in Illinois where the show is set). The husband says that Daria would not have wanted an autopsy; Manning said the medical examiner is the one who decides. The husband leaves the hospital, at which point we learn the entire code and death was an elaborate ruse to free Daria from the control and abuse of this man. Goodwin is understandably upset: “This was a complete misappropriation of medical care.” The doctors put the hospital and their own licenses at risk. Manning tries to explain “if we could have stayed within the lines we would have.” Goodwin lets them know that one more “stunt” and they will be fired. Meanwhile, Goodwin has arranged for a social worker and an immigration attorney to meet Daria.

This ruse was a violation of legal and ethical precepts. By performing compressions during “CPR”, Manning risked dislodging the clot that is preventing the aneurysm from blowing. The doctors lied to family and used hospital resources and personnel to stage their morality play. Yes, the husband was abusive and they had a limited obligation to protect this women: Under Illinois law, that obligation was to inform the patient of her options and to be willing to inform the police if she wishes. They are only required to report to the police if a firearm was involved. Plus, knowing that the husband was violent, they put themselves and everyone in the ED in danger. Goodwin went easy on them, because in this show, like most medical shows, the operating ethics is “the ends justifies the means.” In reality, it does not.

In a second storyline, Gabby, a young girl in a cotton candy Halloween costume comes to the ED. She has swollen legs, jaundice, and vomiting. Her mother tells us that she has been eating vegetarian. Choi finds that her liver is cirrhotic and that she is in liver failure. He diagnoses Wilson’s disease, which is a disorder where the body cannot rid itself of copper and it builds up. The treatment is plasmapheresis to remove the copper but she will eventually need a liver transplant. Choi says that the parents, friends, and family can be tested to see if there is a living donor match. The father is not a match and his blood test shows that he is not the father. Concluding that he may not be aware that Gabby has a different biological father, Charles and Choi meet alone with the mother. The mother explains that Gabby is adopted and the child is unaware of this situation. The hospital will put her on the transplant list but the mother asks if the donor could be a drug user—it is clear that she is hiding something else about the child’s origins. We learn that they never adopted Gabby, but took her from her mother, who was abusing drugs and ignoring the child’s cries: They kidnapped Gabby and the doctors now have an obligation to report this information to the police. The police arrest the “parents” and locate the birth mother who was ecstatic to learn about her daughter. When the birth mother arrives, she wants to thank the people who raised her, because, “they saved her [Gabby’s] life.”

In a third storyline, a construction worker arrives after having a piece of sheet metal fall on his leg—severed femoral artery and muscle in the leg. A medical student is assigned to insert his first central line in a patient desperately needing blood; however he hits the artery, not the vein and they are forced to find another access. Rose complains to Lanik, the new ED chief, that he is not supervising his students appropriately, putting them in situations for which they are not prepared and endangering patients. The student’s mistake leads to compartment syndrome and death of the leg: The patient’s undamaged leg must be amputated to save his life. Lanik suggests they do nothing, that the patient arrived with an unrecoverable, anoxic injury. Rose calls him out suggesting that Lanik hopes the patient dies so that there is not a malpractice suit for the mistake that led to an amputation. Lanik says that if he goes down, he’s taking the med student with him. The patient dies, solving the problem. In reality, a medical student is under the supervision of an attending or a resident. Students are to be supervised. If there is an adverse outcome, it is the responsibility and liability of that supervisor. The idea that a physician would throw a trainee under the bus for something they could not have known how to do, nor be expected to do in that situation is unconscionable.

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