cloth shirt. I extended my hand. âHi, Iâm Dr. Jauhar,â I said. âIâm the cardiologist on call for the weekend.â
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.
âYouâve had a heart attack,â I started off.
âSo you say,â he shot back.
âWell, this is something I can say with confidence,â I replied, trying to project authority. âIâm told youâre 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 youâve had a heart attack. After all, I know how to identify heart attacks. Itâs what I do.â
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: âFine. So you think I had a heart attack.â Clearly, he still did not believe me.
âThe best treatment for a heart attack is angioplasty,â I said.
âI donât want it,â he said, his voice rising. âI told them I donât want a stent.â
âNo one can force you to have it,â I said calmly. Angioplasty, in which tiny balloons and stents are used to relieve coronary blockages, wouldnât work without his cooperation, and I wasnât about to call in security guards to frog-march him to the catheterization lab. âBut I think you should reconsider.â
He glared at me and said he did not want to discuss the matter further.
âOkay,â I said. âWeâll watch you for another twenty-four hours. If your condition remains stable, weâll send you home.â
âNo, Iâm leaving now.â He moved to gather his things.
I watched him for a few moments. âYou canât leave,â I finally said.
âWho says?â
I wasnât sure how to respond. âThe psychiatrist,â I said tentatively.
âWhich psychiatrist?â he snarled. âThe little faggot with the ponytail? The little frilly guy?â
I immediately walked out to the nursesâ station and phoned Mr. Perkinsâs son. He explained that his father had always been âstrong-willedâ and âdone things just the way he wanted.â The behavior I was describing wasnât 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 Perkinsâs mind operated differently from mine, and not because he was sick. Shouldnât 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 Iâd 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. âMs. Northern does not understand the severity or consequences of her disease process,â they wrote to the Department of Human Services in Nashville. â[She] does not appear to understand that failure to amputate the feet at this time would probably result in her death.â
A psychiatrist concurred, stating that Ms. Northern was generally sane but
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