Hard Cases 72 Comments
When Healers Get Too Friendly
By ABIGAIL ZUGER, M.D.
Alex NabaumHard Cases
Dr. Abigail Zuger on the everyday ethical issues doctors face.
The activist became my patient back in the mid-1990s, when H.I.V. was slowly morphing into a treatable disease. He was young then, with a mop of dark curls — excitable, suspicious and frantic about his health. He was convinced the new drugs were pure synthetic poison, a profiteering scam by the government and Big Pharma. He was also feeling sick enough that he thought he might just give them a try
He lurched back and forth between these two incompatible positions once or twice a month, dragging me and my prescription pad behind him in a flurry of abandoned amber plastic bottles. Eventually, though, good sense kicked in and he had to admit that on meds he felt a lot better than otherwise. He managed to retain his contempt for the system while regularly filling his prescriptions. I no longer winced at his name on my schedule.
And now it is suddenly decades later, his H.I.V. has long been perfectly controlled, and he is still fomenting revolution. He used to march and holler; now he works social media with a miserable old desktop computer that keeps breaking down.
As it happens, about a week before one of our infrequent appointments — he barely needs me any more — I had treated myself to a brand new laptop, sending an old perfectly good model into the back of the closet.
Of course I wiped its hard drive clean and gave it to him — for he is my old friend. But (also of course) we met furtively in a back corridor and I carefully concealed the contraband in a nest of old grocery bags — for he is my patient, and gifts to patients …well, we don’t usually do that.
Once again, apparently, we were dealing with two incompatible positions. Everyone knows that professional boundaries guide all medical activity in hospital, office and clinic. But aside from indisputable sexual and financial depredations, no one agrees exactly where these boundaries lie.
Kindness to friend and duty to patient: Are they one and the same? Or separated by a barbed-wire fence? Opinion is all over the map.
At one extreme is the position probably best articulated by one of medicine’s great clinician-scientists, Dr. Donald Seldin of the University of Texas. In a 1981 talk to an audience of physicians, Dr. Seldin deplored “a tendency to construe all sorts of human problems as medical problems” and thus within doctors’ duty and purview to fix. If it isn’t “relief of pain, prevention of disability and postponement of death,” Dr. Seldin said, why then, doctor, leave it alone! He got a standing ovation.
In the opposite corner stands Dr. Gordon Schiff of Harvard’s Brigham and Women’s Hospital, who was issued an official reprimand a few years ago for egregious boundary crossing.
The incident that it set it off: Dr. Schiff (now 63, an experienced senior clinician) had tangled with an insurer on the phone for two hours before he gave up and handed an impoverished patient $30 to pay for her pain pills. A resident observed the transaction and turned him in. But Dr. Schiff is a proud repeat offender, whose past infractions include helping patients get jobs, giving them jobs himself, offering them rides home, extending the occasional dinner invitation and, yes, once handing over a computer.
He was told physicians should stay away from “random acts of kindness” — an activity that may sound harmless but is quite distinct from the practice of medicine, and has its risks. Patients might get too familiar, expect too much.
Dr. Schiff published a long rumination about the incident a few months ago (which, he reported in an interview, has elicited the email equivalent of a standing ovation). In it he considers whom, exactly, the sanctions against befriending patients are designed to protect. The patient in some instances, he concludes, but the doctor in far more. “Let’s not pretend we are imposing limits for patients rather than our own best interests.”
Dr. Schiff draws medicine’s borders around a shared social agenda: doctors help the patient’s health by helping the whole patient. Dr. Seldin’s borders contain specific, technical tasks.
If you think too superficially about all of this, you may begin to hear Dr. Seldin screeching like Ebenezer Scrooge: Are there no charities? Are there no social workers?
But it’s not quite that simple. I too handed out the odd $20 bill at work without thinking much about it, until I didn’t see one patient for almost a full year afterward — and she was a sick person who really needed care. What had happened? “I couldn’t come back without your money,” she said.
So that was a random act of blindness on my part, good evidence of the perils of the terrain and the need to think before each step. I think — I hope — the activist and I understand each other a little better than that.
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