Posted on February 10, 2019 at 2:35 PM
by Craig Klugman, Ph.D.
Jump to The Resident (Season 2; Episode 13): A risky organ transplant; Jump to The Good Doctor (Season 2; Episode 14):Face Transplant; Jump to Chicago Med (Season 4; Episode 13): Suspecting the worst; HIV safety or stigmatization; Suspicion and stealing from patients; Jump to Greys Anatomy (Season 15; Episode 12): Removing Dying Patient’s Autonomy
Eloise is a third year medical student in need of a double lung transplant as a result of her cystic fibrosis. However, she is too sick for the procedure since her liver and pancreas have begun to fail. Voss suggests a triple transplant—lungs, liver, and pancreas—an experimental procedure that has only been successfully done once. The alternative is death. A donor body is at the hospital. The patient agrees and Conrad says, “Now we only have to convince the ethics committee.”
Why? An ethics committee lacks any authority to make medical decisions. An ethics committee makes recommendations about ethical issues and dilemmas. Perhaps the writers meant an IRB, or a transplant review committee, or a medical review board. But putting the idea of final arbiter, of being judge (and potentially executioner in this case) in the hands of an “ethics committee” sends a public message that ethicists are more powerful than we are. No, no one expects to learn medicine from a medical drama, but one does expect some level of accuracy.
Turns out this “ethics committee” is a transplant committee (since everyone there is in a white coat we can only assume that everyone on the committee is a health care provider; no ethicists to be found). The first doctor to speak says that in order to do this one surgery, four people (with better chances for a good outcome) will not receive organs. Thus, he sets up a justice issue similar to trolleyology or the lifeboat: Save 1 life or save 4? Utilitarianism tells us to save the 4. Triage suggests saving the ones with the best potential outcome (not Eloise). Voss says the patient is an exceptional person (she developed a nonprofit to help people in need) and a top-notch medical student (an appeal to emotion)(appeal to feminist ethics). A third doctor says all patients are equally deserving (a call for an egalitarian method of choosing). Conrad agrees and says those people will be next on the list and get the next organs (they won’t because distribution is more complicated than being on the list—the list is actually redone with each potential donor). Voss appeals to Bell’s ego, saying that there is only a 5% chance of success, but think about the prestige to the hospital to “advance the science and make medical history” (an appeal to vanity). In this committee though, it seems that Bell’s vote (or perhaps his ego’s vote) is the only vote since he decides to go ahead even though he would be outvoted by the members present.
In reality, hospitals make these choices all the time, otherwise there would not have been that first triple-organ surgery to which the characters refer. Although maximizing the potential benefit provided by these organs seems a strong way to make choices, since human beings are making these decisions, they often end up considering the person’s role in society (she’s a med student; she created a nonprofit to help others), their ability to afford the procedure and follow up care; and yes, even their own egos and potential boon to the institution.
The donor is unconscious after a drug overdose and is removed from her life support. When her heart stops, they wait an appropriate amount of time and then procure quickly. In a twist, the lungs have nodules. Conrad says to take the liver and pancreas from the cadaver and in emergency surgeries, take lung lobes from the parents (whom we are told haven’t fasted or had recent medical workups; both are compatible donors). In mom’s surgery, the surgeon clips the pulmonary artery and she is bleeding out. Mom survives but has a long road to recovery ahead of her. Eloise thanks her parents for giving her life a second time. A surgery with a 5% chance of success and that denied 4 people organs, succeeds.
Again we see an “ends justifies the means” approach. Even though mom was harmed, 4 people did not receive organs (and likely will die), this surgery is presented as a success. Let’s be real: The surgery succeeded in the immediate hours after the patient wakes up and seems fine. But real success is how she does over the weeks and months of recovery. How long does she live healthy with these organs. Does her mother pull through? I will also mention that the donor died of an overdose, does that change the patient’s outlook since the organs have been exposed to years of drug abuse? (According to recent study, the answer is that such organs lead to similar survival rates as other donors). Success is not in the immediate moments of recovery but in the time after that.
