Posted on February 25, 2019 at 12:30 PM
“Examining ethical issues in TV medical dramas”
Jump to The Resident (Season 2; Episode 15): Insurance Fraud and Endangering Patients in Pursuit of Profit; Jump to The Good Doctor (Season 2; Episode 15): The Risk of Looking, Pediatric Decision-Making; Jump to Chicago Med (Season 4; Episode 15): Racism
Milo Trainor comes to the ED with severe backpain. Pravesh asks him what his job is and the patient responds that he is an ethicist finishing his dissertation on “moral relevancy”. Pravesh says, “Sounds like you found a job that pays less than my residency.” Pravesh diagnoses kidney stones. Trainor’s pain increases and spreads looking like appendicitis but his record shows he had an appendectomy previously. CT shows acute appendicitis; the medical record is wrong. We later learn that Milo traded identities with his identical twin brother, Brent, to use his insurance. Pravesh tells the patient, “Rule #1 if you want to stay alive, don’t lie to your doctor.” Feldman points out to Pravesh that he needs to report the switch because it is insurance fraud; if he doesn’t report then he could lose his license. Pravesh decides not to report so as not to saddle Brent with debt and fines for the fraud.
This episode raises the problem of affordability of health care—for people without health insurance, the cost of care is crippling making medical treatment unavailable. This case also raises two philosophical perspectives on decision-making: Under a deontological view one should follow the standard of right behavior (the “moral law”) and in this case that means reporting Brent’s fraud. Under the utilitarian view, the consequences are what matter and in this case that means saving a patient’s life and not saddling him with unpayable debt. By not reporting the fraud, Pravesh is guilty of a cover up and injuring the hospital. After all, if this occurs with many patients, the hospital will go under and not be able to help anyone. This is the challenge of a for-profit health care system—that the patient is often sacrificed to the pursuit of wealth. In this case the television ethicist is less than ethical when confronted with real life.
In a second storyline, Henry (a child) returns to the hospital because he is having fainting spells. Henry received an implantable vagus nerve stimulator (VNS) to control them. We have learned that the manufacturer is shady and the CEO asked Bell to keep the problems quiet. Conrad wants to keep Henry overnight for observation but Bells says there’s no medical reason, discharge him (to keep things quiet). On the way out of the hospital, Henry codes, twice, in the very public lobby. The vagus nerve also effects the heart and since Henry’s VNS discharges every 3 minutes, that’s how long they have before the machine discharges Henry’s heart again. Mom does not have the control on her and the hospital’s backup is missing. Henry is scared and doesn’t want to die.
The medical device manufacturer has been shady since this storyline was introduced—lying about where the devices are manufactured, lying about the testing, and even killing a sales rep who was coming close to figuring things out. This episode brings to a head the problem of conflict of interest—making medical decisions based on financial interests rather than the patient’s best interest. As the CEO tells Bell, if news of the problem gets out, the company’s IPO will tank.
The new chief of medicine, Jackson Han, brings in wealthy patients for executive physicals. Han subjects patients to full body testing which is a lucrative source of income for the hospital. In this case, an unnecessary MRI shows a tumor which leads to a need for a biopsy. However, the tumor is close to a major artery which makes the biopsy near impossible. Melendez explains to the patient that the tumor is most likely benign. He says that the problem with broad testing is that all bodies have abnormalities and most of them are nothing. “When we do find them, we have to make some tough choices.” In this case, they can remove the tumor which is risky and could lead to paralysis or death. Or they can watch it, but the type of cancer this would be is fast and aggressive, likely to grow and metastasize before it could be detected. The patient decides to have the surgery. Melendez removes the tumor but to get at it, he had to sever the nerve that controls the patient’s left foot. We are never told the biopsy results because after all, the tumor is out.
Melendez correctly points out the problem with aggressive, broad examinations in the absence of a problem—they will discover anomalies that may never affect a person’s health. But once you know about them, one feels obligated to treat them. These multiple day physical exams do bring money to the hospital since they are not covered by insurance and are paid as cash from a company. However, exposure to the diagnostic tests may cause more harm than good. Whether these executive physicals actually prolong life or health is unproven.
In a second storyline, a newborn baby has multiple organ problems—several holes between left and right ventricles as well as bowel problems. There are no easy solutions to the case. When Murphy offers a solution to the heart, Lim says that fixing it takes an option off the table: withdrawing care. The plan for the bowel is poor with only a 10% chance of success, most likely leading to a slow death from inability to absorb nutrition. Lim says, “If we were to turn off the machines, she would pass swiftly and peacefully.” The father feels the best move is to withdraw care and the mother wants to pursue the surgery. The father feels she is deciding out of guilt (were her anti-depressants involved in the birth defect?). Andrews steps into the picture and says that since the parents cannot agree, the decision will be made by a judge based on the medical recommendation. Han says it might be better for the doctors to make the decisions so the parents do not have to live with the guilt of making the decision. Han, as chief of the department, tells the judge that they want to do the surgery—Han believes their team is better than the average surgeon. The repairs are technically successful but the heart is overpowering the lungs. Han tells the parents it is time to withdraw care. Just as the medical team is about to turn off the ventilator, Murphy comes up with an idea to circumvent the problem and the baby’s life is saved.
This storyline demonstrates a challenge in pediatric decision-making. The model for making choices with adults relies on the notion of autonomy—that a patient gets to make their own decisions. However, a child lacks competency to make choices, leaving the decision to the parent. A model of shared decision-making means that a parent in conjunction with medical professionals should reach a decision in the best interest of the child even though the child has no say in the matter. The problem, of course, is when there is a lack of agreement. In such cases, unilateral decision-making may be attractive—the decision made by an authority that alleviates any guilt the parents may have for the decision. However, such a move means that a choice is forced on the parents and the child who may have different values and choices. Rather than making choices by consensus, or by self-interest (as autonomy encourages) a greater reliance on best interest may hold. And given the complexities of this case, it is unclear what the child’s best interest is. The only clear thing is that asking a judge to make the decision is not the best first move when at an impasse: An ethics consult should have been the first move.
The new chief of surgery decides that even though Murphy is brilliant, his lack of communication skills means he is unable to connect with patients. Han arranges for Murphy to start a pathology residency where his social skills will not be a problem. Is this discrimination or is it recognizing that being a surgeon is about more than excellent technique?
This episode surrounds a mass casualty incident. Kenneth Baker has end stage cancer and drives his truck through a street fair, hoping to kill as many non-whites as possible. One of his victims is Jada, a 17-year-old girl just admitted to Northwestern. She is quickly pronounced brain dead.
A second patient (not part of the mass casualty) is Frances Buckley who is an older middle-aged man on the heart transplant list. He needs fluid drawn out of his chest. His condition is serious and he has moved to the top of the transplant list.
Jada is a match for Frances but mom wants her organs to go only to “people like us” meaning people of color. Goodwin explains that the organ network does not select based on race. Mom says she can’t consent if someone who is a white racist, like the one who killed her daughter, could benefit. Later, Goodwin talks to the mother trying to convince her that the hate which took her daughter’s life does not have to be her daughter’s legacy. The mother chooses to donate.
The UNOS system is set up so that people are not aware of to whom they donate or from whom they receive an organ. The idea is to remove potential biases and to make decisions based on the medical facts alone. Of course, given that transplant committees, composed of people, choose who is on the list, this is not an objective system. The issue of race continues to be a challenging one in our society and that includes in medical care: e.g. should patients get to choose the race of their physician?