How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research

In 1926 Francis Peabody ended his most celebrated lecture with the oft-repeated conclusion, "the secret of caring for the patient is caring for the patient" [1]. It's a compelling line, resonant with wisdom and common sense, but it begs an obvious question. What if I don't care for the patient? In particular, what if my reaction to the patient is negative, perhaps intensely so, driven by social and/or moral disapproval? This last question arises occasionally in bioethics and "difficult patient" discussions, but beyond assertions as to what should happen, there is little systematic data on what actually happens.Most healthcare professionals have found themselves treating someone who is flagrantly offensive, whose attitudes and actions have caused others to suffer harm. Physicians and nurses readily admit that empathy is more difficult to achieve in these situations and that their professional ideals feel strained. Two published reports will illustrate:Renate Justin's new patient with emphysema revealed during her intake history that she was an unrepentant Nazi anti-Semite who had supervised slave laborers during the war. Justin, a Jewish family physician, struggled through the turmoil of her feelings and duties before the second visit."I had decided that if she stayed with my practice, I could probably be a skilled and trustworthy physician to her. Intellectually, I had concluded that my job as a doctor was to take care of her, regardless of her history. I felt that I could achieve this: I could treat her emphysema and suppress or control my moral outrage. What I did not know was whether I could be compassionate." [2]In a 2004 account of a Midwestern surgical intensive care unit, anthropologist Joan Cassell found that physicians, male and female, tried to avoid thinking about their patients' personal stories. Not so the nurses."The nurses always know the patients' stories: the accidents, tragedies, and sorrows that brought them to the hospital, their family constella