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Clark (not his real name) came to see me complaining of substernal chest pain.  At first, he said, it had come on only with exertion, but in the last two weeks it had begun to bother him at rest.  It radiated to his jaw and was associated with some mild nausea and sweating.  He’d been a pack-a-day smoker for 35 years, had hypertension and diabetes, and a family history of premature heart disease.

Alarmed, I told him this was without a doubt unstable angina and that he needed to be admitted to the hospital for a cardiac catheterization.  He asked me what that entailed.  I explained that a cardiologist would insert a catheter into his groin and thread it up his aorta until the tip of it was positioned at the openings of his coronary arteries.  Then he would squirt intravenous contrast into them to see where and how extensive the blockages in his heart were.  He would then perform an angioplasty or place a stent or—if the extent of disease was severe enough—pull out without any intervention and recommend a coronary bypass operation.  It all depended on what he found.  Afterward, Clark would have to lie flat on his back for six hours with a sandbag on his groin to ensure the catheter puncture site clotted over properly.

I told Clark that few circumstances existed in medicine in which the choice confronting a patient was as black and white as this one:  if he didn’t have this procedure he would almost certainly suffer a heart attack at some point and possibly die.

To my great surprise, he refused.  Did he understand, I repeated, that he could die?  Yes, he said, he did.  Why then, I asked, was he refusing the procedure?  He looked at me somewhat sheepishly.  Then after several moments, he finally blurted out, “I don’t want anyone looking at my groin.”

I was stunned.  “Why?”

“I’d rather not say,” he told me.

IRRATIONAL ON THE OUTSIDE, RATIONAL ON THE INSIDE

“That makes no sense.”  How many times a day do we find ourselves thinking that about other people’s behavior?  Perhaps someone decides to refuse an offer to come to the head of a line; or chooses to spend more money for a brand name when the generic is identical in every way; or refuses a potentially life-saving procedure he desperately needs.  But no one ever does anything without a reason that makes excellent sense—to them.  Even when the reason is completely divorced from reality, as in schizophrenia, the thought process that flows from that first idea will usually be logical and sound.  Once you accept that the F.B.I is listening in on your conversations through the radio receiver in your dental fillings, being wary of strangers and worrying you might be arrested both become eminently reasonable and entirely rational.

Unless the behavior we’re examining occurs as a result of a true derangement of normal brain functioning, as occurs after a concussion or due to delirium, we err when we label anyone’s behavior “irrational.”  Even demented patients think rationally and logically (until their ability to think is completely destroyed).  I once had a patient complain to me that people were coming in during the night and rearranging his possessions.  His son insisted to him this was impossible, that the doors were always locked, and that it made no rational sense for anyone to do that.  The answer to the riddle turned out to be that he was suffering from advanced dementia and simply didn’t remember that he was moving his things himself.  As he had no memory of even forgetting, he’d arrived at the entirely logical conclusion (to him) that someone else was doing it.

But even if behavior is only rarely genuinely irrational, it certainly is often foolish.  People do frequently act in ways that take them farther from their goals, either because they mistakenly believe their action will bring them closer or because they find themselves compelled by another goal they mistakenly believe is more important to them.

HOW TO APPROACH “IRRATIONAL” BEHAVIOR

I could have dismissed Clark’s choice as irrational and left him at the mercy of its consequences.  In fact, in other circumstances, with other patients, I’ve have.  For example, my Jehovah’s Witness patients believe receiving the blood of others into their bodies is a mortal sin, literally akin to murder.  I’ve had some of them refuse blood transfusions even in the face of potentially life-threatening gastrointestinal bleeding.  When a Jehovah’s Witness does accept a blood transfusion (as I once observed when two parents broke down and allowed a life-saving transfusion to be performed on their 10-year-old son), they’re often ostracized from their community and become pariahs.  Colleagues of mine have made disparaging comments about this kind of behavior, labeling it irrational, but all I had to do was once ask a Jehovah’s Witness why their group refused blood to understand the choice wasn’t irrational at all.  Foolish, you could certainly argue, but not irrational.

The difference ends up being more than just a splitting of hairs.  Labeling someone’s choice “irrational” blocks the impulse of others to understand it.  And what we don’t understand we tend to either fear, ignore, or both.  And if you don’t first understand why a person is making a certain choice, you’ll have no chance to change his mind when changing his mind seems the most compassionate thing to do.

“I respect your right to make this decision,” I told Clark, “even though I believe it’s not in your best interest.  But I really do care about what happens to you, so I’d really like to know why it’s so important that no one sees your groin.”

He could tell I wasn’t going to let it go.  He sighed.  Then in halting tones he answered, “I only have one testicle.”

I knew this, of course.  As a child he’d been cryptorchid—that is, one testicle had simply failed to develop.  I looked at him with sudden understanding.  “You’re embarrassed—”

“I know I’m being ridiculous,” he admitted.  “But maybe there are medicines you can use to treat my heart with instead…?”

Unfortunately, I told him, without knowing his coronary anatomy I had no way to know which treatment was best.  He understood, but I could see he felt horribly trapped.  It turned out not only was he desperately afraid of dying of a heart attack, he recognized his reason for refusing the procedure was foolish, which only embarrassed him further.

“You know that everyone involved in the procedure is a medical professional,” I reminded him.  He nodded.

“If you were missing a portion of your lung,” I argued, “would you be embarrassed about getting a chest x-ray?”

“No.”

“Why not?”

“Because…because…I don’t know…”

I studied him for a minute.  Then I ventured, “Maybe because your lungs have nothing to do with your manhood…?”

His expression grew pained.  Then he nodded.  “You must think I’m being ridiculous.  At my age.”

“No,” I replied.  “I completely understand.  We’re not in charge of how we feel about a lot of things.”  I paused.  “All I can think to tell you is that manhood, in my view, has nothing to do with anatomy.  It has to do with your character.  With doing what’s hard because it’s best.”

Clark didn’t agree to having the catheterization that day.  I told him to think about it, knowing a tincture of time is often what people most need to be able to adjust their thinking.

Which, in fact, he did.  A week later he called me to tell me he wanted to go ahead with it, and he had it done the next day.  We found what in medicine we call a “widowmaker” lesion—a 90% blockage of his left main coronary artery, which bought him a bypass operation the day after that.

Several months later he returned to my office for a follow up.  He still felt embarrassed that he’d almost put his ego before his health, he said with a laugh, but that otherwise he was feeling fine.  I told him I was glad his ego had listened to reason.

Next Week:  Why No Job Can Ever Be Perfect