Posted on January 16, 2020 at 3:29 PM
“Exploring ethical issues in TV medical dramas”
by Craig Klugman, Ph.D.
The Good Doctor (Season 3; Episode 11): Anesthesia and addiction; the limits of compassion; The Resident (Season 3; Episode 12): Dying (or not) on your own terms; Suing patients for medical debt; Chicago Med (Season 5; Episode 11): Quid pro quo—switched embryos, safe injection sites; surrogate withdrawal of life support
Carrie is a patient who arrives with a complicated leg fracture after falling while mountain biking. The patient refuses pain meds, saying that Vicodin makes her sick. After an MRI scan shows she needs surgery (and with her husband out of the room), Carrie admits that she is a recovering opioid addict and has never told her family. She refuses to let them the doctors any narcotics. As a result, the team alters their surgical plan to one that will take longer to heal but will be much less painful. The surgery does not succeed-the patient has compartment syndrome. The surgeons will need to do the original surgery and that cannot be done without anesthesia; she spiked blood pressure during the simple surgery. The patient still refuses and the results will likely mean an amputation. In a group discussion, Andrews mentions that they cannot reveal any secrets to the husband, but they can tell him other things: “There have been some complications and we need to perform additional surgeries” When the spouse asks what complications, Andrews tells him that he can’t say anything more to protect the patient’s confidentiality. Essentially, Andrews is prompting the husband to ask Carrie to share her past in the hopes that he can convince Carrie to take anesthesia and pain meds. She still refuses.
Did Andrews cross the line in his “sorry, not sorry” routine by even suggesting there was something hidden? Andrews takes the letter of the law—do not share information—while violating its spirit— “I can’t talk about it”. Providing benefit to the patient is not an acceptable exemption to confidentiality. What Andrews did was wrong especially because the patient was clear that she did not want her husband to know. Whether that choice is rational or makes sense to someone else is irrelevant; her wishes were clear. In another issue, a physician should not do a surgery in a way that endangers the patient. Perhaps a consult with a pain specialist could have found other ways of treating the pain (although I am not an expert nor am I a physician, why didn’t they try a non-opioid epidural? Any readers with thoughts, please send them in.)
In another storyline, Luca is a young man comes to the ED complaining of bloating and stomach pain. He lacks insurance. Instead of an MRI or x-ray, Brown says they can give him some meds but he has to stay until he defecates. As it turns out, he was laid off from his job and to make some money, he became a drug mule—he is carrying 2 kilograms of heroin in his gut. Brown promises that they would treat him and not call the cops. Park is a former cop and hospital policy says they have to alert local police. Luca says he’s leaving. In a compromise, the hospital agrees to take the bags out and move them to the lab for testing, but to discharge the patient before they call the police—this way they keep their promise, do what is best for the patient, but also follow hospital policy and the law. After the surgery, Luca sneaks out of the hospital and around the same time someone broke into the lab and stole the heroin-filled balloons. With a fake name the police have no leads to follow up on but clearly Brown’s efforts and trust were undeserved. Luca took advantage of them all.
Although compassion is one of the best attributes of a physician, the opioid and narcotic crises as well as the illegal drug economy mean we must not let compassion and desire to help override our suspicions or established policy. Those policies exist for a reason and are often based on previous experience. When in doubt, a policy usually provides useful guidance. Exceptions should be rare and only with good reason.
The Resident (Season 3; Episode 12): Dying (or not) on your own terms; Suing patients for medical debt
A woman brings her sister into a rural outreach clinic. The woman has an LVAD which has been keeping her alive for 5 years. She lives 3 hours away and accidentally left the battery and the backup handpump in the kitchen. Her low battery warning is beeping. The med team hop in a van and drive as quickly as possible toward the hospital while an ambulance leaves the hospital and tries to meet them. With 15 minutes left, it is unlikely that they will make the rendezvous. The patient asks them to pull over to let her die in the sunshine, under a tree. Nevins tries to convince her to continue on. The patient tells Nevins that she wants no heroics: “No CPR that can break my ribs.” The patient asks Nevins what it will be like to die this way, and Nevins describes a peaceful end. As the battery runs out, the patient does not die—she is breathing and has a regular pulse. Her heart seems to be working. Once the ambulance arrives, an ultrasound shows that while her heart is working, the LVAD is starting to clot and that could cause her to die—she needs to be in the hospital and have the LVAD removed, which Austin does successfully.
