I was feeling a bit annoyed by a comment by a student that suggested ethical issues were rare in every day medical practice. Ethical problems are part of every day practice and come in all shapes and sizes.We are still in the holiday season and I thought it might be fun to talk about a real patient of mine who has since died. [Her name has been changed for reasons of confidentiality ]

Away with the fairies

old lady

They are little people. They hide in pictures.’ Mrs De Beauvoir was an immaculately groomed widow in her eighties. One would not dare disagree with her. ‘What are they like; are they nice or are they scary?’ I probed. I was Mrs De Beauvoir’s GP but had not seen her for years. Her accountant had phoned me, he had become a ‘bit concerned by some of the things she told him’. She had no near relatives and he managed her affairs.

The little people were ‘Quite sweet; although at times they could be naughty.’ She also told me that she was a magician. A discussion with the mental health team followed and she was started on an anti-psychotic. She got better. She stopped seeing things and her magical powers disappeared. However in many ways she was worse. She became profoundly depressed. Not surprising really because when you took away her delusions what was left was an old, lonely lady. Much better to be a powerful magician with little people to rule over. In fact she missed the little people so much that I felt that she was suffering a bereavement.

Weeks later she opened the door. She had lost weight, her immaculate flat and her appearance had become unkempt and dishevelled. I felt that I had made her worse. First do no harm. Yes, but what if she jumps out of a window – she said she could fly didn’t she? The opposition battled inside my head. I preferred her happy and hallucinating than sane but sad. But wasn’t that old fashioned paternalism? What was the harm benefit ratio? Did autonomy mean that she should be forced to be sane? What do you think I should have done?