The Clinicide Phenomenon

Australasian Psychiatry http://apy.sagepub.com/ The Clinicide Phenomenon: An Exploration Of Medical Murder Robert Kaplan Australas Psychiatry 2007 15: 299 DOI: 10.1080/10398560701383236 The online version of this article can be found at: http://apy.sagepub.com/content/15/4/299 Published by: http://www.sagepublications.com On behalf of: The Royal Australian and New Zealand College of Psychiatrists Additional services and information for Australasian Psychiatry can be found at: Email Alerts: http://apy.sagepub.com/cgi/alerts Subscriptions: http://apy.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> Version of Record - Aug 1, 2007 What is This? Downloaded from apy.sagepub.com by guest on January 12, 2012 FORENSIC PSYCHIATRY The clinicide phenomenon: an exploration of medical murder Robert Kaplan Objective: The aim of this paper is to explore the phenomenon of clinicide. Conclusions: The study of medical killers is barely in its infancy. Clinicide is the unnatural death of multiple patients in the course of treatment by a doctor. Serial medical killing is a relatively new phenomenon. The role model is Dr Marcel Petiot, the worst serial killer in French history. More recently, Dr Harold Shipman was Britain’s worst serial killer and in the United States and Zimbabwe, Dr Michael Swango killed 60 patients. A number of doctors have such high patient death rates that it cannot be ignored. At some level, these doctors have an awareness of what they are doing, countered by an overweening refusal to acknowledge the implications or desist from further treatment. Treatment killer offences usually occur on the basis of serial mental illness, but may include the contentious area of euthanasia killing. Doctors have frequently been accomplices in state repression, brutality and genocide in direct contravention to their sanctioned role to relieve suffering and save life. They have become mass murderers on an exponential scale, making any comparison with a doctor killing his own patients almost risible. Many clinicidal doctors have extreme narcissistic personalities, a grandiose view of their own capability and inability to accept that they could be criticized or need assistance from other doctors. Such doctors develop a God-complex, getting a vicarious thrill out of ending suffering and by determining when a person dies. Key words: cide. Clinicide, genocide, medical history, psychopathy, serial homi- I n January 2000, Dr Harold Shipman, a 54-year-old general practitioner in the UK town of Hyde, Manchester, was found guilty of murdering 15 patients with lethal injections of heroin.1 After the trial, it was concluded that Shipman had murdered 260 patients (other estimates brought the figure closer to 450),2 making him a medical serial killer of extreme dimensions
easily the worst in English history.3 Everything points to the fact that a doctor with the sinister and macabre motivation of Harold Shipman is a once in a lifetime occurrence. Robert M Kaplan Honorary Clinical Associate Professor, Graduate Medical School, University of Wollongong, and Forensic Psychiatrist, The Liaison Clinic, Wollongong, NSW Australia. Correspondence: Associate Professor Robert M Kaplan, The Liaison Clinic, 310 Crown Street, Wollongong, NSW 2500, Australia. Email: rob.liaison@gmail.com Shipman killed patients from the time he went into practice in 1974, continuing with only a year’s break, when having treatment for drug addiction, until arrested in 1998. His American counterpart, Dr Michael Swango, who worked in hospitals, killed 60 patients across several states, Zimbabwe and Zambia in a spree lasting from 1983 until 1996 (with 3 years out of practice when he was in prison).5 Swango’s case shows that jumping jurisdictions and concealing past misdemeanours is a regular practice for such doctors. The study of medical killers is barely in its infancy. Clinicide is the unnatural death of multiple patients in the course of treatment by a doctor. Clinicide occurs in a group that has a high rate of homicide. Kinnell doi: 10.1080/10398560701383236 # 2007 The Royal Australian and New Zealand College of Psychiatrists Downloaded from apy.sagepub.com by guest on January 12, 2012 Australasian Psychiatry . Vol 15, No 4 . August 2007 Dr Liam Donaldson, who wrote the introduction to the clinical audit on Shipman’s practice, made the following statement4
