Posted on January 10, 2019 at 4:45 PM
BioethicsTV (January 8-10, 2019): #NewAmsterdam; #ChicagoMed
An elderly woman arrives at the ED in the throes of her third heart episodeof the week. She needs an implantable defibrillator but her insurance will not cover the procedure or the device. Reynolds wants to charge the cost to the community fund (i.e. charity), but Goodwin is not available to approve (he’s having his own medical emergency). The patient apologizes for “being a burden.” However, after Goodwin’s collapse, Dean Fulton takes over as medical director and determines that the patient is stable, so does not need the surgery paid for by the community fund. Reynolds did the surgery anyway, saying that if the hospital will not pay then he would personally cover the cost.
While many compassionate doctors are moved to pay for treatments, food, and even rent for their vulnerable patients, doing so sets a problematic precedence. First, it’s not sustainable as a model. Doctors need to make money for their [enormous] student loans and to put food on their own tables. Also, a lot of the money charged in a surgery is for the use of hospital facilities and has nothing to do with the doctor at all. How long can a doctor go paying out of pocket? Should the doctors take out mortgages and loans on their house to pay for patients? And what happens when the well runs dry? Second, there is a justice issue at play here—which patients would get doctor-covered surgeries and which would not? Third, as professionals with long training and hard-learned expertise, doctors should be paid for their work, not work for free (exclusively) or at a deficit. Fourth, what Reynolds offers is simply a band-aid on a broken system. The “heartlessness” that we are supposed to feel toward the Dean is not the problem, the problem is a profit driven system that views people as “customers” and revenue sources rather than ill people in need of help. Until we move away from the profit-motive, until we provide good insurance for everyone irrespective of their social and economic position, such “heroic” actions actually enable this bad system to continue.
In the first storyline, Dennis Mitchell, age 28, drives by the hospital shooting at a trio of nurses when he flips his car and is taken to the ED. We learn that Dennis is an Inceland has written negative and hateful things about women and how he perceives they have treated him (e.g. not falling into his bed after he sexually harasses them). Dennis has undergone $10,000 worth of cosmetic surgery to improve his chances with women and had been in the hospital several months before after one of his implants led to an infection. While in the hospital for that admission, he hit on a nurse who declined his advances. Choi treats the patients physical problems—lacerations, broken arm, and an aneurysm created by a dislodged pectoral implant—while Charles and Curry (a med student) handle his psychiatric problems.
Sexton (whom Dennis grazed with a bullet) tells Choi that he is coddling the patient and that everyone is uncomfortable with Dennis being in the ED. Choi explains to Sexton that he wants revenge for what Dennis did, but his job is to take care of his patient. In reality, Choi is correct. Although health care providers may dislike their patients, or even find their behaviors appalling, the duty of a heatlh care provider is to help all patients irrespective of their own feelings. A person in need is a person in need.
Charles diagnoses the patient as part of an epidemic of loneliness. Curry, meanwhile lashes out at the patient and tells him that he’s “disgusting”. Charles explains to her that no matter how horrible his actions, their job in psychiatry is to determine his mental state. In reality, Charles is correct for the same reasons that Choi is correct. Even though health care providers often have personal feelings about patients, those cannot interfere (positively or negatively) in patient care. Curry is unable to separate her professional duties from the Dennis’s hateful language against women.
In a second storyline, boy around 10 was playing with a nail gun and injected one into his chest. The nail hit a rib, but for safety Rhodes is going to remove it in the OR. The child is scared and wants his dad with him. The dad asks if he could be in the OR and Rhodes agrees but only until the boy is asleep. As the anesthesiologist intubates the patient, the boy develops a pneumothorax (the pressure from the ventilator pushed air through the lung and into the chest cavity through a small hole the nail created). The father grabs the chest tube as Rhode inserts it into the boy’s chest cavity. The anesthesiologist injects the father who collapses and Rhodes calls for security to remove the father. The result is the tube going too far into the chest and lacerates the heart.
This scenario raises several ethical choices. Should parents be in the OR? In most cases parents are not permitted in the surgery but can be with their child before and after. The reason is because the parent is thinking more emotionally, may not understand everything that the health care team does, and surgery can look violent to an outsider (cutting, bleeding). A parent’s presence places the child in danger and poses a harm to the team. Rhodes was trying to be “the nice guy” but his actions endangered his patient. In the realm of do no harm, Rhodes exposed his patient to fairly predictable and preventable harm.
Another perspective asks whether the father grabbing the chest tube is a statement of not consenting to a procedure? In the situation of an unexpected problem appearing that is created by the procedure (too much pressure) and can be reversed, should a parent have the authority to refuse? The closest parallel might be the practice of DNRs in the OR. Essentially, there aren’t any. Many surgeons will not operate on patients with a DNR—they are often suspended during the surgery and the immediate recovery period. The main reason is that surgeons do not want a bad outcome on their stats, but a strong secondary reason is that a DNR would prevent the team from correcting a problem created by the medical intervention. Thus, in this scenario the father’s action is an assault and should not be viewed as withholding consent (it is not well reasoned, there is not time to discuss the risks, benefits, and alternatives).
A third issue is the anesthesiologist sedating the father without any permission, notification, or consent. Given that the father was assaulting Rhodes and the child, and further endangering his son’s life, the assault was probably the least destructive option for handling the situation—defusing the problem and minimizing harm to all. If the father had an allergy to the anesthetic used, then there might have been additional complicating factors to consider. In most circumstances, sedating a patient requires a separate consent (from the surgery) following both informative and volitional components of consent. However, in this case, the anesthesiologist prevented greater harm and subdued the problem. A conversation about options would not have succeeded and action had to occur immediately to prevent the father from further injuring his son.