Doctored by Sandeep Jauhar

cloth shirt. I extended my hand. “Hi, I’m Dr. Jauhar,” I said. “I’m the cardiologist on call for the weekend.”
    He eyed me suspiciously but reluctantly shook my hand. I asked him to sit down, but he remained standing, arms folded, with a fixed and fervent look.
    â€œYou’ve had a heart attack,” I started off.
    â€œSo you say,” he shot back.
    â€œWell, this is something I can say with confidence,” I replied, trying to project authority. “I’m told you’re a building expert. I know next to nothing about buildings, so anything you tell me I am likely to believe. Similarly, I think you should trust me if I tell you that you’ve had a heart attack. After all, I know how to identify heart attacks. It’s what I do.”
    I asked someone to pass me a printout of his test results. After I showed him the abnormal cardiac enzyme levels, he sneered and said: “Fine. So you think I had a heart attack.” Clearly, he still did not believe me.
    â€œThe best treatment for a heart attack is angioplasty,” I said.
    â€œI don’t want it,” he said, his voice rising. “I told them I don’t want a stent.”
    â€œNo one can force you to have it,” I said calmly. Angioplasty, in which tiny balloons and stents are used to relieve coronary blockages, wouldn’t work without his cooperation, and I wasn’t about to call in security guards to frog-march him to the catheterization lab. “But I think you should reconsider.”
    He glared at me and said he did not want to discuss the matter further.
    â€œOkay,” I said. “We’ll watch you for another twenty-four hours. If your condition remains stable, we’ll send you home.”
    â€œNo, I’m leaving now.” He moved to gather his things.
    I watched him for a few moments. “You can’t leave,” I finally said.
    â€œWho says?”
    I wasn’t sure how to respond. “The psychiatrist,” I said tentatively.
    â€œWhich psychiatrist?” he snarled. “The little faggot with the ponytail? The little frilly guy?”
    I immediately walked out to the nurses’ station and phoned Mr. Perkins’s son. He explained that his father had always been “strong-willed” and “done things just the way he wanted.” The behavior I was describing wasn’t so different from his norm.
    Now I felt even more conflicted. On the one hand, my patient clearly did not meet the standards for decision-making capacity. He did not understand his medical condition or its treatment options and the risks and benefits. If I let him sign out against medical advice and something happened to him (sudden death, another myocardial infarction), I would be liable. On the other hand, his intransigence was apparently just a part of who he was. As a doctor, I want to see my patients weigh risks and benefits in a careful, reasoned manner, use logic, have a clear sense of self, etc. In other words, I want them to think like me. But Perkins’s mind operated differently from mine, and not because he was sick. Shouldn’t I just allow him to be himself rather than insist on what I wanted him to be?
    The situation resembled a famous medical ethics case I’d read about. In 1978, Mary Northern, a seventy-two-year-old woman in Tennessee, developed gangrene in both feet, requiring amputation. When she refused to have the surgery, doctors at Nashville General Hospital determined that she did not have decision-making capacity and filed a lawsuit for permission to amputate her legs. “Ms. Northern does not understand the severity or consequences of her disease process,” they wrote to the Department of Human Services in Nashville. “[She] does not appear to understand that failure to amputate the feet at this time would probably result in her death.”
    A psychiatrist concurred, stating that Ms. Northern was generally sane but