While this resolution is a “Hollywood ending” (as Austin states) to this storyline, it does demonstrate a lovely support of patient autonomy and her refusal of CPR. Although they were not in a hospital and there was no DNR order, following the patients clearly stated wishes in the moments before her heart was expected to stop was honoring the patient’s autonomy and long held values.
In another storyline, a man shoots himself after getting an exorbitant bill from the hospital which he cannot possibly pay. He figures with his death his wife will at least keep the house and have his life insurance. The corporate owners of the hospital are suing him for the money that they have not collected. This storyline likely pulls from a 2019 news item about some hospitals suing patients in order to collect on dollars owed for medical procedures. Yes, medicine in the U.S. is mostly a capitalist enterprise with the goal of making money (even if they claim non-profit status). But, suing and bankrupting people for their medical debt seems to lack compassion and is a particularly grotesque aspect of corporate medicine. It shows that capitalism and medical care do not mix. The irony in this storyline is that the patient will have a new set of high cost medical bills based on the surgery and long rehab he will require. Plus, some life insurance does not pay in the event of a suicide.
Chicago Med (Season 5; Episode 11): Quid pro quo—switched embryos, safe injection sites; surrogate withdrawal life support
The first two storylines are inter-related tales. In the first, Manning is in the parking garage when she notices an infant by itself in a locked car. She breaks the window and pulls out the infant who is breathing shallow. It is cold out. This is the Garret’s—the CEO—child. Under Illinois law (where this show takes place), if a child is left unattended in a car for more than ten minutes, it is permissible to break a window to save the child. Garett is undergoing a divorce and doesn’t want her soon-to-be-ex-husband to know. Goodwin says he has the right to know the truth, but that the truth should come from Garrett. We learn that the baby was a little sick and Garrett was bringing him to the hospital with her instead of leaving him in daycare. She had a busy day and just forgot. Garrett begs Manning to say nothing, but as a physician, Manning feels uncomfortable complying.
Halstead has submitted a proposal to create a safe injection site at the hospital. Goodwin thinks it would bring good PR to be the first US site. She mentions a Philadelphia judge who ruled that it was not a violation of US law (this is real: The judge ruled in October 2019). The hospital CEO, Gwen Garrett, says that the legal battle would cost the hospital too much money, no matter how many lives might be saved. The Board thinks it might appear that the hospital is condoning drug use by having a site. Halstead presents evidence that such a site is effective in reducing infections and deaths. The numbers alone are not getting across the message. Charles comes and tells the story of his brother dying from his drug abuse and how a safe site might have prevented his death. In reality, facts and figures are important in changing policies and laws, but what moves people to act (and vote) are stories that appeal to their emotions. Garrett is supportive even though earlier she was not. We learn that this is a quid pro quo and Garrett have no intention of telling the soon-to-be-ex.
Goodwin tells Manning to tell the truth to the father if he asks questions, which he does. Manning knows that a physician should tell the truth in most circumstances and not lie for a reason unconnected to care of the patient. Garrett says the safe injection site plan is dead—no quid pro quo. As we are all learning in the impeachment of a president, offering to do something in exchange for a favor is illegal, never mind unethical. However, Halstead knows a guy starting an illegal safe injection site, and he volunteers to help out. This is a noble gesture, but he puts his job and potentially his medical license at risk. To do the right thing, it might be worth the risk (although Halstead has rarely shown good judgement). The question is: Is this the right thing? And do the benefits outweigh the professional risks?
In a third storyline, after a plane crash, a baby is born a month premature. She is the couples’ last embryo. Nurse Sexton notices that the baby is a little blue and the mother says she seems to be having trouble breathing. The baby has red hair and the father says there’s never been one in the family (foreshadowing?). The baby is brought to the NICU. The baby has a genetic disease where she has scarring of the lungs and the only effective treatment is a lung transplant. Her embryo was genetically tested, the mother says. Mom asks if another baby has to die to get a lung and Halstead says that a living donor might be an option. Testing shows that mom is a match but that the husband is not the baby’s father. Further testing shows neither parent is a genetic parent; Sexton suggests there must have been a mix up at the fertility clinic. The biological parents must be found to save the baby and they are. The couple has the same last name and may be carrying the first couple’s genetic child. The genetic mother is not a match but the father is. The carrying mother offers to donate a lung lobe anyway—she did carry the baby to term and the other couple is carrying her embryo.
