by Craig Klugman, Ph.D.
The Good Doctor (Season 3; Episode 16):Who consents when there is more than one personality; New Amsterdam (Season 2; Episode 15): Unanticipated DNA findings; Fudging clinical trials; Chicago Med (Season 5; Episode 15): Killing a death row prisoner, endangering patients
A college student comes into the hospital. Reznick and Brown get a history and learn that he is a serious, stressed student. Hours later they talk to him again and he has no idea they have ever met. This time he is a partying frat boy. An MRI shows a cyst in his brain that is causing him to “sleep walk”, basically a different personality emerges when he sleeps (the scan shows that his brain is sleeping). The cyst could cause complications at some point including infection and blindness. The patient (serious student) rejects having the cyst drained because he likes parts of the other him. Reznick and Brown then ask the patient (sleeping frat boy personality) to consent to the procedure. In this case, the sleeping version consented to the surgery and made a video to his other self-explaining what he did and why.
In a case where a patient has two distinct personalities and there is a need for someone to consent, who can consent? Can one of the personalities consent but not the other? Must both consent? What if neither consents? Or is such a person incapable of consenting, in which case a guardian should be appointed or a surrogate decision-maker sought. Perhaps, as in this story, only the second personality could consent because consent means his death, or the cessation of his existence. If awake patient consents to the surgery, might that be murder of the sleep personality? The literature on this topic is scarce even if we think about the issue of consent in people with multiple personalities. A 1990 letter to the editor of the American Journal of Psychiatry suggests, “When such complications [personalities disagreeing or trying to harm] are appreciated in nonemergent but medically pressing situations, we would recommend seeking temporary guardianship at an early juncture.” In this story, the doctors could have called for an ethics consult on this difficult issue and seeking a guardian might have been a better option than simply waiting for the personality that gave the answer the doctors wanted.
This week’s big theme on the show is the opioid academic. Brantley mentions to Goodwin the uptick in opioid related deaths (10 per week Max tells us). She gives him full freedom to deal with it—no matter what. Clearly this is personal for her. Goodwin leads an effort among the largest hospitals to cancel opioid contracts with the company that has been pushing the drugs hard—this is clearly a stand in for the Sackler family since each hospital seems to have a building donated by the family. He is unsuccessful, standing alone and finds that the hospital can no longer find a drug company willing to sell them any drugs.
An engaged couple comes to see Frome after taking their DNA tests. The results show that they are half siblings. They met in a philosophy class as undergraduate students. Even with the newfound relation, they still love each other. Frome tells them that children can never be an option. She is finding it hard to look at her betrothed. Frome and the male partner are trying to save the relationship; the question is why? This information is devastating and does change the options available to them. After all, under New York law, marriage between half siblings is illegal. This case is another straight from the headlines story. There have been a few isolated similar cases in the UK and New Zealand. In this story, the two people read the vows they had written for their wedding and remember why they love one another; they will go through with the wedding.
In a continuing story arc from last week: Sharpe talks to a mentor about an NIH trial her new chair is running. Sharpe suspects protocol deviations and a neglect to record adverse events. If true, then the hospital stands to lose all of their federal research dollars. Without proof though, there is not a lot she can do. She digs into the files and finds that Castro altered patient numbers before the trials so that their tumors appeared worse than they really were. The hospital could be in big trouble.
Walter Hobbes, 53-year-old death row prisoner from Indiana brought in complaining of arm pain—he has compartment syndrome—is brought into the ED after surviving his lethal injection. The officers do not know what was in the injection. Goodwin explains that drug companies do not permit their products to be used in executions so the jail probably just used something they could get a hold of. After relieving the pressure on his arm, they still have to get the poison out of his system. Walter asks that the doctors let him die. Goodwin informs us that the warden has re-scheduled the execution and wants Walter back in Indiana as soon as possible. The arm becomes necrotic and Choi says they need to amputate the arm. Marcel argues that there was no sense in the amputation for a man who was just going to be killed. Instead, he suggests they give him pain meds and let him develop sepsis. Choi says they are doctors, not executioners, and they need to amputate the arm. Marcel then agrees. After removing the arm, Marcel says the necrosis has spread and he needs to remove more tissue. Eventually he claims that he can’t close off an artery and the man bleeds to death on the table. A nurse says they should start compressions and Marcel says no, because all of the blood is already on the table. To the officers, Choi claims that they did everything they could to save the patient; I suspect he is covering for Marcel who we are led deliberately created a situation for the patient to die.
In a second storyline, a woman in the 7th month of pregnancy comes into the ED in Sickle Cell crisis. She refuses morphine because she doesn’t want to risk her fetus—this was her third round of IVF. Her OB is Asher, who has promised to check herself into rehab. Halstead gives the patient a transfusion because she is anemic. When she has a reaction to the blood, Halstead wants to deliver the baby. The patient refuses. As she begins to enter respiratory distress, Halstead says she will die very soon and then they will deliver her daughter, or she can agree and they can try to save both of them. Another OB is able to deliver the child and the mother is also saved. Asher shows up talking about a serious of unfortunate incidences (including a flat tire). Halstead doesn’t believe her, assuming she’s lying and was out getting high. He says his mistake was believing she was going to get help on her own (and his was sleeping with her the previous night). The episode ends with Halstead asking the security guard to do a narcotics sweep of the parking garage, where a dog finds drugs in her car. He avoids reporting on her directly (which is his professional duty) but he also assures that no one will believe her if she blurbs that he was working in an illegal injection site. This storyline is a commentary on the opioid epidemic and the risk it poses to physicians.
Medicine is a self-policing profession, meaning that it relies on physicians to help maintain standards. Thus, a physician is supposed to report when another physician is compromised or lacks capacity to practice. After all, the most important thing is protecting patients and a compromised physician endangers them. Out of fear for himself, Halstead put off his duty too long and at the end tried to accomplish it without being a “snitch”. He knew she was practicing while taking drugs and he did not report her immediately. He failed in his duty and patients could have paid the price.