Posted on March 4, 2019 at 12:59 AM
A pastor is scheduled for two surgeries: (1) to fuse part of his spinal cord and (2) to remove a tumor. The pastor is in pain and asks if they can remove the tumor without the fusion. He believes that the pain is his punishment for having counseled a parishioner who later committed suicide. The parishioner was in a moment of crisis and when he called, the pastor was occupied. Browne believes even trying to do the second surgery without the first is “insane.” Melendez says the pastor has autonomy, does she want to override his wishes because he is religious? Browne wants to educate him, that he doesn’t realize how much more dangerous the surgery really is without the first part. The surgery failed without the fusion. Over a second attempt, each of the team explains their religious beliefs and why they do or do not believe in a deity. They remove the tumor and discover it has shrunk in size by two-thirds without any radiation or chemo. It seems like a miracle. With his cancer seemingly vanishing, Browne convinces him to get the spinal fusion.
The relationship between medicine and faith can be a tricky one. About 78% of Americans claim belonging to an organized religion. In many cases, patients may believe in miracles or that God will cure them which creates a situation where they either refuse useful medicine or they continue demanding care far beyond what is physiologically beneficial. In other times, patients want to have their religious beliefs attended to in the hospital. Most health care providers report being asked to praywith patients. On the whole, nurses are more comfortable doing this than physicians. Ten percent of patients wish for “spiritual interaction”during office visits. I have been asked to pray with patients during clinical ethics consults. Usually I ask if they’d like to speak with a chaplain; often I stand quietly while they pray. The point is that unlike Browne’s stance, my beliefs do not matter. Those of the patient and what they need to believe for their care (as long as it does not contradict safe medical practice) are important.
In a second storyline, a female mountain climber is in the ED because she had bad headaches and arm and leg numbness when climbing. Lim suggests that she climb more slowly and drink more water. Park thinks the patient has anxiety. When the patient then shares that she has had a sense of dread all day, Lim orders a brain MRI which showed a malignant meningioma. There is no treatment so all they can offer is palliative care. However, Murphy (who is now in a pathology residency) sees a test result that does not match the diagnosis. A biopsy confirms Murphy’s suspicion that the patient had a worm from eating bad sushi.
For a patient that presents with anxiety and altitude sickness, an MRI is not a necessary test. But Lim believed her patient and understood that sometimes patients know their body best. While patient’s may not always be right, they do live in their body each day and more often than not know when something isn’t quite right. The practice of narrative medicine developed in part to capture patient’s stories. By listening to patients one can learn a lot including when a test might be indicated or not.
Thomas Kramer is a young boy brought into the ED after he starts vomiting, complains of a headache, and can’t move his head. He is also being treated with chemotherapy for leukemia. Thomas has viral meningitis and his leukemia is worsening. Besides antivirals, the next step is a bone marrow transplant. The mom offers the younger brother Gavin as a donor. Choi says transplants from minors are rare. The parents explain that they conceived Gavin as the perfect genetic donor: He has already given cord blood and a kidney. Gavin starts having a panic attack thinking about being under anesthesia. Choi tells the parents that Gavin won’t consent. They respond that they are the parents and get to decide. Choi tells them that he still needs Gavin’s assent and without it he won’t put the boy under anesthesia. The parents beg Gavin to save his sick brother and the boy agrees. Goodwin essentially performs an ethic consult when the medical team expresses concern that Gavin only agreed under duress. Goodwin talks to the parents and Gavin (though she does not speak to Gavin away from his parents) and she says Gavin says he wants to donate. “The Kramers don’t want to hurt Gavin, they want to keep Thomas alive. It’s an impossible situation and if he doesn’t voice his reservations directly, then my hands are tied.” We then learn that Thomas has stopped taking all of his chemo drugs, “I just don’t want to do it anymore, any of it…I’m in pain all the time.” Thomas tells his parents, “I don’t want the transplant. I don’t want to fight anymore…I’m ready to go.”
There are three major ethical issues in this case: the savior child, Thomas’s decision to stop his treatment, and assent. The issue of a savior child is a challenging one: Is the designed child viewed as less than the sick child? Often these situations look for intent. If the parents were going to have another child, if they will treat this child as equal to the sick one, if the savior child will have a strong say in their donations, then it might be acceptable. But if the child is forced to donate and is only conceived in an attempt to save the sick sibling, then it is problematic. As Kant says in his principle of humanity, people should not be treated merely as means but as ends in themselves. It may also be useful to appoint a health care guardian for the savior child, someone who can advise and make choices for the child since the parents may be conflicted in choosing between the best for both children.
The second ethical issue is Thomas’s decision to cease treatment and his fear that he will disappoint his parents if he makes that choice. A dying child is always among the toughest of cases. In many circumstances, the child reaches the decision to cease treatment before the parents and can feel that they are disappointing the parents in the decision. These sick children often spend a substantial amount of their life in the hospital and have strong maturity when it comes to understanding their disease, life and death. Having open communication is important to make sure everyone’s perspective is considered.
For both brothers, the issue of assent is important. Assent is the child’s agreement to go along with the consent. Assent is not a legal requirement but an ethical one. The amount of weight given to assent depends on the invasiveness of the procedure, best interest of the child, the child’s age and maturity. For Thomas, he has a high level of maturity and understanding of his disease, thus his input should receive considerable weight. Gavin is younger but expresses his fear and worries about pain, which must be taken seriously as well.
Caroline Charles (Dr. Charles’s ex-wife) has cancer and during an evaluation for a clinical trial she learns of a damaged heart valve—likely from earlier chemotherapy. Rhodes evaluates her and decides the risk of surgery is too great—30-50% mortality on the operating table. Bekker goes behind his back and says she will do the surgery. When Rhodes takes his concerns to Goodwin, she tells Bekker her actions were unprofessional and she tells Rhodes that the patient has the right to make her own decisions regarding the surgery.While this is true, one has to wonder if consent was truly informed—did Bekker emphasize the mortality risk? Did Bekker discuss whether Caroline should have surgery in order to enter a clinical trial or consider making the most of the months she has left? Caroline says she has to undergo the surgery because her daughter begged her to. The surgery is a success.
In a side story, a continuing story arc takes Manning on a house call to help a grieving father with his baby (Manning was involved with saving the baby who needed surgery at birth and whose mother died in childbirth). As the visit leads to dinner, Manning kisses the father who returns the gesture. Doctors should not date patients or the parents of their patients (in the case of pediatrics). The physician crosses a barrier that can compromise clinical care and in this case, the attraction could be caused from Manning saving the baby (hero syndrome). A pediatrician or neonatologist should not date the parent of a current patient.