Posted on January 18, 2019 at 7:00 PM
by Craig Klugman, Ph.D.
Jump to The Resident (Season 2; Episode 10): What would you do doctor?a>;Jump to The Good Doctor (Season 1; Episode 11): Ignoring patient rights; unnecessary risks; crisis planning; Jump to New Amsterdam (Season 1; Episode 11): Superutilizers and racism; Jump to Chicago Med (Season 4; Episode 11): Triage, gestational surrogacy conflicts; ends justifies the means
As Hunter is released from prison on murder charges for killing patients with unneeded cancer therapy (sometimes on people without cancer), one of her victims is in the ED with a lacerated arm. She received the injury during a protest over Hunter’s release. Soon we learn the patient has weakened bones from the chemo which has led to a fracture in her spine, compressing her spinal cord. Without surgery in the next few hours, she will be paralyzed. An added complication, we learn, is that the chemo damaged her heart, making her a poor risk for the spine surgery. With few options, the doctors tell her that she could have heart treatment and be in a wheelchair, have the spinal treatment and have a fatal heart attack during surgery, or have the surgery and it have it be a success. After all of the information is given and questions are asked, the doctors ask what she wants to do. The patient turns town Conrad and asks what he would do. Conrad has used his and the patient’s shared hatred toward Hunter to bond and develop trust. The patient’s question is common and is also dreaded. Conrad, appropriately, replies “You’re the one who is going to have to live with this decision, so you’re the one who has to make it.” But then he tells her what his choice would be, “I am not letting Hunter hold me down. I’m taking the risk.” The patient goes for the surgery. Of course everything goes wrong that possibly could go wrong and the patient almost dies. But she wakes up surrounded by her doctors (they have time?) and her husband. She needs a heart transplant (which does not phase her considering she started hating all doctors and medicine and is not a simply procedure) and months of rehab but she is all smiles.
Did Conrad exert coercive influence? Because of he was the only doctor the patient trusted, did he not safeguard her trust in him enough? Or was he nudging her toward the choice that she had already made? These are fine lines and one’s that health care providers must traverse all the time.
In a second timeline, Conrad’s father comes through his surgery. His father knows his body is failing and talks to Conrad about an advance directive: He wants to be sure that when the time comes, Conrad will honor his wishes not to prolong his dying.
This episode begins seconds after the fall finale ends. We left off with the ED under quarantine, Lim collapsed after being infected, and a patient whose bone manner was zapped not having a transplant because his donor is in the ED.
After resuscitating the immunocompromised patient—against his stated wishes, Browne says, “We just saved his life and violated his rights. We could lose our licenses.” Melendez calms her down by responding, “You won’t. You were following the instructions given by an attending.” As is usual in medical dramas, the operating philosophy is “the ends justifies the means” so the patient is saved (not without some crazy complications) and is happy that they saved him. The real implications of going against patient wishes is avoided. Whether a patient is pleased with the results, going against patient wishes violates their autonomy, their consent, and is nothing less than a batter. These doctors should be reprimanded less, as we see in this show, they continue in this unethical, unprofessional behavior.
One of my criticisms of the fall finale in regards to the hospital’s approach to the crisis was that they did not make use of their available resources, including asking well people to assist inside the quarantine zone. That oversight was corrected in this second part of the story. We learn that one of the lay persons is a retired veterinarian and she is assisting with feeding a patient and later with a procedure. Others are recruited to help out patients as well. This is smart and is a good part of most crisis response plans—find those with relevant skills and put them to work. Others can visit with patients, help feed patients, and perform other tasks.
As part of the story, Park goes into the quarantine area when his son (who is in the quarantine zone) has an asthma attack and his inhaler is empty. We see a nurse trying to help him but Park runs in anyway and all he does is open a medicine cabinet and grabs an emergency inhaler. Seems like a nurse could have done that and he could have instructed her to do that from safety. Clearly this move was to increase the drama and provide a meaningful few moments between father and son. Breaking a quarantine should only happen in the rarest of circumstances and this simply, was not one of them. Park sacrificing himself does not do his current or future patients any long term good.
