Private Practice: Acting ethically at the Wellness Center?

(Warning – contains plot spoilers!) Private Practice is a spin-off from Seattle hospital drama Grey’s Anatomy in which Dr Addison Montgomery (Kate Walsh) moves from Seattle Grace to join the staff of the Ocean Wellness Center in Los Angeles.

I have to admit that I tired of Grey’s Anatomy during Season 1 and although I was aware it has spawned another series I had no desire to watch. All this changed, however, following an excellent talk on the programme, given by Dublin Doctor Audrey Dillon at the 4th Postgraduate Bioethics Conference (Belfast, June 2009).

The writers of Private Practice, headed by Shonda Rhimes, have made a conscious decision to incorporate ethical issues into the storylines (see ‘Private Practice’ explores bioethics questions). This means, therefore, that the series may well throw up some interesting case studies as discussion starters.

At the time of writing, Living TV (UK) has just started transmission of Season 2 (see here for Episode guide). A Family Thing, the first programme of the series, was aired on 25th June 2009 (TRILT code 00FC042B). True to promise, it contained two subplots featuring ethical dilemmas.

Saviour siblings – a donor by design?

In the first (starting 7 minutes in), Molly and Eric Madison present at the clinic demanding that the staff deliver their baby daughter that day, despite the fact that she is only 27 weeks gestation. The girl, it transpires, has been conceived following Pre-implantation Genetic Diagnosis, to be a ’saviour sibling’ for her older brother, Jason.  The boy has leukaemia and has had his own bone marrow wiped out in preparation for a transplant from a donor who has now fallen unwell with pneumonia. He is therefore immunocompromised and urgently needs umbilical stem cells courtesy of the new child.

After the main credits, Addison challenges her colleague Naomi about why she has chosen a genetic match (”selective IVF” as it is called here, or more formally Preimplantation genetic diagnosis, PGD) for the couple. Naomi defends the actions as “a back-up” which is “done all the time”. Addison counters that the mother considers the child to be “an organ donor… for her she’s growing organs for her sick son”.

The story is picked up again as Addison, Naomi and another colleague Violet discuss the rights and wrongs of Naomi’s actions whilst in the queue for the cash machine, with others present (an interesting ethical dilemma in its own right). “You gave them hope they shouldn’t have” says Addison.

Despite being taken to see the older brother in his isolation unit and heavy emotional appeal from the parents, Addison still refuses to deliver the baby prematurely. The mother, however, takes events into her own hands, breaking her waters with a knitting needle. Addison is forced to proceed with the delivery.

In a teaching context, I think the first two scenes (Molly and Eric showing up at the Clinic, then Addison and Naomi discussing the case) would make an excellent introduction to the ethics of PGD.  There would be no need to include the later scenes.

Confidentiality v responsibility in the consultation?

In the second, pediatrician Dr Cooper Freedman is faced with 14 year old patient Dean Miller, who is HIV positive, but his parents have said they do not want him to know – he thinks he has a kidney infection. Now Dean has indicated to Cooper that he and his girlfriend are about to embark on a sexual relationship.

Aware of this, Cooper calls in the parents and – without revealing Dean’s intentions – try to get the parents to accept it is time for him to be told. For his own protection, they are adamant that time has not yet come.

Torn between his responsibility to Dean and his responsibility to the parents, Cooper calls a conference with all of them and ultimately reveals Dean’s secret to the parents. With the latter having threatened litigation if Dean was told his HIV status without their permission, this must have seemed the more financially-astute way out of the conundrum. In one sense, iturns out to be too late –  Dean and his girlfriend had already had sex the previous day.

Again, for teaching it is probably not necessary to show all of the segments in order to get a flavour of the dilemma. Cooper’s initial conversation with Dean, with his parents and talking with his colleagues on the promenade (again, in public) would do a good job raising the issues for discussion.

Ethical issues are not the same as ethical practice

This episode certainly bore out two points made by Audrey in her analysis of the series as a whole. The first is the absence of any genuine ethical reasoning – no mention was made of frameworks being used in the decision-making which seemed more to be driven by gut feeling and convenience.

Secondly, the medical team do not act in ethical ways. They discuss confidential cases in public, and are sexually promiscuous – including in the office, during work time.

A Family Affair (TRILT code 00FC042B, 60 mins)  was shown on Living TV on Thursday 25th June at 21:00 and will be repeated on Thursday 2nd July at 20:00.

Evaluating medicines – the appliance of science?

