Film's Medical Director Discusses 'John Q'

March 7, 2002 -- A true story. The call came in after midnight. The urgency in the voice of the referring cardiac surgeon catapulted me out of bed towards my notepad.

"I operated on a 51 year-old male in the midst of his MI (heart attack). He is not going to make it without one of your heart assist devices. Can you take him?"

Within six hours he was in my hospital. By 9 a.m. he was in our operating room. Only the obligatory call to the insurance company separated me from the inside of his chest. Their representative's response was confounding.

"Well, we have an interesting situation." In medicine, one strives to avoid being interesting.

"Mr. B is fully employed but just moved from Maryland to New Jersey. Although the policy in Maryland covered transplantation, a clause in the New Jersey version appears to prohibit this."

"Since putting a mechanical heart into the patient will allow him to survive to receive a heart transplant, you cannot proceed."

What were my options? The patient did not know the policy was revised, and even if he did, should he have received the death penalty.

To muddy the waters further, my hospital was in New York City, so was I obliged to follow New Jersey rules?

In fact, if I removed him from the operating room, would I have violated my Hippocratic oath to do no harm? Could I ethically have done this? What about the malpractice liability of letting a salvageable patient die?

The hospital administrators supported surgery, but they cautioned that these operations cost $200,000 and if the program went bankrupt and closed, hundreds of future patients would not have the chance to be saved. Should I save one, but risk the future of many? What would you do?

Transplanting Medicine to the Big Screen

John Q, played by Denzel Washington, faces a similar conundrum to that of Mr. B when seeking a heart for his dying son and in desperation takes the ER hostage.

When the movie's producer Mark Burg brought me the script to review, he had already been warned that many Americans were so angered by our nation's inability to address the financial challenges in health care that the film might catalyze violence.

Thankfully, this has not occurred, although the movie has been No. 1 in the box office with revenues of more than $50 million already.

Burg and director Nick Cassavetes were also concerned that the story was not realistic and they wanted a surgeon in the trenches to bring the story alive. So I immersed them and much of the movie's leadership in our New York City operating rooms at Columbia Presbyterian.

They nervously watched a newly transplanted heart lie dormant, immersed in a pool of blood within a recipient's open chest, and wiggle back to life after being flicked with a surgeon's index finger.

The endless rapid-fire banter of the OR echoed within the cavernous, sterile operating theatres as the tension surrounding the fate of yet another new heart ebbed away.

We recreated these images almost identically in the movie's rendition of the transplant, including use of a silicone heart with crimson syrup to match the consistency of blood. They witnessed the penetrating frustration of families waiting for the organ that never gets donated.

This reinforced a core motivation for John Q and impacted the film's dialogue. And they observed that no evil empire controls who gets hearts and that good people can make and justify bad decisions if they work within an inherently unfair system.

This may have been the most important epiphany for the group and resulted in the creation of multi-dimensional antagonists who reflect the difficult financial decisions health care providers make in this country daily.

Donor Organ Shortage

The major limiting factor for all organ transplants is the lack of donors, rather than money. This reality was highlighted in a tag line to the audience in the original film version, although later removed by New Line cinema executives, who feared that the movie was becoming too political.

Ten percent of the 75,000 people in this country awaiting organ transplantation will die because we cannot find enough organs. This shortage has persisted since the dawn of transplantation and has stimulated aggressive research programs that have created mechanical alternatives to organs.

In fact, heart assist devices have been shown in randomized trials published in our most prestigious journals to be effective in doubling the survival rate of people dying from heart failure.

This month, the FDA will review this data and determine if Americans should have access to this successful innovation.

In our nation's history, despite significant expenses, we have always been willing to support the use of life saving technology for all our citizens.

But who will pay for an advance of this magnitude that offers us the opportunity to save 30,000 lives at a cost of $5 billion? Ultimately you and I, so the decision on whether our country pays for effective new technology must be made in a transparent fashion.

John Q raises this fundamental issue and graphically demonstrates the undesirable consequences of preventing fair access to care.

This is especially relevant to my specialty since patients presenting without insurance who are candidates for life saving procedures will often die if we do not proceed.

In effect, Americans abdicate their responsibility by transferring the burden of this challenge to health care providers without guidance or support.

Although our constitution does not guarantee health, every American deserves the right to have an equal chance at being healthy.

By the way, Mr. B mentioned at the beginning of this article eventually did receive his heart and has since started a very successful organ donation advocacy group.

Dr. Mehmet Oz is Director of the Cardiovascular Institute at Columbia Presbyterian Medical Center in New York.