“You’ll find the next patient interesting Tom, I think he is a lifer.” I grabbed the patient’s chart to assess his clinical history. As I looked up previous lab values and problems, I stumbled across the mental health section – “patient has a steely-eyed gaze,” noted the most recent psychiatric evaluation. I greeted the patient at the door, and as I made eye contact, felt my heart sink into my chest. To describe his stare as vacant would be to undermine its power – his eyes stayed still, almost too still, with little recognition of me as a fellow human being. Mr. D approached coldly. And he had an agenda.

He wanted narcotics and a lower bunk for recent muscle pain. When it came time for an examination, he deferred, demanding to see the real doctor. This would not happen for over an hour, as the doctor was preoccupied. I breathed deeply. I attempted casual conversation. A former serviceman, Mr. D had served two years before returning home and getting caught up on the streets. While he was currently housed in a medium-security facility, he preferred the “Super-Max” where he could be alone and keep to his business. He told me about plans to “appeal my conviction and get some hot girl pregnant,” and in the next breath praised my choice to speak to him as a “human being.” Was this switching a subtle form of manipulation, or the unmasking of an underlying honesty? When asked about his cellmates, he expressed indignation that the prison would house him “with someone with only a five-year sentence.” How dare they! I thought cynically to myself.

One of the tenets of psychiatric interviewers is that your personal reactions are important data about a case. I felt compassionate, vengeful, defensive, sardonic, inquisitive and utterly terrified. We parted ways, and throughout the day felt haunted by the interview. I grasped at my disparate identities to find a structure to contain his troubled mind. The psychiatric diagnosis of anti-social personality disorder seemed to fit clinically, but offered no solace. I turned to humanism, and naively imagined him with infinite human potential, but this did not work. I imagined him playing the guitar, but feeling shame at liking the chords. Sometimes it is not possible to love everyone. I turned to Buddhism, and thought of his path of right mind and action to reduce suffering. While all life clearly contains suffering, I experienced his personal and inflicted suffering as magnitudes larger than most.

I dug back further to more Protestant language to pose the question: Is redemption possible for Mr. D? This is not a questioning style encouraged in any form of training I have undertaken – philosophical, sociological or medical. Those questions are the easy ones, because they demand an intellectual distance from people. What is the nature of evil? Does redemption imply a redeemer? What are the dominant characteristics of inmates who are rehabilitated? What are Mr. D’s medical comorbidities given his incarceration?

Mr. D will spend the next fifty years of his life in the same cell. He will likely never get his hands on a guitar. His medical files will grow exponentially and his thick charts will tower over his doctors. He will get in fights with inmates, excel in the prison courses offered, and demand frequent medication changes from his doctors. But after fifty years, will his eyes be the same? Will there be any discernible wisdom, depth, or compassion? As a humanist, I believe the onus is on us to imagine this reality.  My role as a physician only strengthens this conviction, for in treating his back pain, asthma, or providing inevitable hospice treatment, we must acknowledge at least his will to heal himself.

This photo by Tom Crescibene is featured in accordance with its creative commons license.