The Bargain

I’d heard of him before. He’d been kicked out of many other dialysis units, skipped his treatments, and required frequent emergency care before striking a bargain that kept him coming to dialysis regularly. He’d been addicted to heroin and in and out of jail, although he said he’d been clean for a couple of years now. He was a compact man, heavily muscled. I believed the stories that he’d been a powerful athlete before hypertension and drugs took their toll. I believed he’d so terrified nurses that they called security before approaching him. And I believed that the compromise reached before I assumed his care—large doses of sedatives to treat what he claimed was severe anxiety—was a Faustian bargain that would end with him dead, clutching several prescription bottles bearing my name.

In short, I was afraid of him. I was afraid of making him angry, afraid of what I might do to avoid his anger, angry at him for making me afraid. And I hadn’t even met him yet.

When we did meet, I assumed my most professional demeanor. My job was to treat his kidney disease, and so I addressed bone-mineral problems, blood pressure, and anemia, made appointments for dialysis, and reviewed his laboratory studies monthly. And despite my qualms, every two weeks I refilled the cocktail of anxiolytic medications that kept him “under control.” The clinic directors had been willing to do this instead, but somehow passing this duty off to someone else felt even worse than doing it myself.

Despite my ongoing anxiety, his did seem to be under control. His missed treatments were infrequent, usually accompanied by colorful excuses. My initial fear waned as the months wore on. We joked during rounds, commiserated about the weather, talked about his family and his daily routine. But I sometimes found myself leaving the building at the same time that his dialysis treatment ended, and outside of the confines of the unit, I would return his easy greeting with an involuntary prickle of fear. If he ever chose to vent his anger, I was an easy target. I knew that part of my acquiescence in writing those prescriptions was driven by self-preservation, not medical science.

When I present this case to medical students, they unanimously decry the physician. They say that control by prescribing power has no place in a doctor-patient relationship. Even if receiving medication prompts the patient to come to dialysis and to behave, the means, they say, are unjustified. The physician should find another way: involve a psychiatrist, refuse to treat, taper the dose, talk to the patient and understand his problems. In their eyes, the bargain is morally untenable.

When I present this case to residents only two or three years further in their training, they nod with rueful recognition. They have already taken care of patients they fear or dislike. They have written prescriptions for pain medications or sedatives in similarly doubtful situations. The physician, they say, has only bad choices: write the prescriptions and risk becoming party to an overdose or a drug deal; don’t write the prescriptions and endanger nurses, staff, and other patients until someone else writes them. In their eyes, the bargain is courageous: an imperfect solution in an imperfect world.

Then I tell them the rest of the story. I was walking from work to the subway when I saw someone staggering toward me. It was as if a bubble surrounded him—everyone gave him a wide berth, assuming he was drunk, homeless, dangerous. I, too, started to quickly cross the street, until I recognized my patient. All my fears came to the fore. He wasn’t coherent, his forehead was burning, and he could barely stand. I asked a passing transit officer to call an ambulance, and then I waited. And waited. And waited, for nearly thirty minutes more. He was sweating profusely. Was it drugs? A heart attack? A catheter infection?

We made an odd pair. I was a petite young woman with a ponytail, casually but neatly dressed; he was a disheveled man twice my age and...