The BBC has a four part series featuring Professor Lesley Regan (from the Dept of Obstetrics and Gynecology at St Mary’s Hospital) as she probes the scientific validity of various health and beauty products. At the time of writing, Prof Regan has investigated the diet industry and over the counter medicines (the subject of this post). Future episodes are to look at children’s products and tbc.

The second episode Prof essor Regan’s Medicine Cabinet (first transmitted on BBC2 at 9pm on Thursday 23rd April 2009, and available on iPlayer until 14th May) contained several valuable sections for use in teaching about the evaluation of pharmaceutical products, and about the scientific method in general.

Which remedies will make into Prof Regan's scientifically-tested Pharmacy?

Holby City – Resource allocation UPDATE

The most recent episode of Holby City is available to view of download on via the BBC iPlayer.

Following on from the recent BioethicsBytes post Holby City – “If you can’t look after yourself, then why should we?” (published on January 21 2009; updated February 4th 2009), which concerned ethical issues in NHS resource allocation as highlighted by two episodes of the BBC1 drama Holby City, this update post covers events in more recent episodes of Holby City – including the denouement to the storyline, as depicted in Feet of Clay.

The storyline concerns the “zero tolerance” policy implemented by Head of Surgery, Dr Ric Griffin (Hugh Quarshie), who is refusing to authorise surgical procedures for patients whose lifestyle choices may have contributed to their illness. Previous posts have covered the instigation of this policy in the episode Just (first broadcast on BBC1 on January 20 2009, at 20.00; TRILT Identifier: 00D15A4E),  and the events and debates this creates between the characters in Tough Love (first broadcast on BBC1 on February 3 2009, at 20.00; TRILT Identifier: 00D8E505). This post notes relevant events in the subsequent episodes Trust, Truth and Mercy, and Take Her Breath Away, and the closure of the storyline in Feet of Clay.

Darwin’s Dangerous Idea – Born Equal? (BBC2)

This episode of Darwin's Dangerous Idea can be viewed online via the BBC iPlayer until April7 2009.

In the three-part series, Darwin’s Dangerous Idea, broadcast on BBC2 to mark the 200th anniversary of the birth of Charles Darwin and the 150th anniversary of the publication of On the Origin of Species, broadcaster Andrew Marr explores the impact of the theory of evolution by natural selection on science, politics and society.

While the first and third episodes, respectively entitled Body and Soul and Life and Death, explore the historical spread of Darwin’s theory and the way it can be employed within conservation and ecology, the second episode, Born Equal?, includes a short section (between 00:45:12 and 00:56:20) that could be used in bioethics teaching.

Cognitive enhancement: less sleep = more done?

In Make me… stay awake, the final part of an engaging series of three documentaries (following Make me… smart and Make me… live forever), Michael Mosley investigates the effects of sleep deprivation and ways in which these symptoms may be alleviated. As he puts it in the introduction to the film, he wants to know if there are ways of “conquering… my need and my urge for sleep” (01:40).

Several sections of the programme brought bioethical themes into sharp focus – including the use of model organisms in research (17:53-20:47) and the use of drugs to stay awake longer (26:42- end).

Blood & Guts – A History of Surgery: Fixing Faces

Michael Mosley performing facial surgery on a mannequin/dummy

In the fourth part of the BBC 4 Blood and Guts series, Fixing Faces looks at the evolution of plastic surgery. True to form, Michael Mosley presents a graphic account of how brutal attempts to reconstruct patients’ diseased or damaged faces have led to a modern medical speciality which is now believe to be on the eve of the first full face transplant. This episode describes and illustrates the history of this area of surgery: showing the work of the 16th century Italian doctor Gasparis Taliacotii (00:05:06 – 00:18:02); the beginning of the Botox era (00:18:02 – 00:30:00); and the work of Sir Harold Gillies and Sir Archibald Mclndoe, who developed both surgical techniques and the need for psychological support for patients undergoing reconstructive facial surgery (00:30:00 – 00:50:00) (Please see this Student BMJ article – ‘A brief histoy of plastic surgery’).

This episode highlights two main ethical topics for discussion: functional Magnetic Resonance Imageing (fMRI) and Neuroethics (00: 01:54 – 00:05:06); and face transplants or facial allograft transplantation (00:50:00 – End).

