The Pitt has been praised not only for its superb writing, direction, and acting, but also for its accuracy. For example, MedPage Today editor-in-chief Jeremy Faust (who is also an emergency physician) has lauded it as “a very sophisticated medical show.” The Pitt has addressed a multitude of issues, ranging from end-of-life care to lack of insurance coverage to neurodiversity. Here, we want to focus on The Pitt’s depiction of patients with intellectual disabilities.
Over two recent episodes (Season 2, Episodes 10: “5:00 PM” and 11: “6:00 PM”), second-year resident Dr. ‘Mel’ King informs Dr. Langdon, a senior resident, that she and her intellectually disabled adult sister Becca use “supported decision-making” to make medical (and other) decisions that impact Becca’s life. While the specific details of this arrangement are not illuminated, the mere mention of this important decision-making tool is monumental and opens the door to a more robust discussion of this person-centered approach to decision-making for those who may have capacity limitations.
What is Supported Decision-Making?
This fleeting moment is one of the first times that supported decision-making (SDM) has been mentioned in such a public-facing, popular medium, representing an important moment for raising public awareness to options beyond substitute decision-making, conservatorships, and guardianships for disabled adults. SDM is a process that enables individuals with intellectual, developmental, and psychological disabilities to make their own life choices with the aid of individuals they have selected as ‘supporters.’ According to disability scholar Leslie Francis, supporters have a range of functions, increasingly articulated by state law, from aiding with communication to supporting financial, housing, education, and healthcare decisions. Supporters can help explain the choices at stake, potential costs and benefits, and different outcomes, breaking down information in accessible ways and in the manner best understood by the individual. SDM promotes autonomy and dignity in a way that mechanisms like guardianship preclude.
Supported Decision-Making: Becca and Mel
In Episode 10, Becca presents with a stomach ache at the emergency room. Dr. Mel, coded as neurodivergent herself, is distracted, as she has an upcoming deposition, so Becca’s case is handed off to a senior colleague, [RKS1] [KP2] Dr. Langdon. This turns out to be for the best (physicians typically avoid treating their own friends and family for ethical reasons) as Langdon learns sensitive information about his new patient and quickly diagnoses a urinary tract infection (UTI).
When Mel asks about the diagnosis, Langdon aptly replies that Mel will have to speak to Becca herself. Langdon also assured Becca that it is up to her to share or not share her diagnosis with her sister. Mel is taken aback–she is her sister’s primary caretaker and confidant, and she’s used to knowing everything about Becca’s life due to the significant degree of support Becca requires (Becca lives in a supported living environment). Langdon holds firm, citing HIPAA. Becca eventually reveals to Mel that she has a boyfriend, that they are sexually active, and that she understands that this is how she contracted the UTI. Mel is shocked.
Later, in Episode 11, Becca confirms that she has a boyfriend of six months who is also a resident of her group home. Mel wants to make sure the sex is consensual. Becca, asserting her right to privacy, requests to see Langdon. The sisters fight, and Langdon asks Mel to step out when Becca begins to cry.
Then Langdon sees Mel outside the ER, trying to call Becca’s group home to ask about Becca’s relationship. Langdon intervenes. We then arrive at this key moment of dialogue:
Langdon: Are you Becca’s legal guardian?
Mel: No, I have durable power of attorney but we did this thing called supported decision-making where she can… make her own decisions.
Langdon: There you go.
Mel: Well, this is different.
Langdon: Why?
Mel: Because… it is…
This moment raises questions about whether Mel is in the right or if she is being overprotective. It makes the critical distinction between a durable power of attorney for healthcare that goes into effect when someone loses capacity (for example, if Becca had arrived and was unconscious), and SDM, which highlights Becca’s prerogative to make her own decisions with certain supports in place. Mel’s reaction that “this is different” is also important because it frames a tension that family members may feel despite their knowledge of SDM. Most of the current legislation around SDM, however, has safeguards in place to prohibit potential conflicts of interest that might arise when a family member or an intimate partner is serving in the role of supporter.
Representation of Supported Decision-Making
This rare representation of SDM is incredibly important for awareness, perception, and public opinion. This positive portrayal of SDM connects it to autonomy, positions it as a viable alternative to guardianship, and highlights the ability of people with intellectual disabilities to participate in the decisions that impact their lives. And it draws our attention to several other important issues: disability and sexuality, intellectual disability and capacity to consent (sexually and in healthcare decision-making), and alternatives to models that use substitute decision-making, which have long dominated in the treatment and care of intellectually disabled persons. This storyline presents Becca and Mel as multi-dimensional, humanizing them both and resisting the tropes of infantilization, burdensomeness, or heroizing disabled persons.
Compare this storyline to the very public coverage of Britney Spears’ conservatorship case. Spears was placed under conservatorship (managed by her father and an attorney) in 2008 following her mental health struggles. The court decision resulted in her inability to manage her own finances and participate in other major life decisions, and it lasted thirteen years until the #FreeBritney movement attracted media attention and Spears finally spoke out against what she called a coercive, abusive situation. Her father filed to reverse the conservatorship, likely to avoid deposition and public scrutiny of his actions. The court proceedings drew immense public attention to conservatorships as a human rights issue and the results of the case set a precedent for combating similar abuses in subsequent legislation.
While the public may have this reference point, few are aware of the emerging alternatives to the type of substitute decision-making that occurs under guardian- and conservatorships. That’s why this moment on The Pitt is so important in drawing attention to the options that already exist for individuals like Becca. This attention to SDM through the story of Becca marks yet another positive milestone for The Pitt.
Ally Peabody Smith, PhD, is an Assistant Professor in the Department of Population Health at Lehigh University.
Nanette Elster, JD, MPH, is a Professor at the Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine and is the John B. Francis Co-Chair in Bioethics at the Center for Practical Bioethics.
Debjani Mukherjee, PhD, is an Associate Professor of Medical Ethics in Clinical Medicine and Clinical Rehabilitation Medicine at Weill Cornell Medicine and Senior Clinical Ethicist at New York Presbyterian Weill Cornell Medical Center
Kayhan Parsi, JD, PhD, is Professor and Graduate Program Director at the Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine and is the John B. Francis Co-Chair in Bioethics at the Center for Practical Bioethics.