This is a loving ending to the story, but there are cases of couples learning the embryo they have been carrying is not their genetic progeny. Sometimes the cause is a physician who uses his own sperm in IVF, other times the switch is purely accidental. In this case, it is that the two couples have the same last name—pure chance. In cases of misattributed parenthood, it is appropriate to let the parents know. Halstead was going to take the father out of the room to let him know that he was not the father, but both parents insisted on getting the news together. Often, in this scenarios, the mother is told first because sometimes she is aware of the possibility of a different father already. The fertility clinic should be informed, and perhaps reported, with a full investigation of their procedures to ensure it does not happen again. Civil law suits are also possible. If there were untoward reasons, there may be criminal charges and a hearing before the medical board. In this storyline, the good ending most likely means a good clinic would apologize, refund the cost of the cycle, and offer future cycles for free.
The fourth storyline is that of another accident victim of the plane crash who is an attending at the hospital. Sam is burned significantly over his body, on a ventilator, and will never walk again. His recent wife (they married a few months ago after 3 months of dating) asks that he be taken off of life support. She explains that this is about what her husband would want, not what she wants. Choi says Sam could have a meaningful life even if he could not be a surgeon. She asks how could Sam have a good life when he could never operate again, or take care of himself? Choi suggests that his adult daughter might be better at making the choice. The wife says that he would not want his daughter to (a) see him like this and (b) be burdened with having to make this choice. Choi learns that the wife is the beneficiary of Sam’s substantial life insurance policy. Choi tells Marcel that looking into the patient’s personal business is part of “do no harm” and he will call for an emergency ethics committee meeting (Yea!!!). Marcel meanwhile explains the process to the wife and gives her the necessary forms to complete. The ethics committee supports the wife’s authority to make the decision (as it should have). However, in a twist, Sam walks into the hospital when returning from the hospital. The patient is not who they thought it was. Choi runs back into the treatment room and starts CPR, ordering the ventilator to be attached—they don’t know who the patient is. Choi confronts Sam, telling him that his wife was going to withdraw before his daughter could arrive. Sam tells Choi that he was pleased to hear about the decision his wife would have made and that his wife is a self-made multi-millionaire—his money is pennies compared to hers. Choi’s presumption of a gold-digging wife could not be further from the truth. His personal biases made a tragic situation even worse.
Under Illinois law, without a power of attorney for health care, the wife is the surrogate decision-maker, in a quirk of the law though, a surrogate from the default list cannot choose to withdraw support unless the patient has a “qualifying condition” (a durable power of attorney for healthcare does not have this limitation).
“Life-sustaining treatment” means any medical treatment, procedure, or intervention that, in the judgment of the attending physician, when applied to a patient with a qualifying condition, would not be effective to remove the qualifying condition or would serve only to prolong the dying process. Those procedures can include, but are not limited to, assisted ventilation, renal dialysis, surgical procedures, blood transfusions, and the administration of drugs, antibiotics, and artificial nutrition and hydration.
More specifically, a qualifying condition means the patient is terminally ill or permanently unconscious or has an incurable or irreversible medical condition in which there is no reasonable expectation of recovery, that will cause death even if treated, may create severe pain or burden, or that provides a minimal medical benefit. Although the burns are severe and will be life altering, the doctors believe it is survivable. Thus, under Illinois statute, without a designated power of attorney for health care, the wife may not be able to withdraw life sustaining treatment in this case. But if anyone has the authority, it is her. Thus, the ethics committee was correct in its assessment to support her, though the hospital attorney might suggest she lacks authority to make this decision.
In the twist, though, resuscitating the patient was appropriate and legally (and ethically) required. Until his family is found, given the facts, he has to be maintained. To withdraw support will require a legal surrogate or a court order unless his family is found.