Posted on March 27, 2020 at 2:30 AM
“Exploring ethical issues in TV medical dramas”
by Craig Klugman, Ph.D.
The Resident (Seasons 3; Episode 18): Maintaining the Dead; The Resident (Season 3; Episode 19): Lies, Coverups, Crossing Boundaries; Chicago Med (Season 5; Episode 17): Required Criminal Reporting; Chicago Med (Season 5; Episode 18):Advance Directives and Alzheimer’s; Innovation v. Best Care; Jealousy or Abuse
Dawn Long is a former patient from early this season who reappears. She had the Mother of All Surgeries that left her in a persistent vegetative says and has been in and out of Chastain for treatment and stabilization. On this transfer to the hospital, Cain begins talking about how important it is to save her and keep her alive for her family. But as soon as Nevins says that it’s been 6 months, how much more can she take, Cain changes his tune and talks about telling the family that it’s time to let her go. When he later talks to Kim, the corporate manager, Cain explains that tomorrow Dawn will have survived six months which means she statistically counts as a survivor and a success story. Cain will convince the family to let her go, tomorrow, so that care does not cost the hospital any more money but they can tout a success. When Dawn crashes, Nevins starts the code and Pravesh asks why are they doing this when the family will just pull the plug. Nevins explains that she is full code so they have to resuscitate even if it will just cause more suffering. Cain talks the young family into letting the patient go and even offers to arrange a ceremony for the family when they turn off the vent. After the patient dies, a lab tech informs Cain that Dawn had candida aureus, a superfungus that we are told is dangerous and nearly impossible to eradicate. Everyone who came in touch with the patient will have to be quarantined and treated. The patient’s room may have to be sealed off forever.
Continuing the storyline from last week, the EMT who transported Dawn comes in suffering from non-specific symptoms. Cain does not want anyone to know that he missed the Candida Auris in Dawn. He takes new intern Ezra aside and explains how his letter of support is why Ezra is a first-year resident at the hospital and that one good turn requires another. Cain tells Ezra to administer the right medication but without anyone knowing (including the health department) and without charting it. Ezra does this and also has to prevent others from giving the patient drugs that might poorly interact. However, Conrad makes the diagnosis on his own and delivers the right anti-fungal. He notified the department of health and the truth of Cain’s action will come out. On Cain’s orders, Ezra removes the original bag of anti-fungals that is the only thing which could connect him and Cain to knowing about the candida. The patient dies and Ezra tells Conrad everything. Meanwhile, the other instruments and vent that were used on Dawn are not decontaminated properly and they cause the deaths of other patients.
Lies are almost never acceptable in medicine. Certainly, lies that are a coverup for wrong doing, simply said to protect a reputation, income, or license are also unacceptable. Cain violates ethics, professionalism and law. His status as a celebrity rainmaker notwithstanding, he should be fired immediately. The medical board should begin an investigation and the district attorney may want to file criminal charges—after all, his actions caused deaths. At the same time, Ezra has also lied, covered up, and left medical actions out of the medical record. Some might say he is a trainee and should be put on probation and required to take ethics courses. However, others would say he should be fired and banned from applying for another residency.
In a second storyline, a young man without a family is need of a lung transplant from pulmonary fibrosis. He is a volunteer and does a great deal of good work in the community. However, one of the requirements of being on the transplant list is having a support system, and he does not have one. Nevins and Conrad step in and decide to be his support system—they will take care of him for his recovery. While a noble gesture, this action is actually a professional boundary crossing and is inappropriate. Why this patient? Will they do this again for the next needy patient? They have created a problematic precedent and one that requires a crossing of professional and personal lives, which should not happen. In the end, an unknown cousin steps forward after hearing about the story and the family will provide his support. Boundary crossing averted.
The episode starts with a video featuring Max on a GoFundMe page for Allie, a young girl who needs heart surgery. The goal is to raise $50,000 and we see that so far she has raised $54,000. As a result, many patients in the hospital want Max to be featured in their video to raise money for their medical needs. The systemic problem featured in this episode is about the use of crowdfunding to pay for medical care, when many people lack health insurance and go without care because they can’t afford it. The president of the board asks Max to do more videos, saying it allows patients to get medical care through their stories. Max disagrees with her, saying that the hospital and insurance companies leave patients no choice but to sell their dignity. Max calls it the “tragedy Olympics” and proposes that instead of letting strangers vote with emotion (the most appealing video, the cutest patient), the doctors should use logic to decide who gets the money—he just has to find the money. His solution is to have successful cured/treated patients crowdfund for future patients. I’m not clear how having current patients crowdfund for their medical care dollars is exploitative but having past patients crowdfund for current and future patients is not—it’s still forcing people to sell their stories to get what most countries consider to be a basic human right. Crowdfunding shows the failure of American for-profit health care to provide for our health needs. J. Snyder in the Hastings Center Report said, “medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services”. In addition, people often use crowdfunding to pay for unproven (and often dangerous) treatments that may put them into debt.
