Monday, August 2, 2010

"The Kids are All Right" and Doctor-Patient Sex

A few days ago my wife and I saw the new film "The Kids are All Right" at the charming little (100 or so seats) Savoy Theater in Montpelier, Vermont. It's an engaging, funny-but-serious family comedy, centered on Nic (Annette Bening) and Jules (Julianne Moore), a middle-aged lesbian couple, their children - 18-year Joni (Mia Wasikowska) and 15 year-old Laser (Josh Hutcherson) - and Paul (Mark Ruffalo), their sperm-donor father. The kids set the plot in motion by making secret contact with Paul. The rest is a form of chaos, misunderstanding, conflict and reconciliation most folks who've been in a long term relationship will recognize.

I'm not going to review the film, but I promise that you'll enjoy it. (If you want more than my word, here are links to reviews in the New York Times and the New Yorker.)

What struck me as relevant to medical ethics was a moment when the five characters are having dinner. Paul asks Nic and Jules how they met. We already know that Nic, the bread winner, is a hard-working, rigid, wine-loving OB/GYN, while Jules is the slightly flaky and lost homemaker. It turns out that they met in the UCLA emergency room. Nic was a resident doing an ER rotation. Jules was a sexy young student scared because her tongue was numb. (We're left to imagine what she'd been doing with her tongue.) Nic cures her with a Valium and some teasing. The rest is history. Joni and Laser groan - they've heard the story so many times.

(FYI, in the 1960s I did a year of medical internship at UCLA. I remember a UCLA student a bit like Jules who came to the ER in her pink undies with chest pain that I was wise enough to recognize as a panic attack.)

So is anything wrong here? Nic and Jules are an attractive, responsible couple, bringing up attractive, responsible kids. They're screwed up, but only in the way most people are. One would be happy to have them as friends.

The prevailing fashion in medical ethics is to dwell on "unequal power relationships," "transference," "idealization of the doctor," "rescue fantasies," and the likelihood of doing harm to the patient, as the rationale for precluding moving from the exam room to the bedroom.

But there's no reason to doubt that a romantic relationship that started in a doctor-patient context could work out just as well (or badly) as relationships that start in all the other "normal" ways relationships get going. Love entails risks, but that's not unique to romance between doctors and patients. I learned that from seeing "South Pacific" as a kid when I heard Emile (Ezio Pinza) sing "Some Enchanted Evening" after meeting Nellie (Mary Martin). There would have been no more reason to warn Nic and Jules about getting involved after they met in the ER than if they'd met at a GLBT mixer or had been fixed up on a blind date.

Here's what might have transpired if Nic had consulted me after she'd met Jules in the UCLA ER:
Nic: Jim, I want to ask your advice. Last night in the ER I met a girl who seemed exactly right for me. Her name is Jules. She's smart, pretty, sexy, and we really hit it off. I really want to date her. It may sound crazy, but I can picture spending my life with her and having kids with her..."

Jim: Nic - you've told me that you feel ready to settle down when you meet the right person. If we had a crystal ball it might tell us that you and Jules were made for each other and would live happily ever after. Of course it might say something different, but that's always the case. I feel sad saying this, but I don't think you should contact her. There are two big reasons. First, Jules came to the ER because she was scared about her tongue and trusted us to look after her. Patients tell us secrets they haven't told anyone else, and let is touch them in ways we'd never let strangers touch us. You did a great job relieving Jules's symptoms and helping her understand what was going on. To carry out our responsibilities and do things like you did, we physicians need to be trusted. If patients don't trust us to respect boundaries and stay in our professional role they won't open up the way Jules did with you and we won't be able to help them the way you did for Jules. Second, part of our vocation is to put patients first. A relationship with Jules might work out well, but it might not. If you'd met her in a bar or at a party I'd congratulate you and say "good luck - go for it!" But you met her as a doctor, so primum non nocere applies. You wouldn't prescribe a medicine for Jules that might break her heart, so you shouldn't "prescribe" a relationship that could do that!
My guess is that Lisa Cholodenko, the director and co-author of "The Kids are All Right," put in the ER detail to show that Nic is a romantic at heart, not just a rigid, up-tight scold. If I can find Cholodenko's email address I'll send her the post and ask her.

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