by Craig Klugman, Ph.D.
A look at the ethical and professionals issues raised in medical dramas this week: Chicago Med and Heartbeat.
This new show is always good for presenting challenges in professionalism and bioethics. This week (season 1; episode 16) is no exception as the fictional hospital finds itself in the middle of a surprise Joint Commission visit (though they often refer to the organization as “jay-koh” it’s previous abbreviation). One of the storyline this week deals with a retired neurologist and her husband with Lewy Body syndrome. She diagnosed him originally and took him to see two specialists who confirmed her diagnosis. But the staff at the hospital is confused because he has moments of extreme lucidity and has not declined as much as he should have with this disease. Dr. Charles, the resident font of wisdom and psychiatrist, orders an MRI for the patient. The scan shows not Lewy body but rather a small tumor that is responsible for his observed behaviors.
This storyline demonstrates two professional issue and two ethical ones. The first professional concern is a boundary issue: Don’t treat your own family. As we learn, the neurologist made the diagnosis based on the symptoms she saw and her experience of seeing many patients with that disease. What she didn’t do was order brain scans to support her differential diagnosis. One also wonders if the two specialists actually bothered to examine the patient independently, or did they start the examination with the bias of what their esteemed colleague found? In this case, not only was the neurologist led astray by her biases and her neglect to expose her husband to lots of scans (she already knew the diagnosis!) but she swayed the thinking of her colleagues as well.
One ethical issue is that of informed consent. Dr. Charles ordered a brain scan without anyone’s consent as part of his hunch. He wants to run a scan that most consider unnecessary and that is unauthorized:
Dr. Rhodes, “We need the wife’s consent?”
Dr. Charles, “Hasn’t she been through enough. I’m just trying to spare her some false hope here.”
In short, he commits a battery against a patient. His intention was to avoid causing “hope” for the neurologist in case the scan showed nothing other than Lewy body. He acts unethically and illegally. However, as in most of these shows, the ends justifies the means: He was right about the diagnosis so the assault is overlooked.
The other ethical issue is equally concerning. The story is that the patient has a trauma from being hit by a bus, which has caused an aortic aneurysm. Given his disease and the difficulty of the surgery (two previous heart surgeries have left lots of scar tissue), the decision is made to let him be comfortable and not do the surgery. However, once the neurologist learns that her husband’s mental issues are reversible, she wants to proceed with the risky surgery. The decision is in large part out of guilt—that because of her misdiagnosis, she cheated her husband and herself out of time. The medical issues concerning the heart problem and the riskiness of the surgery have not changed. And in fact, the senior cardiac surgeon does not want to do the surgery because in regards to the heart problem, nothing has changed. But the arrogant resident decides that he can do it and that he owes it to give them the chance. The ethical question is why the trauma fellow believed the risk/benefit ratio changed based on his perception of neurological deficits? This is a morality tale for medical-decision-making—do we recommend comfort care too easily for some patients? Do we push aggressively too hard for patients we perceive as having “something worth living for? Is this presentation a statement on an inherent bias against people with certain handicaps in medical decision-making? The possible answers are chilling.
The second professional issue seen is that of “work-arounds.” Work-arounds are commonly used pragmatic shortcuts to get things done. For example, when a patient excretes a radioactive pellet for treating prostate cancer, the team spends considerable time trying to get environmental health & safety to clean it. However, after 8 hours, they simply use tongs and a thermos to pick up and dispose of the pellet. This violates proper protocol (and perhaps common sense) but it does get the job done and makes the treatment room available for use once again. A work around can solve a current problem but the need for it exposes a flaw in the system or existing processes. As one study showed, “work arounds enable, yet potentially compromise, the execution of patient care.”
Heartbeat
This week was light on ethical issues but there was an interesting storyline about a transgender woman who needed a mastectomy for breast cancer. From a professionalism standpoint, the physicians demonstrated support and understanding of the patient’s concerns. For example, upon entering the hospital the patient identifies herself as trans (because previous doctors have not wanted to work with her for that reason) and the doctor immediately asks, “What pronouns do you prefer?” When she is told there is no makeup allowed in the OR, a compromise is reached that she can wear glamorous sunglasses. After her mastectomy, she is introduced to the women of her support group who said it was the surgical experience that they cared about, not anything else about her. When she is concerned about remaining pretty as a woman, she is introduced to a medical tattooist. And when she does not want the surgery after learning she would have to stop taking hormones, she says that she’d rather die after a short life as a woman. Her physician then says that strong women do not give up but they fight everyday. This line convinces her to get the surgery.
Although the story is set up to pit this woman’s feelings and needs (and her history of being discriminated against for who she is) against the medical establishment, that trope is disrupted when the health care providers do everything possible to ensure her confidence, her health, and her holistic well being.