A cop is brought in with a gunshot wound after taking a gun from a 10-year-old girl at a concert. In surgery, the doctors discover an abscess from a previous shooting. Goodwin explains that the hospital has a legal obligation to report this discovered gunshot. When the patient awakens, we learn that he was shot when he was 17 and tried to rob a store. Since the shooting was never reported, the doctors are obligated to report the incident, even though it is in the past. In most states, a gunshot must be reported, no matter when it occurred
Chicago Med (Season 5; Episode 18): Advance Directives and Alzheimer’s; Innovation v. Best Care; Jealousy or Abuse
Molly is home from college on spring break and calls an ambulance when her mother, Evelyn, is unconscious. Halstead diagnoses end-stage renal disease and recommends dialysis. The girl’s father says that the advance directive is very clear and refuses dialysis. Evelyn awakes and says not to listen to her husband, that he is a liar. He says, “You don’t want dialysis” and Evelyn says “I do, I do. Help me.” Goodwin examines the advance directive which Evelyn prepared shortly after her Alzheimer’s diagnosis which clearly outlines what she does not want, including dialysis. Halstead points out that people can change their directives. Charles states that changing a directive is limited to the person being competent to do so. Charles evaluates Evelyn and finds she lacks decisional capacity. Halstead asks if she is depressed or lacks a will to live—he is clearly searching for a way to keep this woman alive. When Charles says her mental status is normal for her condition, Halstead says they should call for an ethics committee to get other perspectives. Charles thinks that the ethics committee is not necessary. Evelyn starts having low oxygenation because of fluid in her lungs. Molly wants them to intubate and she says to her mom that she wants the intubation, right? When Evelyn mumbles, Molly takes it as her mother saying her name. Halstead grabs the patient’s face and says, “Evelyn, do I have permission to intubate to save your life” (a very coercive statement). Evelyn says “yes” and Halstead does so. Goodwin is incensed at the intubation, especially because Halstead was previously sued for ignoring an advance directive. Charles explains, “Signing that piece of paper was her final act of self-determination”.
Goodwin later speaks with Molly who asks, “What if I don’t want the doctors to take out my mom’s breathing tube? Would I have to sue my dad?” Goodwin asks if she is sure she wants to do that: “Are you really sure that your father isn’t acting in your mom’s best interest?” Molly explains that she was kept in the dark about her mom’s condition and she does not want to lose her mother. The family comes together and they agree to take Evelyn home on hospice care until she dies.
In reality, medicine has a bias where If the patient agrees with the doctor, few question whether there is capacity to consent. However, if the patient rejects the doctor’s preferences, then capacity is often questioned. In this case, Halstead rejected the idea that Evelyn and her medical power of attorney were competent to refuse dialysis but he accepted Evelyn’s consent to intubate even after Charles said she lacked capacity and her advance directive explicitly said no. How can a patient be both incapable of understanding and perfectly capable of understanding? The answer is, they cannot—this is physician bias to follow what they wish to do. What the hospital also seems to not know is that although one needs to be competent to create an advance directive, that standard is not required to rescind it. Evelyn’s Alzheimer’s does not mean the right to rescind is relinquished. It is highly unlikely that the AD could be written in a such a way to prevent this; thus, Evelyn had to rely on her husband being strong enough to fight for what his wife wanted before her disease progressed.
Whether to honor an AD of someone with Alzheimer’s is controversial. Some ethicists hold that what matters if the values of the person across a lifespan and thus, their directive should be honored. For example, Corinna Porteri writes in BMC Medical Ethics, “not to honor a demented individual’s directive would be an unacceptable form of discrimination towards those patients.” There is even stock language that can be added to an AD for people at risk for dementia-related disease. Others hold that the person with Alzheimer’s (or other form of dementia) is a different person who has interests that are different than the person they were before. Thus, when Evelyn says “yes” that should be taken as her true wishes as a person with Alzheimer’s. Overall, having an AD is better for the family than having them guess at what a person might have wanted. It’s also important to note that an advance directive is not instructions to shorten the lifespan (assisted suicide) but directs people not to take aggressive measures when the body fails or is beset with another life-threatening disease.
I am also concerned with how this episode presents the ethics committee. Calling for a consult is not raising the stakes as it appears to be offered here. It is also not second guessing a physician’s diagnosis or treatment plan. An ethics committee would have been quite appropriate in this circumstance and could have helped communication between the parties and generate understanding, not undermine the physician’s authority.
In a second storyline, Nick Elmsford arrives in the ED with severe abdominal pain. He suffers from familial adenomatous polyposis (FAP) which causes polyps in the large intestines, He also has heart failure as a result of chemotherapy for his rectal cancer. He has a prognosis of four months and Manning thinks he may need a colostomy. His wife is pregnant and he wants to see his child born. Marcel talks the patient into a TaTME, which is a radical surgery that is unlikely to be successful. Manning asks if Marcel explained the risks and Marcel says yes. Is Marcel being reckless as Manning believes, or is he being courageous? Manning finds a paper that Marcel wrote as a trainee under a pioneer of the technique. She thinks Marcel is biased and “motivated by professional advancement” rather than doing what is in the patient’s best interest. Manning talks to the patient’s wife who is against the decision but her husband wanted the change to perhaps see his child grow up. Marcel says the surgery went well and the wife is thankful. However, after he is able to speak and is picking out baby names with his wife, Nick codes. Resuscitation is unsuccessful. Marcel blames himself—the patient would have still been alive without the surgery, just with a colostomy. Manning tries to make him feel better, which feels inauthentic to her character or any character to change their mind that quickly. Manning’s original claim is not wrong—sometimes there is a conflict of interests between what is best for the patient and a physician’s desire for innovation, promotion, and recognition. The patient’s best interest should always be the reason for medical decision-making, but innovation is also necessary for medicine to progress. Doing both when they can conflict is often an impossible choice.
In a third storyline, a woman comes in after passing out on a treadmill and breaking her leg. She has had trouble losing weight and joined the gym to help. Her labs are normal but she starts seizing. She has high levels of ammonia in her blood, the result of a genetic urea disorder that would be triggered by eating too much protein. We learn that the husband was secretly been dosing her food with protein powder to prevent her from losing weight. He was worried that if she lost weight, she would leave him. Choi offers to help the patient call the police, but she refuses saying that it was wrong but her husband’s heart was in a good place. Does this rise to the level of abuse that would require reporting? Without her underlying condition, the protein dosing would have been cruel but not dangerous and the husband was unaware of this condition. Thus, most likely not. Plus, the victim is unwilling to press charges.