Jim
Jim wasn’t the typical “Chelsea Boy” — a somewhat disparaging moniker given to gay, muscle-bound, intellectually-challenged men living in the west-side Manhattan neighborhood of Chelsea. He was sure trying, however. He had lost fifty pounds over the last two years, accomplished at the expense of sagging skin trying in vain to conform to his abdomen. But he otherwise had the requisite Chelsea Boy attitude, haircut, and wardrobe. And the drug habit.

Jim used crystal meth, mostly at his weekend Fire Island timeshare. I had seen him many times to discuss quitting. But he couldn’t do it. The sex was too good. Once, while I was examining a sore on his large penis, he somehow felt inadequate and explained that, when erect, it swelled to even larger proportions. And, because of that, he was popular with the boys. The sore turned out to be a friction burn — a product of crystal-fueled sex sessions that went on for hours. Even penis skin has its limits.

Jim was in the clinic for another HIV test. He tried to always use a condom, but sometimes the hits of “Tina” made him feel invincible and convinced him otherwise. There was a possibility that he had HIV.

He had another big party coming up over the weekend. His main concern for the visit was his erections. Although strategic doses of crystal, as a stimulant, could keep him awake and horny for three days straight, it oftentimes led to erectile dysfunction. He requested a prescription for Viagra to synch his dick to the crystal high.

I felt anxious about giving him the Viagra. If he were HIV positive, he could spread the virus all weekend long. But if he were negative, the Viagra might be the unfortunate catalyst to catching HIV. Would I be enabling his behavior? After a discussion about my concerns, I gave him the prescription.

Mary
I am on call every other week. If patients have a medical need outside of office hours, they can reach me on my pager.

Mary’s mother, Alice, paged me. Mary is my patient; her mother is not. Alice frantically explained how her twenty-two-year-old daughter was spiralling out of control. Alice reported that Mary was suddenly looking disheveled and dirty and acting irritable and abrasive. Mary had just stormed out of the house without indicating where she was going or when she’d be returning. Alice didn’t claim to know anything about Mary’s condition or treatment, but assumed that Mary had a psychological problem. She expressed concern that maybe Mary wasn’t taking her medicines or checking in with her psychiatrist. Maybe she was using drugs. Alice wept. She desperately wanted me to help Mary.

I wanted to help, but the case was complicated. Should I be taking information from well-intentioned family members? Since Mary hadn’t asked me for help, should I even get involved? What would she think about me talking to someone about her care, even though I didn’t reveal any medical information? I had to wonder if I could even help someone who doesn’t want it. In fact, I wasn’t even sure she needed help. At her last visit, just a few weeks prior, Mary acted normal and talked about her great job and attentive boyfriend. She was taking her medicines and seeing her psychiatrist. Ultimately, I had little recourse. In the eyes of the law, her autonomy disallows forced treatment or confinement unless her behavior poses an immediate danger to herself or others.

I called Mary the next day from my office. She sounded well. She agreed to come in for an appointment. At the visit, she did look mildly unkempt, but otherwise acted normal. When I mentioned her mother’s call, she became upset and accused her mother of having mental problems and trying to transfer them to her. She requested that I not talk to her mother anymore.

Two weeks later, Alice paged me again after hours. According to her, Mary took a turn for the worse and started behaving more erratically. Alice cried and pleaded that I help her daughter. She was slightly irrational and mostly inconsolable. At that moment, I started getting the eerie feeling that something was amiss. I no longer knew who needed the help. I couldn’t figure out who was telling the truth and who was decompensating: the mother or the daughter. I didn’t know what to do next. I asked Alice not to call back again, but rather to call the police if Mary posed a danger to herself or others. I called Mary but she declined my requests for further appointments.