*See character reference at the end in ‘References’.
As I embark on this tortuous journey to become a good doctor, I have made it my duty to humbly absorb the wisdom and the extensive sea of knowledge that the physicians and lecturers have instilled in me. From inception, I’ve been taught that it isn’t enough to simply be an intelligent or adept doctor. My professors implored and stressed the importance of core moral and ethical values, as well as a humane touch. They referred to the oath I took- to respect the autonomy and dignity of my patient, to not violate human rights or civil liberties, to do no harm and remain confidential. Via this piece of literature, I will attempt to challenge whether time, repetition, comfort or worse- indifference; has changed the way physicians practice the art of medicine.
"All that I am, or hope to be, I owe to my angel mother". These are the eloquent words of the illustrious Abraham Lincoln about his mother-Nancy, who died when he was 9 years old. This quote came to mind as I scrutinized the 2009 American drama film directed by Nick Cassavetes- My Sister's Keeper. I drew inspiration from it because I believe it masterfully showed a myriad of medical ethics dilemmas and potential pitfalls that those practicing the art of medicine can be exposed to.
One of the themes coming from this film was that of medical decision making. This encompasses the pillars of autonomy, beneficence, non- maleficence, and justice.
A situation presents where Anna, an 11-year-old is being coerced by her parents to donate her kidney to her ill sister-Kate. Kate has Acute Promyelocytic Leukemia (APL) and has been receiving medical treatment at the expense of Anna’s well-being.
In retrospect, Dr. Chance, an oncologist was the one who initially presented the option of genetically engineering a child which could help treat Kate’s condition. He presented the facts to the parents about the benefits of umbilical blood for leukemia patients. He mentioned that legally he couldn’t recommend it. The parents then consented and made the decision to have a genetically engineered child.
In more recent times, Kate finally reached a breaking point where all she wanted was to enjoy the finer things in life. She had a love interest- Taylor, who she met at her chemotherapy sessions. He made her happy and she felt the joys of being a teenage girl. She also longed to go to the beach and to Montana.
Conversely, her wishes were not initially respected, which resulted in problems which could’ve been avoided. Things got so bad that Anna paid a successful lawyer to sue her parents for medical emancipation. Her brother Jesse was the one who spoke up in court for Kate, saying that she convinced Anna to file for medical emancipation because, she wanted to die.
Furthermore, Anna’s role in Kate’s survival had been a blessing and a curse for her. She felt as if she was Kate’s savior, but simultaneously, Anna was not able to enjoy her life.
Their father Brian- a busy firefighter admits on multiple occasions that what he and his wife are doing is wrong and against Anna’s will. After 14 years of complying, he decided to turn against his wife and do what’s best for his children. He respected Kate’s wish to go to the beach despite being given a divorce ultimatum by his wife -Sara. Later, she is seen respecting Kate’s wishes and joining the family.
Sometimes what’s in the best interest of a patient may not be more medication, hospitalization, surgeries, and family arguments. A more palliative approach can prove to be the best option for some patients, and physicians should honor this decision. Doctors also need to advocate for their patients when injustices are seen; particularly in the case of vulnerable populations- elderly, children and domestic violence victims.
Another concept that I grasped was that of ethical considerations (Quality of life). This point ties in seamlessly with the previous one, because respecting a patient’s autonomy and decision, usually improves their quality of life. Kate wanted to go to Montana, the beach and date a boy. Anna on the other hand wanted to do cheerleading, play sports, and eventually have a family. Undergoing more treatment and a renal transplant, would’ve potentially resulted in a longer life for Kate, but at what cost? Is a longer life full of guilt, regret, and wariness worth it?
When a patient is clear about end-of-life care or their preference of treatment. We as doctors, family members and friends need to learn to be understanding and supportive, given the fact that the patient is competent and well informed. It is a misconception that the degree of satisfaction people experience is determinant on the length of days that they have lived.
Another collective theme is that of parental responsibility, family dynamics and sibling relationships. Jesse said his family is dysfunctional; holidays and disasters are what seem to unite them. Kate said, “I am okay with my disease killing me, but it’s also killing my family”. The approach to Kate’s condition affected every relationship within the family. The wife gave her husband a divorce ultimatum, a daughter was left no choice but to take legal action against her parents, a son’s dyslexia, drinking, and delinquency were all overlooked, and siblings were made to lie and act belligerent toward each other. Contrastingly, following Kate’s death, a switch was seen where Jesse turned his life around and even got a scholarship, the family now takes annual vacations, the mother returned to work, and the father is counseling troubled youth.
Many times, in the medical profession, we see the importance of family and a strong social support system. This factor alone can prove to have beneficial effects on the patient’s health outcome and highly influences their emotional and mental wellbeing.
Genetic engineering is another ethical issue presented in this movie. Anna recalls being told when she was young that she came into the world because her parents loved her. However, she soon realized that this was a lie. Imagine such a hurtful statement coming from the mouth of a child. She further goes on to say that she was ‘engineered’ rather than born.
Dr. Chance suggested that the parents could guarantee that their newborn child would be a match for Kate by pre-implanted genetic procedures.