In a side story, a pregnant woman goes into labor but the baby is in distress and a C-section is needed. This is Murphy’s first solo surgery as he tells her. The chair of Ob/Gyn stands on the other side of a glass barrier (outside the quarantine area and thus addressing another one of the criticisms I raised in the fall finale) to direct him. The baby is removed but not breathing when the mother crashes as she bleeds out. No one else is available and Murphy has to decide whether to treat the baby or the mother. Realistically, he cannot attend to both. He chooses the baby. However, the Ob chief tells him, “The rules of medical priority are clear: Focus on saving the mother” (I verified with a physician that this is indeed true). I expected a crazy deus ex machina moment where he finds an unrealistic way to save both. While Murphy does find a way to save both, his solution is wise and realistic. He draws on available resources—improvising and using a lay person to perform CPR on the baby while Murphy takes care of the mother. When the mom is stable, Murphy is able to clear the blockage from the baby’s lung.
Andy is a middle aged male living on the streets. He has a housing voucher starting in 4 days and comes to the ED falsely claiming chest pain in hopes he can find a clean bed until then. He is “the Amelia Earhart of frequent fliers” according to Bloom. Goodwin explains that Andy has been in the hospital over 100 times, costing the hospital $1.4 million dollars in a single year and they have not been able to help him. Goodwin brings together his department heads to try to reduce Andy’s cost to the hospital, to no avail. Goodwin decides he can make the patient’s health better by prescribing him a home. When the dean learns of the plan he takes Goodwin to task, especially when learning that the plan is for the hospital to pay for the apartment for the rest of the patient’s life: “This is socialism. This is exactly what’s wrong with our whole health care system.” The dean raises a concern about fairness of people who work hard and have trouble finding affordable housing (especially in NYC). The hospital rents Andy the apartment but he still returns. Andy needs not only housing, but he likes the camaraderie and being in the hospital—he becomes a volunteer there. However, the dean is wrong: This is not socialism since they are only helping one person.
However, the approach to providing housing is unusual but also effective. The University of Illinois Hospital calculated that it would cost them less to provide housing for homeless patients than to repeatedly pay for their health issues caused by being on the streets. An apartment costs $1,000 a month while hospitalization costs $3,000 per day. The hospital saves money and the patient’s health is preserved by preventing problems in the first place.
Another issue in this case is that patients on this show usually get full names (first and last) or no names at all. By using just a first name, the writers are trying to show how familiar the patient is with the staff. However, it also belittles the patient and robs him of dignity by being a person with a full identity. A third, related, issue is the use of the term “frequent flyer.” Originally this phrase reflected the notion of a patient who visits the hospital often, such as a frequent flier on an airplane. But, the term is only applied to people who are poor, often homeless, and often alcoholics. On an airplane, your frequent flyers are the most desirable customers, but in the hospital, the term is code speakfor an (financially) undesirable patient. The term should be retired because of its disrespectful and dismissive connotations.
In a second storyline, Reynolds is being interviewed for a feature on diversity in hospital leadership. The writer digs up a mugshot of Reynolds and she wants to tell a Horatio Algiers story. Reynolds immediately ends the interview. We learn that he is embarrassed and has tried to separate himself from the incident, but on advice of counsel, he shares his story with the writer. Reynolds explains that he was arrested on the night of Obama’s election win, guilty of driving while black. He tells the interviewer that it is the height of hypocrisy that in a story celebrating a black chief of cardiology, she wants to bring out the trope of the “one who made it”. Instead of writing a piece about an excellent doctor, she wants to tell a tale that makes white folks feel good. The ethical issue raised in this story is the continual racism that black doctors face in practice from their colleagues and their patients: A recent example is Dr. Stanford who identified herself as a physician on a flightwhere a passage needed help. The flight attendants (more than once) asked this black professional for her license and questioned whether she was really an MD even when she presented her credentials.
Chicago Med (Season 4; Episode 11): Triage, gestational surrogacy conflicts; ends justifies the means
Choi finds a homeless man on the street who is short of breath, has petechiae, and gangrene in his leg stump. Choi calls an ambulance and brings him to the ED. In a lockbox, Choi finds a silver star and dog tags—the man is a vet. Reggie—the patient—is suffering from PTSD and lost his leg to an IED. In addition he has MCI, a blood disorder. The man collapses due to internal bleeding and needs blood and platelets. When he needs more, the blood bank refuses to send saying there is a citywide shortage and they need to save what’s left for patients who have a better chance of survival. Reggie dies.
