by Craig Klugman, Ph.D.

The Good Doctor (Season 3; Episode 14): Lying; Social Media; Internet Medicine; The Good Doctor (Season 3; Episode 15): Pressuring a patient; Surgery to correct social problems; New Amsterdam (Seasons 2; Episode 13): End of life; Battery; Chicago Med (Season 5; Episode 14): Can an abuser’s victim make his medical decisions?; Misdiagnosis

The Good Doctor (Season 3; Episode 14): Lying; Social Media; Internet Medicine

Cassie is a patient with a rare disorder—hey hyoid bone is too long and this causes problems. She is also a social media influencer and can or break reputations: She is turning Shaun into a bit of a celebrity. On the OR table she has a passing cerebral ischemia event while in surgery, under the lead of Reznick (who is hiding her RA). The team gathers to decide what to tell the patient: Andrews suggests saying nothing since there is no permanent damage and no evidence on any scan of a problem. Lim says that hospital policy is full transparency. Andrews says they don’t always give all information: Patients don’t know the music they play or what conversations they have during surgery. Andrews says not telling saves the future of the hospital and the only reason to tell is to assuage Lim’s guilt. Andrews wants to make sure that Shaun can “limit his answers” because he has a problem lying. In reality, this action is safe for the hospital and their careers, but is the wrong choice since it breaks hospital policy and violates the principle of truth telling. While the music played and the conversation are unlikely to affect the patient’s outcome (though some studies suggest they could), the cerebral ischemia did. I often recommend the front-page news test: If the issue hit the front page of the newspaper (or social media influencer feed) would that be a problem? If so, you may have an ethical issue. The team made the wrong call. It will be interesting to see if this comes back to haunt them.

In a second story, a woman arrives in the ED with stomach pain and a distended abdomen. We learn the woman had a UTI that did not respond and following the instructions of an internet video, she gave herself a fecal transplant from her 3-year-old daughter. The home blender she used must have had some bacteria in it. Although the patient loses part of her colon from the resulting infection, the team also discovers the daughter has a rare disease that causes her to have very high cholesterol. Without this situation, the daughter might have had a heart attack and died. A similar real-life case was recently discussed by Keisha Ray on this blog who wrote: “The internet can be a great source of knowledge and community, especially when we are going through the hardships of illness. But the internet must be used responsibly, especially when we are using it in life and death manners….” Dr. Google or Nurse YouTube does not equal a medical or nursing license and experimental treatments (that also require sterile conditions) should never be attempted without medical supervision.

The Good Doctor (Season 3; Episode 15): Pressuring a patient; Surgery to correct social problems

A 10-year-old boy was born with an open trachea. He has lived his whole life with a trach and the doctors perform a surgery that closes it, enabling him to finally breath through his mouth and nose. He uses sign language to communicate. However, Murphy sees himself in the child and figures out a risky surgery (utilizing his ribs and cartilage to build a voice box) that might enable the boy to speak. If they do it, the surgery should be done soon while he could still learn speaking skills. The surgery is risky and could undo the good that the team just did; the parents are not in favor. Murphy believes the surgery is the boy’s best chance of making friends and being accepted by others. At discharge the boy was unhappy and Morgan realized that he wanted this surgery. Despite the challenges, the surgery is successful and the boy thanks Murphy for “pushing him to get the surgery”. One problem is that a physician should not “push a patient” to get surgery, especially when it is not medically indicated.

A second problem is the ableist slant this story offers. In reality, signing is how many people interact with others and communicate with the world. This is an example of what disabilities scholars would call finding a medical solution to “normalize” a person when the problem is in the social structure—more people need to know how to sign. The procedure required two surgeries—(1) to the abdomen to remove the ribs and cartilage and (2) to the throat to implant their constructed voicebox—which has high risks (and in this case causes bleeding from an anomaly in the jugular). Is the risk of surgery worth the benefit of correcting a social problem? Should the child suffer from social ostracizing with a potentially surgically correctable situation? These are decisions that only the family can make, but somehow the social peer pressure seems like it interfered with considering what was medically best.

