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 was repeated on Thursday 2nd July at 20:00.