In reality, this represents one of the most challenging ethical situations for physicians. Doctors are trained to think about their individual patient and to advocate for that one person. But when resources are in short supply or there is a crisis, shifting to a more community health approach (utilitarian, communitarian) is necessary. The goal has to shift from saving every patient (since there is not enough of a resource available to make that happen) to saving as many lives as possible. The ethical framework adopted here is triage which often requires letting the sickest people who require the most resources with the lowest odds of survival, are given comfort care only.
In a second storyline, Celine arrives in the ED with an asthma attack. She is a gestational surrogate, carrying twins for Nate and Stephanie Addison. The male fetus (we do not know the exact age of the fetuses) is diagnosed with a congenital diaphragmatic hernia-his abdominal organs have migrated into his chest through a hole. Halstead informs the parents that the prognosis is poor and that the male is compressing the female twin, endangering her. He recommends selective reduction of the male fetus. The parents explain that these are their last two embryos and they want the reduction. Celine, however, refuses the procedure, wanting to save the fetuses. The surrogacy contract says that the parents can request a reduction at any time and she agreed to it when she signed. Halstead does an 180 degree turn, refusing to do any procedure without Celine’s consent, “It’s her body.” The Addison’s lawyer informs Celine that she is in breach of contract, “That doesn’t give her the right to hold my client’s fetuses hostage.” The Addisons request a different doctor because they see Halstead has a clear bias in this case. Halstead offers Celine a hail mary pass—an experimental fetal surgery procedure. When Goodwin later confronts him, he says, “I felt I had an ethical obligation to present Celine with all the options.” Goodwin responds, “Well, you had no qualms about leaving the Addisons out of the discussion entirely.” The surgery is a success and everyone pulls through—thus finding a way out of the ethical dilemma by simply vacating it.
In reality, there are two ethical concerns in this story: (1) Rights of the surrogate v. rights of the parents and (2) Halstead’s unprofessional behavior. (1) Such potential scenariosshould be discussed beforesigning the contract. If the surrogate wants to act to break her contract, the case would most likely end up in court. This scenario is similar to a California casewhere a 50-year-old single father wanted the surrogate to reduce one of a set of triplets to increase the chances of health for the other two and because he did not feel he could care for three children. The surrogate refused and gave birth to all three. The eggs used in creating the embryos were not the surrogate’s eggs. She sued to vacate the contract and take custody of the children, a case that California and the Ninth Circuit courts ruledagainst her on, saying that she signed away any parental rights. The US Supreme Court declined to hear the case. Ethically, this is a challenging situation pitting the right of a patient to determine what happens to their own body, against the rights a parent has to make decisions for their children. In this episode, the parents thought they were making the best choice for their children—saving one child when it appeared that two would die. These challenges are why many statesand countries have passed laws against surrogacy. However, as this show takes place in Chicago, it’s important to note that Illinois has a gestational surrogacy act that supports such arrangements.
(2) Halstead’s behavior was unprofessional. The fetuses belong (legally, they are her property) to the Addisons and Halstead was not including the parents, the only people who could consent for the fetuses, in the conversation. He was advocating for his patient, but in this case the patient’s choices affected others (the fetuses; their parents) and Celine was making decisions over things to which she did not have full authority. Halstead should have included the Addisons since he needed their consent to operate on the fetuses and Celine’s consent to operate through her body.
In a third story, Leslie Taylor is a 37-year-old pedestrian struck by a car in a crosswalk. Hospital records show that Leslie is on the liver transplant list and because of the accident, she needs a new organ immediately. The patient’s sister arrives and agrees to be tested as a live liver donor (she’s a match). Later, Leslie reacts angrily to hearing her sister was in the hospital and screams to her, “I don’t want your help.” Leslie believes that her sister “killed my little girl”. We learn that the sister was babysitting and got high, forgetting about the baby when the house was on fire. The child died. Leslie says, “I won’t accept anything from her. I’d rather die.” Hours later, Bekker announces that an anonymous donor stepped forward. Rhodes soon learns that the anonymous donor is the sister and Bekker lied to him. She justifies her actions by saying, “The ends justifies the means.”
In most TV dramas that is the standard philosophy used to justify all sorts of unethical and unprofessional behavior. Bekker has a history of manipulating people to achieve certain outcomes. In reality, ethics is about good character and making well-reasoned decisions. Good outcomes are only one possible way of making decisions—virtue ethics, deontology, narrative, feminist, natural law are others. The juxtaposition of Bekker’s unsavory actions over the last year are finally catching up with her, and hopefully there is a lesson in good character for everyone involved.
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