Sunday, September 7, 2008

image: National Library Medicine

Normally, I don't talk about ethics much on this blog, but occasionally I find something that makes me ponder and want to know how others feel/think. So I guess I'm just putting this disclaimer that this post is about ethics and it's your choice to read or not. And if commenting, please be considerate.


The USA Network is running a "House" marathon this weekend. This is a show I like but often don't watch since it conflicts with another program. That, and I rarely ever watch much of the Fox station. Occasionally, I watch a few episodes of "American Idol," but that's about it.

Although I like House, his sarcastic, dry wit, and think Hugh Laurie does a great job in the role, I'm not sure I could actually stand him as a doctor. The one thing going for him is that he is an excellent diagnostician. That's a good thing, because his bedside manner sucks. I'm sure if this was a real hospital (and there's bound to be a few in the US--egos and all), I'd probably be like one of his assistants in always worrying about getting fired or not doing the right thing. But if I was really dying or needed an answer, I do think I would maximize the situation and want him as a doctor.

Anyway, yesterday, I caught most of an episode from the first season, titled "Control." In this show, Carly, a 30+ year old comes in with what looks like paralysis of the left leg and pain in her right quadricep. She undergoes an angiogram for any clots as well as a virtual scope for colon cancer. During the second angiogram (the first one got botched), Carly's lungs fill with fluid which must be drained. Later, House examines her leg while she's sleeping and sees marks on her thigh, implicating she is a cutter. I'm not sure how he went from cutting to eating disorder and that she needed a new heart. Somehow that jump was made in his mind despite the fact that tests suggesting she had congestive heart failure had not come back yet. Of course, that's House for you.

Now, House, knowing she needs an immediate heart transplant and figuring out she has an eating disorder, must decide what to tell the committee. He sees Carly first, exchanging the details of the facts he knows about her. The ipecac syrup she had been using destroyed her heart and caused muscle damage. Then he says how he has an emergency meeting with the committee to rank how high in need her case is. Normally, her case would be ranked high since she has little time to live. However, due to her psychiatric history, the eating disorder can be an exclusionary factor, much like a suicide risk or substance/chemical dependency case.

I can't remember the exact dialogue between House and Carly, but one essential issue Carly felt was whether she was worth it or not. Really, House wanted to know whether she wanted to live. At the end, Carly said she didn't want to die.

House, then lied to the committe saying she had no exclusionary criteria for an immediate heart trasnplant. He fought hard for her and she got the heart. After the transplant, he visited her and basically told her not to screw it up. And then talks about how she would be on a strict diet and hands her some chicken or something. Okay, that wasa bit ironic, but I could see the point being made.

So, I think this episode brings up some interesting ethical type questions. If you were in the same situation as Carly, ie, needing an organ transplant due to your eating disorder, how would you feel? Would you feel worthy of a transplant or that you should even be considered or ranked high? Would you want your Dr. to be proactive for you and perhaps lie to the committee? How would you feel if your Dr. was truthful about the eating disorder, and you were ranked low on the list for an organ transplant? Would you then feel like you were not worth saving? Or, if you did receive an organ, would it be enough for you to adhere towards recovery?

I'm not sure how I'd feel honestly. If I knew someone was "ranked" the same as me, had a congenital heart defect, and there was only one heart...well, I'd feel that that person should get the heart over me. I'm not sure if I'd feel it was more of a worthiness issue or rather a fair issue. After all, some people wait months and years to receive an organ which is in high demand. And unfortunately, some die waiting.

On the flip side to this, if I did receive a heart over someone else, would I feel guilty?

I also wonder if eating disorders were looked at as more on a biological basis, thus taking out the assumed idea of "choice" which most people believe, would the exclusionary criteria be different? I know suicide and other psychiatric illnesses not being treated are also on the exclusionary list, as well as your lifestyle choices, like smoking and alcohol. BMI is also considered with those over 40 or 100 pounds overweight not recommended for transplant unless brought down to BMI of 30. Other factors are considered as well in terms of health and psychosocial aspects with some criteria recently broadened like age, having cancer, and other illnesses. I should note that any organ transplant case is looked at on an individual basis by each transplant/treatment team, so these guidelines are only suggestions.

Anyway, I just thought this was an interesting case and makes you realize the importance of well...your organs and how eating disorders can affect them. Personally, I do not know of anyone who has had to have an organ transplant due to their eating disorder (sadly, my feeling is that their organs might shut down before organ donation would be considered or they would have already passed away), though I have heard of people having organs like their gall bladder removed due to malnutrition. The point being is that this could happen. Maybe for some, it would be the impetus for change and recovery, while for others maybe not. But in the end, why do we even really want to take that chance?

Heart transplant criteria broadened
Transcript of show "Control"


Gaining Back My Life said...

I do plan on reading through the transcript - I found this to be a fascinating story.

I honestly don't know how I would feel - if it were guilt, would it be guilt because I've always felt guilty and ashamed of myself? Or would it be a genuine sorrow for my selfishness?

On the other hand, if you look at the ED solely as a mental illness, then it would hold no bearing that I should feel guilt.

But for me personally, I view my ED as an addiction, and in that respect, I would hope to be courageous enough to let another person go before me.

Tiptoe said...

Gaining, I was hoping someone would comment on this post, so I'm really glad you did. Yes, I think it would be such a hard decision with so many emotions involved. And the emotions would only volunteer more questions. I hope none of us ever have to make that type of decision.

Gaining Back My Life said...

There's such a fine line between what we deserve and....what we deserve.

Part of my challenge with my ED is to learn to take responsibility, and if the Dr. made the decision for me, I probably wouldn't feel guilty. Since, technically, I would not be responsible.

I still haven't read it, but hope to today.

It was a very interesting article, Tiptoe. Thanks for sharing!