On top of all these ethical issues, at the patient’s request, her surgery is livestreamed to her medical school as a teachable moment.
Although it is not unusual to tweet and stream surgeries, especially big ones for learning purposes, this must be done carefully. The permission of the patient is paramount as is the agreement of the surgeon and hospital. Also, as was done in this case, the streaming was limited to that patient’s medical school which limits the potential violation of patient confidentiality and institutional liability (what happens if things go wrong?). However, whenever anything is sent digitally there is a potential for hacking the feed, for someone hand recording, or unintended and unexpected threats to privacy. These must be minimized (for example, through encryption, closed circuit instead of using the internet) and informed consent.
Karen is a 14-year-old girl brought unconscious to the ED after a car accident. She has both head and heart (aortic dissection; pseudoaneurysm) trauma. Melendez wants to start with the head. Lim does not see major brain bleeds on the scans and states, “heart trumps head.” Melendez follows her lead. During the heart surgery her brain herniates and she immediate needs a craniectomy. Before they can begin cutting near the head though, Karen is declared “brain dead.” In the chapel, Andrews approaches the mother to ask about organ donation. Due to the nature of her injuries most organs are not viable, but her face is—Andrews asks to donate Karen’s face to another patient. The mother initially refuses but after accidentally running into the other patient in the elevator, she consents.
Shannon had an accident with her father’s gun that left her face deformed. She is in the hospital for a surgery to re-align her eyes. This will be her 12th surgery. Andrews approaches Shannon with the idea of the face transplant. Karen is the perfect match. The hospital cancels all elective surgeries and spends two days preparing. When mom is ready, Karen is wheeled past “the walk of honor” where the hospital staff lines up “to honor her sacrifice”. After Lim removes Karen’s face, the ventilator is deactivated in a solemn moment. Browne introduces the three parents. Shannon’s parents ask Karen’s mom all about her daughter. The surgery turns out well and Karen says goodbye to her daughter’s face.
This case is ethically well done except that we do not see anyone explain the risks to Shannon. The donation is treated compassionately. The patient’s mother gives consent. The staff is respectful and professional. The only reason to point out this storyline is to emphasize that face transplants are a risky procedure and still relatively rare—fewer than 50 have been performed worldwide. For the recipient, the challenge is that a healthy person undergoes surgery to transplant a new face and then spend the rest of their lives taking antirejection drugs. The ethical challenge is exposing a healthy person to a great deal at risk for a surgery that is not medically necessarily (but socially and psychologically desirable). Currently, these surgeries are still experimental, requiring due diligence in consenting donors’ families and in ensuring truly informed consent.
Chicago Med (Season 4; Episode 13): Suspecting the worst; HIV safety or stigmatization; Suspicion and stealing from patients
Mr. Cominsky comes to the ED with heart palpitations and high blood pressure. Hank, a nurse, enters the room and walks out immediately. No nurses will fill doctor orders or see the patient. When a nurse finally draws blood, she stabs him several times (on purpose). Choi learns that the patient was a child molester and Hank was one of his victims. Choi talks to Sexton and tells her “You know how unethical it is denying a patient care, treating him like a pin cushion. I should write you up….It’s not up to us to administer justice…No matter how awful this patient may been, we have an ethical obligation to treat him as we would anyone else”. The patient is fine and then suddenly goes into v-fib while Sexton walks out of his room. The patient died with a high level of epinephrine: Did Sexton kill him? Choi used on amp of epinephrine in the resuscitation attempt but there were four in the trash. An autopsy shows he had an adrenal tumor which caused the high epinephrine—he died of natural causes.
In reality, treating someone one knows has hurt others can be challenging. Choi is right, all patients should be treated well irrespective of what they may have done. Purposefully injuring a patient is nonmaleficence and a violation of trust as well as a battery. Being slow to diagnose and treat a patient violates an ethical duty to care for patients and can be just as harmful as hurting them with sloppy blood draws.
