COLUMN: Wheel of Misfortune

From Bertie Bregman's "On Call," Fall '94 From Bertie Bregman's "On Call," Fall '94Two recent encounters are linked in my mind by the familiar human compulsion to make indefensible choices and take wild risks. A sign above the patient's bed alerted us that she was blind, but it soon became clear that she was no more demented than you or I (probably less). She knew who and where she was, and argued a passionate case for returning home. She had lived with her sister in West Philadelphia for over fifty years, and the thought of spending months or years in a nursing home, in a foreign environment around strange people, seemed to her like a death sentence. Those of us present were deeply moved by her tearful pleas. Unfortunately, her doctors felt that sending her home was the real death sentence. A social worker had visited the house and reported that it was an absolute wreck -- with garbage strewn everywhere -- unlivable by almost anyone's standards. The woman couldn't walk, and her sister (who apparently really was demented) had a broken wrist and couldn't help. A real doubt existed as to whether she would be able to feed herself, or even get out of bed. Her ulcer had originally developed from lying motionless in bed, and would only get worse. The chance of it developing into a life-threatening infection from contamination with feces was practically one hundred percent. For the patient's doctors, it seemed as though the only responsible medical decision was to commit her to a nursing home where she would receive adequate medical care. But the patient -- sound of mind if not of body -- insisted on going home whatever the risks or the consequences. My second encounter was with a female character in the French film Savage Nights. The film tells the story of a live-fast-die-young bisexual HIV+ man with two lovers -- a buff young neo-fascist rugby player and an innocent, bored, middle-class 17 year-old girl. The heroine is a classic French type, a passionate pouty nymph with a head full of romantic fantasies. She falls hopelessly and psychotically in love with the hero, he rejects her, she fills his answering machine with crazed, jealous, threatening messages and soon winds up in a mental hospital. So it goes. Earlier on, however, is the scene that made the movie slightly famous. After having unprotected sex with her a few times, our hero finally reveals his HIV status to our heroine (I especially love his excuse: "I never thought you could get it -- I always feel so pure when I'm with you"). Our heroine rants and raves and slaps him around a bit, and of course they end up in bed. Just before consummating the act, he starts to put on a condom. She hesitates, then takes it out of his hand and puts it back on the dresser. Gasps rise from the audience. Of course, they have wild, uninhibited sex with multiple Gallic orgasms, their reckless disregard for safety and convention serving as a powerful aphrodisiac. The filmmaker (who also plays the male lead) based the screenplay on his memoir, so presumably the plot has some basis in real life. Even if it didn't, however, the scene makes a certain crazy sense. All dramatic romantic gestures have an element of the irrational in them. In an age when the deadly threat of a sexually-borne virus threatens to turn our lovers into our executioners, what more delirious expression of unconditional devotion exists than to embrace that fate? In each of these encounters, the budding doctor within me looked at the woman with a cool eye and rejected her case. To send an elderly woman home to certain sickness and infection? Can't justify it. To even consider the idea of unprotected sex with an HIV+ partner? Laughable! But in each encounter a part of me also looked at the woman and recognized myself. I thought of times in the past when I had taken risks for no reason other than to make a dramatic gesture, or because I wanted something so badly that I didn't care about the consequences, however horrible they promised to be. Didn't I consider taking those risks to be my privilege as a human being? Wouldn't I have viewed anyone who stood in my way as my enemy, a meddling jerk with no right to forcibly impose their detestable rationality on me? Am I deluded in thinking that I am better off today for my experiences? One could make the argument that had those risks backfired (and they were mostly physical, typical of the average testosterone-poisoned young male) -- had I ended up paralyzed or otherwise maimed -- I would have felt differently. Certainly this is true. If we were to meet the heroine of Savage Nights ten years down the road, bedridden and covered with Kaposi's sarcoma lesions, she would surely bemoan her youthful, impulsive gesture. And if the elderly woman does in fact go home and contract a massive infection, it's possible that she too will end up regretting her decision. But the mere fact of a disastrous outcome doesn't necessarily delegitimize the grand, stupid, poetic, or desperate gesture. Some gestures are legitimized by the circumstances that compel them, whatever the outcome. Those who accuse doctors of being cold technicians may be thinking of the clinical calculus, so common in medicine, that leaves no room for human impulses and desires that run counter to physical health and attenuated life. I know that as a doctor my professional responsibility will be to try and prolong the health and life of my patients; I only hope I remember my responsibility as a human being to understand when my patients stubbornly, even if stupidly, choose another path. Bertie Bregman is a second-year medical student from New York City. On Call appears alternate Wednesdays.