one that he may come regret: 299 maintains that doctors kill more than any other group (veterinarians, apparently, have never produced a serial killer).6 Mostly, medical murderers kill people around them, that is, partners, family and lovers. Two uxorious medical killers, one psychopathic and one paranoid, are psychiatrist Dr Colin Bouwer and Dr Geza de Kaplany. Bouwer emigrated to New Zealand from South Africa, omitting to disclose that he had earlier been deregistered for drug abuse, concocting an elaborate myth about his anti-apartheid credentials. He had a relationship with a fellow psychiatrist and went to elaborate lengths to camouflage a plot to kill his wife with insulin injections. Baffled doctors removed part of Angela Bouwer’s pancreas, convinced she had an occult insulinoma. She still died, but Bouwer’s subterfuge failed as he was soon charged and convicted.7 In 1962, Dr Geza de Kaplany, a 36-year-old anaesthetist in San Jose, California, tied beauty-queen wife Hajne Piller to the bed, apparently in a fit of jealousy, proceeding to slash and pour acid on her body, leaving her to die in agony in hospital. He claimed to have a double personality at trial, but pleaded guilty. In a bizarre development, de Kaplany was later paroled and went as a ‘‘medical missionary’’ to Taiwan before settling in Germany.8 CATEGORIES OF CLINICIDE Medical serial killers Australasian Psychiatry . Vol 15, No 4 . August 2007 While reckless, incompetent, inept, mad or just plain dangerous doctors have been around for as long as medicine has been practiced, serial medical killing is a relatively new phenomenon. Dr William Palmer, Dr Edward William Pritchard, Dr Thomas Cream and Dr H Holmes were nineteenth century serial murderers who happened to be doctors, and used the skills they learned for this purpose, although as a rule they rarely killed patients.9 These doctors invariably used poison, a reflection of the availability of potent drugs that could be administered by injection. When doctors turn on patients because they derive some perverse pleasure from the act of killing, they tend to be prolific murderers, not surprising in view of their access to both trusting victims and the easy means to dispatch them. The incidence of serial medical killing is very low, but this is little consolation to their victims. Between them, Shipman and Swango are credited with at least 313 deaths. These figures, far in excess of what the average serial killer attains,10 reveal just how dangerous an unleashed medical killer can be. The role model is Dr Marcel Petiot, the worst serial killer in French history.11 His period of destruction extends from 1926 (if not earlier) until 1944. A reasonable estimate is 100
200 victims. Petiot’s awful train of carnage was facilitated by compressed medical training after World War I and the confusions of loyalty in Nazi-occupied France during World War II. He claimed to be running an escape network for refugees from the Nazis, executing spies who infiltrated his ring. At the trial, it was shown that Petiot had no Resistance involvement and he was guillotined in 1946. Preceding Shipman was another serial killer who succeeded in getting away with it. Dr John Bodkin Adams, the Eastbourne GP, is believed to have killed over a hundred patients.12 He inherited money, cars, jewellery and antique furniture from 132 patients, many of whom died soon after changing their wills. At a sensational trial at the Old Bailey in 1957, Bodkin Adams claimed he was merely ‘‘easing the passing’’ in elderly patients who were close to death, and was easily found not guilty. To this day, as many people who knew him believe he was guilty of murder as believe he was innocent. Dr Arnfinn Nesset, who has the dubious distinction of being Scandinavia’s worst serial killer, is credited with 137 murders in over half a decade. Nesset injected nursing home patients with curare, causing respiratory paralysis. Claiming to have various psychiatric diagnoses at his trial, Nesset was jailed for the maximum period permissible. The unpalatable conclusion is that medical serial killing, like other serial killing, will continue in the future. The only thing that will change is the circumstances. As controls and means of detection improve in first-world countries, medical serial killing will move to countries where there is massive social upheaval associated with poor regulation. South Africa, a country where firstworld medicine meets third-world populations, is just such a place. Furthermore, as the gender bias shifts, a female medical serial killer can be predicted with certainty. Treatment killers Treatment killers are doctors associated with multiple patient deaths in which it is not immediately obvious that they intended patients to die and the issue of motivation is not evident. When the list of death progresses beyond two or four or 20 patients, it is not possible to continue without the realization that death is a likely outcome of treatment. At some level, these doctors have an awareness of what they are doing, countered