Intended for healthcare professionals

Observations Ethics Man

Patients we don’t like

BMJ 2013; 346 doi: (Published 19 June 2013) Cite this as: BMJ 2013;346:f3956
  1. Daniel K Sokol, senior lecturer in medical ethics and law, King’s College London, and practising barrister
  1. daniel.sokol{at}

Doctors should not let their moral evaluations of patients affect their treatment

A few months ago I represented a man who had been involved in a road crash. Shortly before the trial we discussed—in private—what had happened on that day.

During the trial, it became evident that under cross examination my client was lying. There was video footage to confirm it. He had also breached my trust and lied to me repeatedly. Not a white lie, or a slight inaccuracy, but whopping great untruths. With each passing minute, as his credibility floundered, my resolve to win the case weakened. I grew emotionally more distant from my client. By the end of the cross examination I was filled with a profound dislike for him. It was an unsettling experience.

The trial was not over. In my closing submissions I still had to persuade the judge that my client was not negligent.

Similar situations arise in medicine. Until medicine is performed by robots, emotions will always feature in practice. Patients who are rude, angry, abusive, malodorous, self destructive, time wasters, or non-compliant and bed blocking can arouse negative emotions in the treating clinician, especially when he or she is tired. These emotions, in turn, can lead to a lower standard of care for these “problem” patients.

In Richard Selzer’s essay “Brute” a surgeon has to suture a deep wound on a drunken, violent, and enraged patient’s forehead at 2 45 am.1 When the surgeon asks him to hold still, the patient retorts, “You fuckin’ hold still.” Furious and exhausted, the surgeon sutures the patient’s ears to the mattress of the stretcher, pinning his head still, then leans in to the patient and whispers, “Now you fuckin’ hold still.”

While saints can feel compassion, empathy, and love for the most loathsome of patients and construct scenarios in which patients’ bad behaviour is explained by difficult circumstances, to mere mortals such patients are, at best, unpleasant to endure. In these circumstances the doctor-patient relationship is strained.

Teachers of medical ethics will know that many medical students, and some clinicians, believe there to be no right or wrong answers in ethics. Ethics, they say, is merely a matter of opinion. This is a situation where the answer to the ethical question is clear. Under the General Medical Council’s Duties of a Doctor, doctors should “make the care of your patient your first concern,” however odious the patient may be. Doctors should never discriminate unfairly against patients. The ethical principles of beneficence (doing good) and non-maleficence (not doing harm) underpin the guidance. The principle of justice also requires the fair treatment of patients, in accordance with their human rights.

Similarly, in the moments before making my closing submissions, I remembered the Bar Code of Conduct, which states that barristers “must promote and protect fearlessly . . . the lay client’s best interests.”

In addition to the underlying ethical tensions, such cases are psychologically stressful. In an attempt to put my negative emotions aside, I recalled John Mortimer’s instruction that barristers should cultivate lucid indifference. And so, buoyed by the demands of professionalism, I stood on my hind legs and delivered an impassioned speech on why my client should win. While I hoped that my body language revealed nothing of my inner doubts, in my heart of hearts I did not believe one word of my speech. Thankfully, neither did the judge. He found in favour of the other side.

Doctors are susceptible to making moral evaluations of their patients, but they should not let those evaluations adversely affect their treatment of their patients’ illnesses. Like barristers in court, they are not judges of right and wrong. Their role is primarily focused on treating the sick. Like actors, they should show nothing of their displeasure. There should be no disapproving look or frown or words. Expression of any moral judgment should be suppressed.

This ability to provide expert services dispassionately (at least) to all patients and clients lies at the heart of professionalism. For those of us who are not saintly, this may involve the biting of tongues and, literally, “acting” professionally. When dealing in a professional capacity with people we dislike, perhaps lucid indifference and professional concern are more realistic goals than full blown compassion.

Yet, it is important to recognise in ourselves the feelings of dislike, when they do arise. Unless we do we cannot consciously manage them and reduce the likelihood of bias. Our more brutish instincts may take over, and our profession, reputation, self respect, and patients may suffer.


Cite this as: BMJ 2013;346:f3956


  • Many thanks to Raanan Gillon for comments on an earlier draft.


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