Author’s Note: This is a fictionalized account.
Additionally, they were mental gymnastics that go on with writing this sort of writing. A real issue with being a writer and a psychiatrist at the same time is that, for the most part, writing about our patients is not some thing we can do. There are very strong ethical prohibitions around breaches of privacy.
There are equally strong ethical provisions around doing things that might make others think privacy was breached. One of the things about ethical considerations is that they're always in conflict. There are four ethical principles. I didn't intend for this to be an essay on ethics. But I couldn't finish it without doing this part.
The four ethical principles are as follows:
Autonomy: this is a principal that regards respect for the individual and their own choice as Paramount.
Beneficence: this is a principal that privileges doing the right thing for someone else, the thing that is in their best interest, as Paramount.
Non-maleficence: this is a principal that privileges not doing a bad thing as Paramount not causing harm is the height of Mount non-maleficence.
Justice: this is an ethical principle that privileges the best things for the most people, even if it's not necessarily the right thing for an individual person.
As you can imagine, autonomy for someone who wishes to commit murder is a thing that
— is not beneficent for the person who will be murdered
—would respect the autonomy of the murderer
—would put the non-maleficence of the provider who did not report the intended murder in question.
Furthermore, Justice is not served in the above case. The principles are in conflict. Always.
The paradox, for myself as a physician-writer, is the balance that I need to strike. I'm trying to write in the service of Justice. I'm trying to create good in the world.
So when I write about issues related to patient care, I have to think about the benefit to the world, “Justice.”
My duty to my patient about whom I could be writing, and acting in a way that would not harm them, this is considered to be a much higher value than any good to others I could create by writing about them specifically. It's better to protect an individual than it is to create tremendous benefit for any, if the oath took is not cause harm to that person.
And this is true, but it's also true to a point. One of the issues is that even if I were to write about someone totally fictional, everyone would assume, if I framed it in the context of someone who had been a patient, that I was writing about my patients.
This risks everybody worrying that their privacy would be put in Jeopardy if they came to see me, or anybody else. And this is a risk I'm looking to avoid.
However, if nobody believes that therapists or doctors are helpful people, if nobody believes we are relatable, it leads to less people getting help. Not writing causing harm. This is important. This is crucial. It is the ethical thing to do, because we privileged not harming our patients. We have to stop lying—to ourselves—about the fact that never risking any harm is the same thing as always doing good.
It's not. The good of never doing harm and the good of always doing the best thing are often diametrically opposed to each other. The most good for one could be the worst harm to many. Doing some thing ethical doesn't mean doing it right. It means walking a tight rope. And it means falling. And it means thinking about why you're doing the thing. It means doing things for reasons that are considered, and accepting that you will get it wrong, and you will be held accountable.
I could write entirely fictional story. And I'm a doctor. And you would believe it was about a patient even if I told you it was a lie. People will be harmed by that. And others would be protected.
This, by the way, is why I write about myself. I have much more latitude in my ability to “out” myself, make fun of myself, get made fun of, and expose the things I'm thinking and feeling about myself and my own care. My duty to myself is satisfied by checking in with myself. The consent I would obtain for patients for any writing, which by the way is what I do, generally, is how I handle it otherwise.
It is fraught. I think medicine, as a field, needs to build trust. And I think we need to let people know that hope exists. And sometimes that means stories. And sometimes it means never telling a story. We hold our patients’ secrets close to our chest.
There are so many things I will never say. And I should not. And nobody should. Because they were shared in confidence. So I'm going to tell the following story, and I'm going to end it.
Abruptly.
Pizza, Interrupted.
Recently I was in a lunch joint in SoHo with two of my tech coworkers when a man walked in and shouted at the top of his voice:
“I NEED 20 DOLLARS! I’M SUICIDAL! SOMEONE GIVE ME SOME MONEY NOW!”
No one responded. Some pretended to ignore him. The guy behind the counter looked really uncomfortable. You could hear chairs shift. Shift. Shuffle. Squeak.
“I AM NOT KIDDING!” the man shouted out again.
In fairness, I don’t believe anyone thought the gentleman who had entered, whose body odor I could smell from where I was sitting, was kidding. It wasn’t funny, that was for sure. Nothing about it was funny. He had a wild look in his eyes.
“SOMEBODY HELP ME! IS ANYONE GOING TO HELP ME?”
He didn’t know it at the time, but he was asking a really good question. The answer should be yes. But so often, it’s not. Everyone wants to be a superhero, but mostly to petite victims or cute animals. It’s harder to be a traditional superhero with a stranger who smells and could possibly harm you.
I stood up and turned to him. “Hey, come with me, I got you. But let’s talk outside?”
Now, no one inside the pizza restaurant could hear what we were talking about. They could only watch through the glass the following scene unfold: An unkempt man, who’s about my height, a little bit thinner, losing his hair, with a scraggly beard, now visibly relaxes. He points at me, and a huge smile breaks out across his face. I smile back. He’s Hispanic. I’m white. I am wearing a button-down shirt, jeans, and Converse sneakers.
Watching from inside the restaurant, you could see the man transition from what was rage or fear or hurt or something into what looked like a whole different guy. He was gesturing broadly and looked more animated. The next thing you know, he and I are hugging. And not in the kind of BS way you’d hug a “homeless person–”gingerly, so as to not get their homelessness all over you. It’s a real, serious hug. A hug like when two people are reunited after they haven’t seen each other since senior year. He pushed back off of me, still holding onto my arm, me holding onto his on the other side.
He took a step back. He put his hands together like he was praying. He slapped me on the shoulder. Our mouths did some more moving, and as he walked away from me, I tapped him on the shoulder. He walked away from the restaurant silently, with a spring in his step.
“That was incredible. What happened?” my colleague Lewis asked me wide-eyed. We’d been working together for about six months, but he’d never seen me interact with someone in crisis.
“I admitted that I had no idea what was going on with him.” That was the most important first step in earning his trust.
Most of us spend our lives trying to pretend we know what’s going on. This is a mistake—not the pretend part, but the idea that the goal in life is to know.
Most of us don’t know. How could we? That sense of obligation is a heavy burden, which is why we don’t get up to confront the stranger in the pizza shop. We are all exhausted, Atlases, shrugging. We feel we don’t have the answers to his problem. But the truth is no one has the answers. We’re all winging it—and in our most important moments, no less.