old ladyThey 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?

What happened next

She stopped the tablets herself. I am not sure whether this was to some extent a subconscious decision on her part. I could have arranged for a CPN [community psychiatric nurse to visit] but I felt [ more than thought] she was better of without the tablets. I did not discuss it with the MDU [medical defence lawyers] or the CPN. I was too afraid they might disagree. Luckily the little people came back and so did her magical powers. She promised me she would not do anything dangerous such as jumping out of windows. I was partly reassured by her reply ‘Dr , I would not dream of making an exhibition of my self. It would be so vulgar.’

However worries regarding her safety remained. So it was with some alarm that I visited a few years later after a phone call from her to come and help because the little people were ‘Out of control!’ When I went round, she opened the door of her flat her face glowing and her eyes shining like an excited teenager. She looked very, very happy.

It transpired that the little people were sitting in the washing machine and would not get out! Mrs De Beauvoir had a pile of washing to do and she had coaxed, pleaded but they were not listening. I offered to have a go and talk to them but she bustled me out of her flat saying she had called the washing machine repair man and she was sure that he was the right person for the job not me! I passed the washing machine repair man in the car park. He was a young, smooth faced boy of about 20. I watched him take his tool kit out of his boot and start to walk into the building. I ought to warn him, I thought. He looked so innocent; this to him was just a normal working day and he had a machine to fix; perhaps the washing machine was not draining properly, the element burnt out and needing to be replaced. No, I thought, let him find out himself what the problem was. It is will be more interesting for  him; he’d have quite a tale to tell afterwards.  If I tell him –he might not go. I telephoned later that day ‘Oh the washing machine repair man sorted it.’ Mrs Beauvoir said dismissively. Hats off to him! I am not sure what he did but I wish I could have been a fly on the wall of that kitchen!’

Mrs De Beauvoir lived another 6 years with her little people. During that time she never went out of her flat. She remained happily and pleasantly delusional. One day the milk man noticed she had not collected her milk from her door step and she did not answer the bell to her grocer who contacted us at the surgery. She had died in her sleep. This story, like many ethical issues showed me that there is not necessarily a right answer. But I think it; like most fairy stories, turned out for the best in the end!