by Craig Klugman, Ph.D.
Our favorite television dramas this week were light on bioethics issues with the exception of Chicago Med (season 1; episode 17 “Withdrawal”) that continues to explore bioethical issues. This week the theme was arrogant paternalism—residents and fellows believing that only they know what is in the best interest of the patient.
The first storyline concerns a patient brought into the ED in the throes of alcohol withdrawal. He is a frequent flyer patient and has not had a drink in 2 days. Dr. Halstead (resident) believes that what is best for the patient is to help him through withdrawal so he can quit drinking and enter recovery. Nurse April Sexton has taken care of this patient before. The patient clearly has no desire to quit his addiction and is asking for a drink. The patient is also likely to die from the withdrawal. Sexton tries to sneak in alcohol for the patient because one drink and he will be fine. Halstead stops her.
The contrast of the two approaches—to “cure” him of his alcohol dependency versus giving him the short term fix of the drink that will end his suffering—is presented as a physician versus nurse difference. Consider this exchange:
Halstead: “No, no, no. It’s not my job to listen. I’m a doctor. It’s my job to decide what is best for him”
Sexton: “That’s exactly why I’m a nurse”
Although presented as a a stereotype of professions, a deeper examination offers a look into paternalism and autonomy. The physician’s statement is not only paternalistic, it is arrogant and a misunderstanding of the physician role, which is not to force treatment on a patient, but to work with the patient to establish a realistic goal and find the best way to get there. The patient stated that he wanted a drink and he had no desire to get sober. Halstead took the perspective that an alcoholic lacks capacity to make decisions and the rationality to know what’s best. The problem is that what the patient wants and what is best for him at the moment, goes against Halstead’s preconceived notions.
Another way to look at this is harm reduction versus zero-tolerance. In public health endeavors, harm reduction is the idea that people will engage in unhealthy behaviors so educational efforts are focused at reducing harm. This perspective leads to needle exchange programs for IV drug users, to giving out condoms to teenagers, to giving methadone to heroin addicts. Another worldview is zero-tolerance, that is, there should be no use of these substances at all. The substance and behavior is inherently wrong and must be stopped. This leads us to programs such as abstinence only, “just say no” for drugs, and removing families from welfare roles if a parent has a single positive drug test. Sexton represents a harm reduction model whereas Halstead is zero-tolerance.
This story ends with the patient suddenly fine and back to himself. As we learn, Administrator Goodwin, herself a nurse with much experience in dealing with alcoholics, has given the patient a drink. In fact, alcohol is often on hospital formularies for just this purpose.
A second storyline concerns a patient who enters the hospital in need of bypass surgery. The man and his wife are Jehovah’s Witnesses and will not accept blood, which is usually needed for this procedure. They even refuse a heart-lung bypass machine because as they explain, once the blood leaves the body—even if it is their own blood—it is polluted and cannot be returned. They explain that being together for eternity is more important than receiving this operation that would keep the patient alive. Dr. Downey offers them a bloodless surgery where the heart beats throughout the procedure. Dr. Rose (a fellow) tells the couple that they are much safer with a traditional bypass surgery. During the surgery, things go awry and Dr. Rose is massaging the heart in his hand to maintain blood flow. The wife is brought into the OR to see this image. Dr. Rose asks her if she would consent to traditional surgery because her husband will not survive the bloodless procedure. Torn between her faith and her love in this life, she agrees. Perhaps seeing her husband’s heart being pumped by a doctor might be a little coercive in decision-making. Did she really consent under these circumstances, or was she manipulated into this decision? We are led to believe that Dr. Rose thinks there was coercion.
When the patient awakes he is distraught that his wife consented and the procedure was done. She has threatened their eternity together, he tells her. Dr. Rose is pleased with himself for having saved his patient’s life—he had the technical skill. While the couple is reuniting after surgery and dealing with this transgression against their faith, Dr. Rose takes his fellow aside and says:
“You’re a good surgeon Dr. Rose. Saving a life isn’t always the answer. And you’ll never be a great surgeon until you understand that. “
Dr. Downey spent the episode as a patient advocate, working with the patient to find a treatment that aligns with his beliefs and being sure not to violate their autonomy. Dr. Rose has no such compunctions.
As we know, this show has had some problems with following patient autonomy. This episode brought that to a head and hopefully provides some lessons on how physicians should not behave.