New Amsterdam (Seasons 2; Episode 13): End of life; Battery

This episode opens with a woman in the ED who needs a new heart. Her hospital has dumped her on this county facility to die. This way the death is not on their record. When Goodwin confronts the hospital president she says, “Every hospital dumps patients, including New Amsterdam”. In a world where metrics are all important, having patients die (especially in a transplant program) can risk their rating and their reputation. But if the patient dies somewhere else, then the stigma does not affect them. Goodwin finds that when patients are near death, they are turfed to hospice facilities, nursing homes, and rehabs. Instead, he thinks they should be in the hospital in a palliative care program. However, the result is that he has to find place for people in the hospital to die there. This is often undesirable spaces. What he learns is that people who are dying don’t want to be in the hospital for their final days. Goodwin manages to hoodwink a donor into paying for a palliative care wing, providing a warm, inviting, and meaningful environment for the patients.

In a related storyline, Mary Anne, the first patient turfed, collapses in her ED bed. She was just talking about seeing her grandkid. Reynolds says she is DNR. Bloom says that in 2 minutes she can get back a heart rhythm. Reynolds holds up the pile of paper he’s holding and says, “We got to let her go…She made her wishes clear. The legal and binding choice she made was no shocks, no medical interventions.” Bloom states that the woman would revoke it if she could speak. Bloom starts CPR anyway and calls for a crash cart. Reynolds tells her that she is assaulting the patient. After Mary Anne is stabilized (but unconscious), Reynolds states “the ends do not justify the means” and asks when Bloom would stop CPR, “a few broken ribs, or after you revived her only to learn she’s braindead. She wanted a good death and you just took that away.” At the end, we see her granddaughter being brought to Mary Anne’s bedside. It is unclear if she is conscious. In reality, a DNR is a physician order, not anything a patient signs. The paper that Reynolds holds is actually an advance directive, which can be reversed by the patient. But the physician should not make the unilateral decision that the patient changed their mind without the patient actually changing their mind. While there are rarely repercussions for ignoring an advance directive (though there have been lawsuits), Bloom committed a battery, putting her values in front of those of the patient.

Chicago Med (Season 5; Episode 14): Can an abuser’s victim make his medical decisions?; Misdiagnosis

A couple is brought into the ED after a motor vehicle accident. Rick is 40 years old with injuries to his spleen and leg. The leg needs to be amputated as it is compromising his liver and kidneys. His wife, Kim, was driving the car when she went through a red light (perhaps deliberately). She has large bruises on her back that could not have come from the crash; she claims she fell on the stairs. The wife is not certain what Rick would want and is concerned that losing his leg would make him angry. Manning says to her colleagues “That woman was abused by her husband. In my opinion, that woman should not be making decisions for him”. As Manning tells Goodwin, the concern would be that she might (a) make decisions that shorten his life so she can be free of her abuser, (b) that she might be punished later for whatever decision she might make for him, and (c) that as a victim of abuse, she lacks the capacity to make a reasoned choice. Manning is concerned about the emotional and psychological burden she has been under. Marcel worries that as his wife she has the right to make his choices and wouldn’t removing this power be further abusing her. Goodwin says she will convene an ethics committee (good choice!). After reviewing the case, “the ethics committee has decided to take away decision-making rights from Kim…the committee believes that Kim does not appreciate the risk [of waiting to amputate].” Goodwin then tells Marcel that he can take Rick to surgery. Goodwin tells Kim that the hospital is taking control of making Rick’s decisions.

First, ethics committees make recommendations but lack authority to remove anyone’s decision-making powers. Second, if the wife can no longer make decisions, then who is making them? If it’s an emergency, then two doctors could do so, but given that they’ve already waited a while, the argument for immediate urgency is thin. In the case of Illinois, next decision makers would be adult children and then the patient’s parents. Why has no one decided to contact his parents? Even if Kim was seen to be a poor choice of decision-maker, why would they also take away the parent’s ability to make choices. Or those of a close friend (who is also on the list of surrogate decision-makers). Nowhere in Illinois law is a hospital permitted to make decisions for a patient except in emergency situations. If there is no one else possibly around to make these choices, then a court order would be needed. Third, as we see the ethics committee leave the meeting room, we see a line of people dressed in business clothing. An ethics committee is composed of people from many disciplines including doctors, nurses, and perhaps ethicists. There should have been some people in scrubs and some in white coats.

When alone in the room with her husband after surgery, Kim turns off the ventilator and admits to it. Manning does not try very hard to resuscitate him (not even 30 seconds; he is in multi-organ failure) before calling his death. Kim committed murder and the story ends with her in handcuffs.