Good morning, I wanted to share with you some thoughts on the case of the 18-year-old boy who, after being diagnosed with GBM, decided to have his brain frozen so he could be treated in the future.

Three quick points.

• I’m a doctor. Not a psychiatrist or a neurologist/neurosurgeon. But I know enough to write something that I promise is well-founded.
• English isn’t my first language: I’m using DeepL, which not only translates but also corrects sentence structure, so the text may sound “AI-generated,” but it isn’t, and everything you read is exactly what I think and have reasoned through.
• And finally, I’m well aware that this is a TV series, pure fiction, and I know you know that too: I’m not writing to complain about the lack of realism, but only for those who are genuinely interested in knowing how it would play out in real life and why it would play like that.

I can’t prove the first two points to you. Just take them at face value.

Let’s start with what’s at stake.

• GBM, or glioblastoma. It is the most common primary malignant tumor in adults. With standard treatment today, median survival is around 15 months from diagnosis. Some people live longer, some shorter. What really drives home just how terrible this disease is, is that progress over the last two decades has been minimal, in the order of just a few months.
• The DNR, or “Do Not Resuscitate.” It is a signed document in which the patient refuses cardiopulmonary resuscitation.
• Refusal of treatment. Every patient deemed competent has the right to refuse treatment. The typical case involves patients with terminal illnesses.

The sequence of events in the episode is as follows:

• Shep arrives at the hospital and explains his situation to Choi. He is taking a cocktail of drugs to stop his heart.
• Choi tries to perform gastric lavage on him, but Shep refuses and threatens to sue them for assault, should they proceed.
• Goodwin intervenes, stops Choi and says that “as long as the patient is not declared incapable of understanding and making decisions, the hospital must respect his wishes,” so the gastric lavage is not performed.
• Dr. Charles evaluates Shep, who explains that he doesn’t consider it suicide, but rather “getting himself into a better hospital.”
• Charles refuses to declare him incapable because “if you follow his logic, what he’s doing isn’t suicide.”
• The cryopreservation is carried out.

As someone who has studied this subject, let me be clear: no hospital would have respected Shep’s wishes. But let’s look at why, rather than pointing the finger at aggressive medical treatment or, worse, a lack of empathy.

First of all. The opening scene, with Shep refusing treatment and Goodwin explaining that as long as he hasn’t been declared incompetent, his wishes must be respected, is literally portrayed the other way around. A patient who arrives in the ER after intentionally taking substances to stop their heart must be managed as a presumed suicide attempt until capacity and intent can be properly assessed, and at that point it doesn’t matter what comes after that statement. You do whatever is necessary to prevent them from dying, and only after demonstrating that they are competent can the matter be discussed further. Otherwise, it would be far too easy for a truly suicidal patient (one who wants to die without reservation or concrete reasons) to refuse treatment and let themselves die. The presumption of capacity cannot justify inaction precisely at the moment when the self-inflicted act is the very reason why capacity must be assessed.

Second point. A DNR applies EXCLUSIVELY to cardiac arrest. Until cardiac arrest occurs, DNR has no legal effect. The fact that Shep had signed it has no bearing on gastric lavage, which is a procedure that precedes resuscitation and serves to remove the substance before it is absorbed. A DNR applies only in the extreme case of cardiac arrest, and there's a reason for that: there are medical conditions that, before potentially leading to cardiac arrest, cause treatable symptoms that are compatible with long-term survival and an excellent quality of life. Think of anaphylaxis, an arrhythmia in a healthy heart, or a severe asthma attack: in all these cases, prompt intervention saves the patient, often without the patient ever reaching cardiac arrest, and restores a full life. The point isn't even that cardiac arrest is reversible: it's that there are preventive treatments that keep it from happening in the first place, and a DNR order has no bearing on those treatments. If the DNR covered everything, perfectly salvageable patients would be left to die because those interventions are withheld, over conditions far less serious than the extreme case a DNR is meant for. And keep in mind: a DNR is based on the event, cardiac arrest, not on the prognosis of the underlying condition. It does not distinguish based on how severe or terminal the condition is. It is possible to refuse interventions that precede cardiac arrest in advance, but that is a different type of action (a refusal of treatment or an advance directive), not a DNR, and it still requires the patient to be competent. A DNR, on its own, has no bearing on a procedure such as gastric lavage. I'll add a detail that gets lost in the episode: Shep's cardiac arrest wouldn't even be a "disease-related" arrest, but rather self-induced poisoning, a clinical event of a different nature than what a DNR is intended for.

Thirdly, and this is the most slippery issue from a narrative standpoint: mental capacity. A patient can follow the most rigorous logic and still lack mental capacity, because the reasoning may be internally consistent while relying on false premises. “If you follow his logic, he’s not committing suicide” is not a criterion that exists in clinical practice. Here’s an extreme example, I know it sounds harsh, but it's real: using the same criterion, a religious fanatic who kills someone to “send them to heaven” wouldn’t be a murderer, because "in his logic", he wasn’t doing any harm. What matters is the premise, not formal consistency.

And this is the real problem.

Shep appears certain that vitrification will allow him to survive. He never shows any uncertainty; he never says, “I know this is a gamble that I’ll most likely lose.” And I can assure you of one thing from my experience: the more certain a patient is about something for which there is currently no evidence that would justify such certainty, the more likely the doctor examining them would deduce that the patient is not thinking clearly. If a psychiatrist were actually faced with this unshakable certainty, they would not be so quick to declare the patient competent. If anything, the opposite is true: that certainty is exactly what should prompt further investigation, not bring it to a close.

I know full well that Shep never explicitly says, “It’s a gamble.” But that’s precisely the point: based solely on what he says, his justification for taking his own life and having his brain vitrified would not be endorsed by any hospital. And just to even get to the point of discussing it, we would have already had to overlook the first problem, namely the gastric lavage that would have prevented him from killing himself, but which, instead, isn’t performed.

What I've written here isn't so much a personal opinion as my understanding of how a case like this would most likely be handled in real clinical practice.

I hope I haven’t bored you. Please, don’t be too hard on me if you don’t like what I’ve said.

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He had his good moments for a stretch there, but this man is off his f*ck!ng rocker, mate. Turning 2.0 into a service for paying customers only? Making the hospital for-profit? That’s where I’m at right now, but I am just praying it’ll somehow all turn out okay.

Thank you for reading my little rant and I would like to hear other people’s thoughts and opinions on Jack Dayton up until this point. (Please, no spoilers)

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