Posted on November 7, 2019 at 3:31 AM
by Craig Klugman, Ph.D.
A girls trip to New York ends up in the ED with the women injured in accident. The organizer of the trip, we learn, caused the accident deliberately because she took out the supplemental car insurance. The woman in the group all have health problems and lack the money to get the medical care they need. However, her deliberate actions negate the policy. When the police pick her up, she has an attack of brittle diabetes and is brought back in. The police ask Goodwin, “Could that have caused the accident” and he says “very well could have”. Max lied to the police to help his patient in an insurance scam. In general, physicians should not lie to patients on their behalf, especially when the lying is commission of a crime.
Shante, One of the women is a young woman with Down’s Syndrome. The doctors learn that she is 9 weeks pregnant and Shante wants an abortion. Her mother, her legal guardian, is a religious woman and refuses an abortion. Frome believes the patient is capable of making this particular choice. Frome goes to the court which restores her right to make this decision. The storyline is not completed this week. This episode deals with a bias that just because someone is cognitively different that we assume they cannot any choices, when there are some that they can and should make. The woman is capacitated for this decision, understanding her situation, the choices, and the implications. Frome stands by his patient and acts appropriately.
Chicago Med (Season 5; Episode 6): Excusing battery; Jehovah’s Witness and blood transfusion; Be yourself or maintain health
Manning’s patient from last week is getting worse. She kidnapped the child from the parents to give him medical treatment (they prefer naturopathic treatment). Hospital attorneys went to a judge and after the fact, got a court order to treat the child. As he worsens, the parents want to take him away from the hospital, but Manning things that’s dangerous. The parents are removed from the treatment room by security. When the parents learn the court order was issued after Manning started treating, they call the police. Before they can get there, Manning does a bronchoscopy and learns the child is very sick. She sends a biopsy to the lab just as she is arrested. The CEO says that the hospital will not protect Manning and will not provide legal services to her. Goodwin convinces the parents to drop the charges and the labs show the child has Granulomatosis with Polyangiitis (GPA). Manning saved his life and thus all is forgiven. This show holds, like most medical dramas, that the ends justify the means. And thus, Manning kidnapping, assaulting, and deceiving the parents is not only forgotten, but she is hailed for it. Instead, she should be under medical board review.
Meanwhile, David Bridges is brought into the ED after a motor vehicle accident where he wasn’t wearing a seatbelt. He went through the windshield and lost a lot of blood. In his wallet is a No Blood card stating that he is a Jehovah’s Witness. Halstead says the card is a decade old and signed by his parents when he was a minor. Marcel says they should get ahold of the parents. His parents said their son was spreading the word and they refuse any blood, even after Halstead says without the surgery his son will likely die. Halstead is not ready to give up, trying to get Marcel to do the surgery anyway. Marcel explains that for the family, receiving blood is worth than death, and he suggests that Halstead review his medical ethics. Halstead finds that the patient had alcohol and marijuana in his blood, activities that the Witnesses do not support. Also, Halstead points to a trinity tattoo that he thinks may indicate the patient left the faith. Marcel replies, “A tattoo is not an advance directive.” Marcel learned that a year ago the patient was in the hospital for strep throat and put his parents down as his emergency contact. When the patient goes downhill, Halstead tells the parents that they did not know their son who has not been to the Hall or turned in a service report in several months. Halstead says they did not know their son as well as they thought. The tattoo convinces them that their son has left the faith and they abandon him. Halstead says, “The Bridges’ have abandoned their son; we now have the authority to make all decisions on David’s care. Do the surgery and transfuse him.” Marcel does the surgery. In reality, the physicians can make this decision because the patient’s death is imminent. But they do not have the authority to make all decisions, just the ones needed to save his life. At this time, an ethics consult would be helpful and working through the hospital to have a guardian appointed to make David’s decisions. After David’s surgery, he is in recovery, minus his spleen. David asks about his parents and Halstead says they left. “Why would they leave,” he asks. Halstead explains that he told them that he had left the faith. David flips out when he learns that he had been given blood. He explains that the alcohol, marijuana and tattoo were all mistakes and he was returning to his religion: “What have you done to me?” Halstead later says to Marcel that he destroyed the patient’s soul because he wouldn’t accept the parent’s choice. Marcel lets him off easy, saying that Halstead had convinced him as well.
In reality, these are tough cases. Does a patient maintain their childhood faith, especially with evidence that indicates they may have strayed? The cost for receiving blood is being thrown out of the community and separated from one’s family; nevermind the cost to their belief in an eternal life. Halstead always takes the position the he knows better than everyone else, and that doing everything possible to save a life is always the best option. Here is one of the exceptions to the medical drama philosophy—in this case the ends did not justify the means. The patient physically lives, but his faith and his mental well-being have been harmed. If this were brought to an ethics committee, we would have asked the same questions: Is the patient still a follower of the faith? Evidence is presented on both sides. But at the end of the day, the parents had the legal right in the Illinois surrogacy act to make decisions for their son. Halstead’s hubris made him act to push them away so that he could make decisions instead. Indeed, his ethics do need a review.
In a third storyline, Charles’ childhood friend is in the ED in distress. They are in transition from male to female and is diagnosed with a heart attack. Although the hormones did not cause the heart attack, they can affect cardiac function and the recommendation is to discontinue them. The patient is faced with a difficult choice: To take the hormones that allow them to be themselves (and risk their health) or to protect their health. We are never told what the patient decides.
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