BioethicsTV (January 27-31, 2020)


Craig Klugman

Publish date

Tag(s): Legacy post
Topic(s): BioethicsTV End of Life Care Professionalism Psychiatric Ethics

by Craig Klugman, Ph.D.

The Good Doctor (Season 3; Episode 13): Making emotional decisions regarding cancer care; New Amsterdam (Season 2; Episode 12): Withdrawing ANH in PVS; Treating the Physical to Heal the Mental

The Good Doctor (Season 3; Episode 13): Making emotional decisions regarding cancer care

Reznick’s mother is dying of brain cancer. She is an artist and is unwilling to do any treatments that will affect her ability to create art. When her mother becomes unconscious and has a brain bleed, Reznick chooses a brain surgery to remove part of the brain that is bleeding rather than the full tumor removal that her mother has refused. “We choose procedures based on what will provide the greatest benefit.” She says. In this case, she believes the benefit is that once they get started, they will have to complete the full tumor removal. She wants to do an end run around her mother’s wishes.

Reznick has two siblings. Other than her being a doctor, it’s not clear why Reznick is making her mother’s decisions alone. There is not a durable power of attorney for health care that the viewer has been told about. And in places where adult children are the decision-makers, it is usually all of the children, not just the one who puts forth their opinion most strongly. We learn that the other two siblings have been discussing mom’s condition without Reznick, suggesting mom did not want her making any choices. The patient has been clear that she does not want any surgery that could affect her art skills and yet Reznick is willing to go against her mother’s wishes to fulfill her own emotional desire to keep her mother alive. In a hail mary, Renick comes across a new method for surgery that would remove the tumor and keep the rest of the brain intact. Rather than having to decide, the show finds a way around it.

New Amsterdam (Season 2; Episode 12): Withdrawing ANH in PVS; Treating the Physical to Heal the Mental

A man has been in a persistent vegetative state for over 14 years. On this day, however, his eyes open. His wife takes it as a sign that he is waking up and she calls her adult children to come in from out of town. Kapoor tries to explain to her that the patient is not showing signs of wakefulness but involuntary reflexes; he shows no signs of higher brain function. The kids say they are done and want to remove the feeding tube and the wife is about to agree when the patient moans. Kapoor explains that the sound was simply air passing the vocal cords and the wife sees it as a sign that he’s telling her to keep him alive. Later his eyes close again and the wife panics because “he was improving” and now he’s not. Kapoor tells her again that he was not improving. The wife has given up her whole life in hopes that her husband would awake and look in her eyes again. We learn that she never even met her out-of-town grandchildren because she won’t go a day without visiting her husband. Kapoor explains to the kids that if the wife/mother lets go, then she might feel completely alone. In reality, a PVS patient looks fairly “normal” with sleep-wake cycles, warm to the touch, good skin tone, and brain stem responses. There is certainty that this patient will not recover; cannot recover. If previous cases can serve as a guide, at this point, much of the brain has been replaced with free CNS fluid. At the end, the children embrace their mom who agrees to removing the feeding tube. The patient dies peacefully and the children work to make sure their mother does not feel alone.

In another storyline, a patient lost a lot of weight and has been left with extra skin. She gets rashes from wearing stockings to try and hide her arms (she can’t afford medical compression garments) and has continual bouts of infections and rashes. When she expresses a desire to self-harm rather than live in her body, Frome goes to the insurance program to get them to cover the skin removal surgery. They refuse saying the surgery is elective and that they do not cover cosmetic surgery for mental health issues. The insurance will cover meds for her rashes (physical problem), but nothing to take care of the underlying issue. In reality, our medical system and health insurance system do not treat mental illness and physical illness equally. Mental illness is still underdiagnosed, undertreated, and not taken seriously. However, if a patient has cancer then there is insurance coverage for everything needed to make the patient whole, even cosmetic surgery. Sharpe looks at the patient and sees she has a lot of moles on the excess skin; Sharpe recommends that the best move would be to remove all the skin. In other words, Sharpe and Goodwin are “gaming the system”. Nothing they are saying is untrue but they are stretching that truth to get what they want. They are lying to get the surgery covered. Physicians should not lie, even if it benefits the patient.

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