As a result, her parent’s zygotes were used to make genes that could potentially save her sister’s life.
While this form of technology has numerous advantages, human life is multi-dimensional. I believe that the humane, ethical, and emotional aspect also needs to be accounted for to have an overall favorable outcome. In this case, the treatment could’ve theoretically worked. However, can we limit and control human life to a series of figures and experiments?
Another interesting ethical principle explored, is the rights of terminally ill patients.
The doctor mentioned to Sara to consider hospice care as an option for Kate, but she vehemently denied. Kate expressed on multiple occasions that she didn’t want to continue the treatment and she wanted to enjoy the rest of her life. Unfortunately, her wishes were only respected at the 11th hour.
Terminally ill patients should have the same rights as patients with better prognoses. There are provisions put in the medical system to account for their situation. These include: the ability to express their wishes in an advance directive, appointing a surrogate to make care decisions when the patient is no longer able to do so and do-not-resuscitate orders. Specifically in this film, palliative care was the highlight, because it is medical treatment aimed at alleviating or eliminating the patient’s physical, psychological, and spiritual suffering to improve their remaining life’s quality. There is something dignified and empowering about living your last few days on your terms. Being happy and in the presence of those you love and care about is all some people need. Not every patient wants to die attached to machines and with a defibrillator scorching their skin. I believe that part of being humane is having genuine respect and concern for other people’s life choices.
The penultimate lesson that can be learned from this film, is the rights of a child.
Ever since Anna was a newborn, she had been hospitalized 8 times, received 6 catheterizations, 2 bone marrow transplants, 2 stem cell purges and donated lymphocytes. In addition, she has had many complications including infections, bruising and bleedings.
It begs the question, if parents aren’t doing their job to stand up for the rights of a minor, who should?
Being a newborn or even 6 years old leaves a child unable to understand the context of any given medical situation and provide consent. 11-year-old Anna is seen going to a successful lawyer to sue her parents for the rights to her body. She utilized her little savings to try to pay the fee. That just shows how desperate she was! The lawyer, who is also an epileptic, empathized and took on the case, because he understood how it felt to not have control over one’s own body.
Anna was aware that her rights were being violated, so she signed a document to make the lawyer her power of attorney. Her parents weren’t advocates for her.
Although Kate had already passed away, Anna won the court case for medical emancipation.
Children should have equal protection of their civil rights. All children should have rights to health, education, family life, play and recreation. They should also be free from physical, mental, and emotional abuse.
If a child is victimized, traumatized, displaced, separated from their parents, or otherwise subject to harm, they should receive reparation and rehabilitation. Children have the right to receive help after enduring any type of pain, trauma, or neglect, so they can regain their health, dignity, and identity. All children should have the right to receive legal help and fair treatment.
The final lesson as it relates to ethics that can be taken from this film is that of organ donation.
As mentioned earlier, there came a point in Kate’s health crisis, where her kidneys were failing, and she needed a renal transplant. Neither her parents nor her brother was a match and so the idea of genetically engineering a child for the purpose of donating organs was conceptualized.
Anna’s parents made it very clear that she was the only HLA and organ donor match for Kate. This created the issue of feeling responsible and obligated for the survival of her sister. This is too much of a heavy burden to be placed on the impressionable mind of a child. Autonomy should always shine through, and coercion should be frowned upon regardless of the patient’s age. The absence of harm to the donors should also be a top priority. Anna stated that she didn’t want to live with the complications after the procedure and that should be respected.
As I conclude, my wish to you would be to reinforce the need for a culture of nobility and humanitarianism to be disseminated in the minds of upcoming and practicing medical professionals. I hope that these teachings would pervade our minds and spread across nations faster than SARS-CoV-2. The effects of which would be everlastingly beneficial to all of us directly and indirectly. I anticipate that this tiny piece of literature would awaken and revitalize everyone who comes across it to do better. It is an honor to be practicing the art of medicine, let us not only do it proficiently, but let us intertwine the ethical principles of humanity and strong virtues.
My sister’s keeper is based on the Molly and Adam Nash family. This means that knowing how to handle such sensitive situations ethically and effectively, are of paramount importance for all medical personnel. There are multitudinous lessons which can been learned from this film. I hope we can all put them into practice for the sake of our patients and their families.
Let us work collectively to revamp the art of medicine and keep its virtue and humanistic touch!
*References:
- My Sister's Keeper (2009) by Nick Cassavetes
- Https://childrenfirstcanada.org/blog/12-child-rights-everyone-should-know/
- Https://law.moj.gov.tw/ENG/LawClass/LawAll.aspx?pcode=L0020189
*Character Reference
- Sara Fitzgerald- Mother
- Brian Fitzgerald-Father
- Kate Fitzgerald- Older, sick daughter (leukemia)
- Anna Fitzgerald- Younger, healthy daughter
- Jesse Fitzgerald- Son
- Campbell Alexander (Lawyer)
- Taylor Ambrose- Kate’s - Love interest and fellow cancer patient
- Dr. Harrison Chance- Kate’s oncologist