Cody is brought into the ED after a car hit him while he was riding his motorcycle. The patient is in pain and tells Rhodes that he is HIV+. The patient is given fentanyl and it has no effect. Rhodes tells the patient that he has a lot of broken and displaced ribs and that the only way to reduce the pain is surgery to put the ribs back in place. He asks the patient, “is that okay” and the patient says “okay”. Latham refuses to operate, saying that the surgery isn’t necessary and with his HIV status, the risk is too high. Bekker agrees to operate. During an incision she cuts herself on a scalpel that has the patient’s blood. Goodwin initiates hospital protocol—Bekker must be seen by infectious disease, must start antiviral medication, and is removed from surgery for a few days to see how she reacts to the meds. At the end of the episode, we are given cause to suspect that Bekker is faking her injury or got it on purpose in order to bring Rhodes back to her romantically.
When Cody first states his status, Rhodes said it was okay because they are always prepared. This is accurate as universal precautions should always be practiced on every patient. Latham’s refusal is less defensible. Health care providers are not obligated to put themselves in harm’s way, but if the decision to not operate is solely because of the patient’s HIV status (and the same operation would be done without hesitation on a negative patient), then the choice may be coming from discrimination. The line is fine and can be difficult to identify. It’s important, though, to not treat someone differently because of their status, which means, health care providers should always practice universal precautions and safety on every patient, every time.
Jared has a “seizure” at work and is brought to the ED. He has had colon cancer for two years and is receiving chemo. Manning suggests some scans to make sure he’s okay and the patient refuses, “No, I don’t want to blow up my insurance more than I already have plus my oncologist scanned me just last week.” Manning says she can check the records with oncology if Jared gives her written consent. He says no because he doesn’t want to bother his doctor. The patient asks Manning to get something from his bag, which she sees is filled with green pills. Later, the patient has a second seizure. Manning goes to Charles sharing her suspicions that Jared is lying about having cancer. Charles can’t make a definitive diagnosis because Munchausen’s Syndrome is a diagnosis of exclusion. Manning is impatient so she goes through the patient’s bags and grabs the pills she saw earlier and takes them to the lab for analysis (they end up being benign). Jared thought Manning had stolen the pills so he gave permission to Goodwin to access his entire record. What he was hiding was the severity of his cancer.
Stealing from a patient is never acceptable. The case did present Manning with cause and reason to suspect the patient was lying/hiding something. There are more appropriate ways to deal with this situation, such as talking to the patient first. Goodwin chooses not to penalize Manning, but stealing is an ethical violation as well as breaking the law.
This episode followed the storyline of a patient badly injured in a car accident on her way to her wedding. We follow the months of her recovery and then a severe setback. Her fiancé stays by her side the entire time. She regains consciousness after the first month. After four months in the hospital, the patient and her fiancé decide that enough is enough, and they ask her doctors to remove her ventilator. The doctors have no issue with this request. However, just before they deactivate the ventilator, the couple is holding hands and Karev says to the fiancée, “We need you to give verbal consent as her power of attorney.” The fiancée says yes. What is strange is that the patient herself is competent and capacitated when Karev asks for consent. She is unable to speak, but she could nod her head, write, or communicate in another manner. The patient’s autonomy is stripped from her at this moment in her life. The patient is not dead; she is dying. Dying people who are conscious have the legal ability to make their own decision.
A medical power of attorney is a document that appoints someone to make a person’s decisions usually only if that person is competent and incapacitated. But as long as the person is both of those, the patient gets to speak (write, blink, squeeze a hand) and the surrogate decision-maker’s choice has no legal or ethical weight. In some states, one can choose to have a medical power of attorney come into effect immediately. Either way, in this case the patient is present and alert: Essentially, Karev denied a dying woman her right to autonomy. I have to wonder if this situation occurred because the patient was a female: Would Karev have done the same thing to a male patient with a female fiancée? It is important to note that dying patient’s retain their right to self governance and to remove it from them prematurely is paternalistic, unethical, and illegal.
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