Blood & Guts – A History of Surgery: Spare Parts

Blood & Guts - A History of Surgery: Spare Parts is the third part of the BBC Four documentary series about the “brutal, bloody and dangerous history of surgery” focusing on the development of transplant surgery. The documentary primarily gives a graphic account of the history of transplant surgery, in particular focusing on the work of Alexis Carrel (00:04:24 – 00:22:47),  Joseph E. Murray (00:22:47 – 00:45:32) and Sir Roy Calne (00:36:40 – 00:45:32). However both at the beginning (Start – 00:04:24) and the end of the programme (00:45:32 – End) Michael Mosley (Also seen in BBC’s documentary series Medical Mavericks) discusses some of the ethical concerns that may arise from transplant surgery. Mosley meets with two patients who have both had a hand transplant, however only one of the patients is able to keep his new hand as it illustrates the success and failure of the radical surgery.

Michael Mosley (00:02:00 - 00:04:24): "I'm really intrigued by David (patient because to me this is something more than just incredible surgery. The whole idea of living with a dead man's hand is one I find fascinating but also disturbing. A lot of people I've talked to are really freaked by the idea of having something like an arm transplant, its also true frankly of all the buts of the body that show like; noses, eyes, and faces probably the freakiest of them all. No other form of surgery impacts on our sense of self in quite the way transplants do. There is something profoundly strange about swoping body parts, melding your flesh with others. And these days there seems to be no limits."

The Daily Politics Show – “Should we be more wary of genetic screening?”

The Daily Politics Show

The edition of The Daily Politics Show broadcast on BBC2 on February 3rd 2009 contained an item on the use of embryo screening during IVF (see 00:15:42 to 00:22:25). The section begins with a short explanatory VT, which covers the technique of prenatal genetic diagnosis – PGD – and its uses in IVF, and some of the main ethical positions. The programme’s hosts – Andew Neil and Sangita Myska – then discuss the ethical implications of genetic screening and embryo selection with Professor Robert Winston. This short post summaries the main bioethical arguments put forward in this 7 minute clip, and suggests how it may be used in teaching.

BBC Radio 4 – Cancer Tales

Listen again to Cancer Tales via the BBC iPlayer (available until Monday 2nd February 2009)

On Monday 26th January 2009 BBC Radio 4 broadcast Cancer Tales as the Afternoon Play (aired at 2.15pm). This interesting and emotional radio adaptation was based on the play of the same name written by Nell Dunn (first published in the UK in 2002 by Amber Lane Press) which provides fictional accounts of experiences of cancer diagnosis and treatment. The accounts are very emotional and moving, and include the perspectives of the patients themselves, their family members and, occasionally, members of their clinical care teams. Dunn’s narratives are based upon the real-life experiences of cancer patients and offer a true-to-life snapshot of their experience of cancer diagnosis and treatment. Thus, Cancer Tales provides an opportunity to see many aspects of medical care and services from the patients perspective. This is particularly the case with the recent Radio 4 adaptation, which, within it 45minute running time, focusses on three of the narratives contained in the original script. These are all female experiences and explicitly dealt with experiences of clinical services (as opposed to wider social and psychological themes connected to cancer diagnosis).

A Short Stay in Switzerland

A Short Stay in Switzerland is a BBC dramatisation telling the true story of Dr Anne Turner. Diagnosed with the degenerative neurological condition Progressive Supranuclear Palsy (PSP) and facing progressive deterioration in her condition, Dr Turner decided that she would end her own life by travelling to the Swiss clinic ‘Dignitas’. Unlike the UK, assisted euthanasia is legal in Switzerland. A Short Stay in Switzerland tells a highly emotive account of a woman who wishes to “die with dignity”, a decision eventually supported by her children.

A Short Stay In Switzerland - BBC 1 Sunday 25th January 2009, 21:00. The moment Dr Anne Turner tells her children that she has PSP.

The programme follows the events during the final stages of Anne Turner’s life. Although the dramatisation attempts to illustrate events as accurately as possible, it does so with a clear agenda in favour of her autonomous decision and it does not discuss the other possible alternatives when faced with such a situation in any detail.

There is, however, a section of the programme which shows Dr Turner’s children attempting to convince her that her life is worth living and that they can provide palliative care for her (00:25 :10 – 00:33:33). In this specific case, Dr Turner succeeds in her wish after an unsuccessful suicide attempt in her home persuades her children how determined she is. (Warning:  if using the section indicated by the timings above, please be aware that the scenes that follow, graphically depict Turner’s earlier suicide attempt and therefore may not be suitable for all audiences).

There is also a BBC news article about the programme and you may be interested in this post on Panorama – I’ll die when I choose.

BBC News article 22nd January 2009. 'A Short Stay in Switzerland'.

 A Short Stay in Switzerland was first broadcast on BBC 1 21:00 – 22:30  (90 minutes) Sunday 25th January 2009, and is available on BBC iPlayer until 10:29pm Sunday 1st February 2009.

(DJW)