by Craig Klugman, Ph.D.

This week another new medical show premiered; this time on NBC. Heartbeat follows the story of Dr. Alex Pannttiere one of the few female heart surgeons and chief innovations officer at fictional St. Matthews Hospital in Los Angeles. This series is based on the book Heart Matters by Dr. Kathy Magliato.

The second episode (#102) features a case of conjoined twins who have shared every moment of their lives. The two patients are as different as two people can be, but they share a liver, spleen, parts of a pelvis, and parts of the circulatory system (though both has her own heart). They were never separated because her mother believed “this is how nature intended” them to be.

Now one twin has an aggressive cancer. The other has a heart condition. If the cancer is not treated, then the cancer will metastasize to spread to the other twin. The surgery is risky and the chemo is dangerous to the twin with a heart condition, most likely killing her. If one twin dies, sepsis will soon kill the second. Alex recommends a separation surgery, which the twins do not want.

The surgery is offered as a “natural” solution to being able to treat the cancer and not threaten the health of the second twin. But the only risks offered to the audience are psychological—that the twins have not only a shared body, but a shared sense of identity—being connected is who they are. It’s nice to see a consideration of the effect of a procedure on the person rather than just is it medically possible. The show barely mentions the physical risks to the adult twins who end up being under anesthesia for over 24 hours—a risk factor in itself.

While success rates are difficult to find, the University of Maryland suggests that without heart involvement, the rate may be 68% success (at least in infants). No mention is made of the prolonged recovery which often includes extensive rehabilitation because of the twisting their spines have accommodated for a lifetime and how the muscles were flexed to support them. Conjoined twins often have trouble walking and even sitting up after separation.

In minute 18 of the show, three doctors and the physician-administrator are engaged in a meeting where they are discussing how to handle this case. As the administrator says, “There are medical and ethical considerations that the bioethics committee will rule on. So, we have to make some recommendations.” Later on, the viewer learns that the bioethics committee rejected the proposed surgery and chemo for cancer saying that they would only approve a separation of the twins with the patients’ full consent. The administrator mentions the committees concern over hospital liability. This committee is a combination of surgical, ethics, legal review, and risk management committees.

It’s interesting that in this hospital, the doctors make the recommendations and the bioethics committee makes the “ruling.” In reality, ethics committees can do no more than make recommendations and the physicians make the decisions (or rulings in this parlance). Perhaps this switch is a set up for Alex to be able to rebel at some later time. Most likely, a medical committee would make the decisions regarding an innovative and dangerous surgery and an ethics consultant would be invited to be part of those deliberations.

The disregard in which this committee is held, even though its “rulings” are followed is also found in minute 18 when a senior physician says, “I recommend we stop catering to that committee. They’re a conservative…[drifts off].” The implication is that the bioethics committee impedes innovation and the progress of medicine and serves as an obstacle for doctors.

When the twins realize the pain the one with cancer is in and the likelihood that treatment will kill the other, they agree to separate to save the other twin. The decision is presented as a selfless act. At the end, the twins wake up to see each other for the first time and argue over who is prettier, showing that in all aspects, the surgery was a success. The cancer treatment and long term rehabilitation are not even mentioned—medicine has saved their lives and “normalized” them.

Perhaps this story is better viewed as one that shows the limits of medicine in dealing with patients who do not fit a standard mold. Why couldn’t the medical innovation of this storyline be finding a way to treat the cancer without harming the second twin? Instead, the focusing is on making patients that look like our standard person and puts forth a message that conjoined twins should be separated. Whenever the suggestion is made of pursuing more conservative cancer treatment instead of separation, the twins are told that the hospital will arrange their transfer elsewhere: Rejecting any choice other than normalization. Even at the end, the cancer hasn’t been treated and likely can’t be for months while the twins heal, regain their strength, and undergo rehab.

This show has gotten a poor response from TV critics. Likely, it won’t return for a second season.