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Posted on May 14, 2019 at 2:09 AM

Exploring ethical issues in medical dramas

The Resident (Season 2; Episode 23): Unrepresented patient and substance abuse; Chicago Med (Season 4; Episode 20): Violating a patient’s autonomy; organ trafficking

The Resident (Season 2; Episode 23): Unrepresented patient and substance abuse

A middle-aged man comes to the ER unable to speak and without ID. The staff gives him the name “Sunflower”. He is presumed to be homeless based on the state of his clothing and dirt under his fingernails; thus, without insurance. But Chastain is a private hospital. How much do they do for him? Pravesh says that an MRI for his condition is the standard of care, so that is what they do—we know he’s stretching the reality here to help his patient. Sunflower has a small aneurysm near Broca’s center in the brain. On this discovery, Pravesh and Conrad mention that being uninsured and unbefriended, the hospital makes all the decisions and is unlikely to cover the surgery. Ultimately, Bell approves the surgery even though the hospital is in financial trouble. After surgery, we learn the patient’s name is George Wilson and that he is married. And most likely is insured.

A patient in the ED is required to be evaluated and stabilized under federal law. But there is no requirement to do a surgery that is not an immediate threat to life. However, ethically health care providers are supposed to help people in need. The challenge in a capitalist health system, is that the hospital also must make enough money to stay in business. This balancing act can mean patients often do not receive care or that hospitals fail. As for the issue of whether the hospital gets to make all decisions for an unbefriended patient, that is questionable. The situation does raise the issue of the lack of policies and methods for surrogate decision-making for patients in this situation.

Meanwhile, the new anesthesiologist is stealing leftover drugs and giving them to a dealer to sell for her, as well as using some herself to get her through her long hours. She collapses while in the OR, crashing against the patient and operating team, pulling out tubes and leading to a severed artery in the surgical field. The anesthesiologist herself stops breathing and requires Narcan. When she recovers, she is arrested. The patient (who happens to be Nevins’ father and is donating a kidney to the sister/daughter) dies.

Anesthesiologists do have 2.7 times the risk of substance abusethan other medical physicians. This specialty, in particular, has access to a wide variety of potentially addictive sedative medications as part of their job, experience high stress because of their role in keeping patients asleep but not too asleep, and their responsibilities for the patient’s overall well-being during surgery.

Chicago Med (Season 4; Episode 20): Violating a patient’s autonomy; organ trafficking

Two women (Gaia and Meta) are brought to the ED from a flop house. They are having severe reaction to a drug but no one can identify what drug and the women are not saying anything. Charles says the woman are competent and can refuse care. Goodwin asks if a promise of patient-physician confidentiality would help get them to open up. Charles replies that HIPAA probably doesn’t matter much to them. Gaia is found later with a plastic bag over head—she killed herself. Post mortem review shows high thallium levels and Prussian Blue can help with that. However, Meta refuses to take it. We learn that she is part of a suicide cult. Manning wants a psych hold, which Charles explains means they observe her but they cannot make her take the meds or undo her programming without her permission. Charles suggests petitioning a court to declare her incompetent because of brainwashing and says it’s a tactic unlikely to work. Manning, however, just wants to save the patient and thus deems the patient “nondecisional”, placing her in restraints and forcing the medication through an NG tube. A nurse gets Charles who tells Manning that her actions have broken the law. Charles removes the tube and stops the medication delivery, but convinces the patient to take sleeping pills so she does not have suffer. He tells Manning that “once she’s out, she will no longer have the ability to advocate for herself and a strong legal case could be that we then have the right to act under implied consent as surrogate decision makers on her behalf, so you can replace the NG tube and administer the Prussian Blue.”

Manning’s actions violate nonmaleficence and are clearly a battery—she ignores a competent patient’s wishes to refuse treatment. Charles thinks he is being altruistic, but ethically, he is doing the exact same thing—removing a patient’s right to autonomy. Even unconscious, the patient has repeatedly and consistently established her refusal of treatment. Just because she is medically unconscious does not mean her wishes have changed.  This is still a battery. Implied consent should only be used in well-understood, noninvasive procedures (an NG tube is pretty invasive) and is generally used for competent, conscious patients. Perhaps Charles actually meant emergency consent (used when a patient cannot give consent, but can be revoked by the patient) or presumed consent (patient cannot give consent but is a standard that requires significant justification). The problem is that since the patient has expressed her wishes and was found to be competent, there is no room for implied, presumed, or emergency consent. Charles is creating a convenient fiction to cover what he wants to do—treat the patient against her will. Both physicians violate nonmaleficence—one does so directly and one does so indirectly.

In a second storyline, V is a 29-year-old man from Moldovia brought in by his “cousin” (30-year old Wyckoff)  after falling the shower. The patient speaks no English and we are told that his language is rare; the American cousin will speak for him. Wyckoff explains that V is his kidney donor. Are they really related or is this a case of organ selling? A clerk comes by to ask questions such as date of birth, which Wyckoff does not know. Instead, he says that he’s paying cash so it doesn’t matter. The hospital CEO comes to the ED alongside Wyckoff’s personal nephrologist who is taking care of the surgery. When Halstead speaks up, the CEO says “This is an easy and profitable win.” Halstead goes to V and asks if he knows what is happening: “Do you have to give or want to”?  V does not respond. Halstead tries to slow down the transplant until he can get a translator because “the case smells illegal”. Goodwin finds that all of the paperwork checks out. Eventually V shows a picture of the two men together from when they were 8 years old. The donation is genuine.

There are thousands of kidneys purchased on the black market each year. Estimates place the number of kidneys bought and sold at 10,000 annually, worldwide. In some cases, the sellers are brought to the US and introduced as relatives (since the purchase and selling of organs is illegal here) who are later given a “gift” for their “donation.” In this situation, the case is a convenient mechanism for exploring this global problem.

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