Posted on December 3, 2018 at 3:27 PM
by Craig Klugman, Ph.D.
When Hawkins’ father (Winthrop) collapses, he is brought to Chastain (the hospital he owns) even though he asks to be taken somewhere else. He has a stricture that is affecting blood flow to his intestine that could become life threatening. In his consent process, he says anyone but Bell can do the surgery; his doctors go over the risks and benefits to surgery. The chief of general surgery says that she has all of her patients complete an advance directive, a task that Nevins says is part of the standard of care. Rather than a written document, Winthrop offers an oral one: Hawkins is his power of attorney. Hawkins is not thrilled with this because they have been estranged for 20 years. This scene feels like heavy-handed foreshadowing. Later, Winthrop has an intestinal rupture that requires emergency surgery and Bell is the only surgeon available.
In reality, an oral statement of one’s wishes in front of witnesses and documented in the record is sufficient for knowing a patient’s wishes. However, Winthrop only stated who should make his decisions without a conversation about his values, his idea of a quality of life, or even what he might want under various scenarios. Nor is there a written directive that indicates his care goals. While it is helpful to know who is the legal surrogate, leaving that surrogate with no guidance places an incredible hardship on them and the potential for them to remain with guilt over whether they made the “right” choice can linger. If the time comes when Hawkins must make decisions for his father, Hawkins could refuse but he cannot appoint someone else to take on that mantle. Also, the one directive that Winthrop does leave is that Bell should not operate on him and yet, at the end of the episode, Bell is the only surgeon available and thus the one thing Winthrop did not want to happen, happens. Since no one else was available (they were all at a wedding) and the situation was emergent, Bell doing the surgery is ethically appropriate. However, given Bell’s high mortality rates (as a results of his disease that has not been discussed this season), the outcome may be bad.
This episode focuses on empathy and its role in medical decision-making with people who act against society’s interests (i.e. those who have done a crime or are considering doing so). During a lunch scene, Murphy asks “do you need empathy to be a good doctor”? Brown says no because it can interfere with clinical decision-making. Reznick says that empathy is important to be able to tell the truth even when it hurts. Murphy’s concern is that because of his autism, empathy is very difficult; he asks if that means he can’t be a good doctor. Reznick tells him that he can still be a good doctor. Later in the episode, Lim says “Empathy can be an invaluable motivator that truly connects the patient with the physician.” However, she only says this because she is being observed by the hospital president at that moment for the chief of surgery position. In reality, there is a distinction to be made here that the characters are missing: One can be a good technical practitioner without empathy, but to be a good healer requires connecting to patients (witnessing their suffering and their narratives) and that does require empathy. Thus, Murphy can be a good practitioner with excellent outcomes, but he may not be able to be a full healer. This conversation is the philosophy underlying the two main stories in this episode.
In the first storyline, a young male prisoner (in juvie) is in the hospital having his lung reinflated, split lip, and a broken orbital after being beaten and kicked. He is a target because he has an indentation in his forehead from where his father hit him with a baseball bat in anger. Park says that they can fix the divot, to which Murphy says “no, because it’s a pre-existing condition.” Lim agrees the cosmetic repair to the forehead is not necessary. The challenge in this case is that the prison system will only pay for medically necessary surgeries and the repair is cosmetic. One discussion is that the prison system would pay for sex re-assignment surgery, but not this repair which would hopefully lead to the inmate being less of a target.
While doing surgery to repair the orbit, Murphy latches onto the discussion about how gender reassignment surgery would be covered when he says the surgeons can use a breast implant to fill out the divot. While the viewer understands how Murphy made this connection, what is not clear is why the use of a breast implant suddenly makes this a covered procedure? Or do the doctors not care and are going ahead anyway? The latter is hinted at, but not explained.
After Murphy explains his idea (in surgery), Park says “he did give us verbal consent when he was first admitted.” No, Park, the patient did not give verbal consent because at the time you spoke in generalities and did not discuss the specific procedure, risks, benefits or alternatives. A broad consent of “yes, do a repair” is not informed consent by any stretch of the imagination.
In the second storyline, a 20-something male patient is brought in with a stroke, saying he is taking anti-androgens for the last three months to treat hyperplasia. However, the doctors suspect he is taking them for different reasons since they see no sign of the disease. As it turns out, he is on the meds to control his sex drive—which interferes with his ability to function in his everyday life. But taking the drugs may kill him from a stroke. When he signs himself out AMA, Brown chases him down because she thinks they may have just released “a child molester” even though there is no evidence whatsoever that he is a sexual offender. The patient soon comes into the ED, this time with lacerations to the scrotum. We learn that he has never touched a child, but has had strong urges to do so. He asks for them to “finish the job” and remove his testes. Brown wants to help him learn to manage his urges by sending him to psych. Reznick says they should do the surgery the patient wants. Melendez weighs in and says that they “cannot remove healthy organs for crime prevention”. He makes an analogy to removing a person’s hands so they do not steal and he sides with Brown: The patient has to be evaluated by psych before castration can be considered. The patient says he will leave AMA without antibiotics, a blood transfusion, or further evaluation. He does not leave but refuses all pain meds and is writhing in agony. In a discussion between Reznick, Brown, and Melendez, Brown says “We are doing nothing besides hiding behind ethical red tape.” Melendez responds, “Ethical red tape is there to protect people like him from making permanent regrettable mistakes.” Brown says she will take the fault and write in a note that his testicles are beyond repair; castration is the only option. Melendez says that he will not falsify medical records. Later Brown takes him to surgery because of ischemia in the testicles at which point the team discovers he is septic. However, Melendez determines that the side effects of loss of testosterone would imperil the patient’s health further—they need to stabilize him and repair the testicles. The patient leaves soon thereafter and throws himself in front of a bus.
One of the frustrations I have with this show is that the characters do not show any moral growth. They make the same bad judgements over and over again. Brown has tried to lie to get patients to do what she wants. She has lied to help patients get what they want. But there are very few situations in medicine when lying is acceptable. Also, ethics is not “red tape” preventing people from doing what they want. Ethics is not about bureaucracy. Ethics is about helping people and care providers to make their own informed decisions. Ethics is about protecting the process of moral deliberation. Although the patient clearly stated, multiple times, his desire for castration, there is a question as to whether he was capacitated to make his own medical choices—Lacerating his own testicles and his suicide suggest that he was not able to make how own decisions.
This patient tried to manipulate the doctors into doing what he wanted (a tactic often associated with [potential] sex offenders). However, Melendez is right, to remove a healthy organ should only be done under the rarest of circumstances and even then only after thorough evaluation and a long consenting process.
The question of castration for [potential] sex offenders is a tricky question and therefore usually requires psychiatric evaluations, consent, and many conversations. When I was a PhD student, my first research job was with a prison health project, specifically looking at a new law that permitted offenders to request chemical castration to prevent them from acting on their urges. Our paper suggestedthat the view of the predatory offender was not found in the data and that historical approaches that have dealt with this population have either been penal or medicolegal (using medicine to solve a medical problem). One of the challenges is that laws often do not follow what is considered the best treatment and getting offenders what they need can be difficult. This episode demonstrates this challenge. The ethical decision is often the more difficult decision and that can require time—to reflect, to consider, and to explain.