by an overweening refusal to acknowledge the implications or desist from further treatment. Doctors are expected to provide optimum care at all times, to seek help or second opinions, regardless of vanity or fear of criticism. For a doctor to ignore death after death after death of patients under their care is untenable, and cannot be explained by mere denial. Their role is to take responsibility for the patient’s care as far as can be reasonably expected. Treatment killer doctors achieve recognition, and only reluctantly so, when the extent of the deaths associated 300 Downloaded from apy.sagepub.com by guest on January 12, 2012 with their treatment is exposed to the public. There is shock, horror and outrage, often leading to disciplinary inquiries or manslaughter charges. To the onlooker, investigator or public, this is predicated on the idea that incompetence, wilful or witless, caused patient deaths, and they were not deliberate or intended. As the courts put it, there is no apparent motive. The most notorious example of medical mass killing in Australia is Dr Harry Bailey, who treated large numbers of patients by a dubious treatment modality, deep sleep therapy.13 On the slimmest of pretexts, patients were put into deep levels of coma with high doses of drugs under minimum supervision or care. Bailey was found to be responsible for (at least) 87 deaths and several hundred casualties. Included in this group, treatment killers, are doctors with serious mental illness. This problem is as old as medicine, and particularly difficult with the prominent physician, an example of the Great Man Syndrome. They have such authority and charisma that underlings are reluctant to tell them to stand down. This results in any number of unnecessary deaths, and enormous distress to survivors. One of the worst examples is Dr Ferdinand Sauerbruch, one of the most famous surgeons of the twentieth century.14 Vascular dementia led to a catastrophic loss of judgement, outbursts of violent rage and disinhibited, impulsive behaviour. His operations degenerated into crude butchery but staff were too intimidated to intervene. After World War II, communist authorities in East Berlin were prepared to overlook casualties for the prestige of having such a prominent surgeon under their aegis. Eventually forced to retire, Sauerbruch performed operations without anaesthetic on the dining table in his sitting room. He used kitchen implements, sutured with needle and thread from his wife’s sewing basket, killing patients by the score. More recently, Dr Jayant Patel was associated with 87 patient deaths during his short time in practice in Bundaberg, Queensland. Patel had a long path of surgical mayhem in the United States and did not disclose that he was under disciplinary review in several states before he arrived in Australia.16 There is a spectrum of serious psychiatric disorder in the clinicidal doctor, ranging from personality disorder to bipolar affective disorder and psychosis. Bailey was thought by many to have had manic depression. Petiot was psychotic and had psychiatric changes induced by temporal lobe epilepsy. Sauerbruch had a Lord Dawson of Penn was the Royal Physician to King George V who died in 1938.17 Dawson gave the king a lethal injection into the jugular vein, ostensibly for the news to be released the next morning by The Times , rather than the tabloid papers. ‘‘‘God damn you’’ said the King
not unreasonably
as he slipped away. Euthanasia killing is an area of contention, both in the legal and medical sphere. There are cases of palliative care physicians being unjustly accused of murder. More difficult are situations where doctors adopt an evangelical approach, attracting patients who are coerced, misled, vulnerable or simply unaware of the help available. Such platitudinous death-dispensing doctors may include Philip Nietske and Jack Kevorkian, now in a US jail.18 Political mass murderers Doctors have frequently been accomplices in state repression, brutality and genocide in direct contravention to their sanctioned role to relieve suffering and save life. Doctors have performed inhumane experiments on victims, participated in torture and directed programmes to exterminate the enemy. In addition, they have beaten, tortured and killed victims for no other reason than they had the power to do it at the time. In doing so, they became mass murderers on an exponential scale, making any comparison with a doctor may killing his own patients almost risible. Political medical murderers reverse the process of patients seeking help from a doctor, instead misusing their medical skills in the most horrendous fashion to commit appalling abuse on a vulnerable group on the basis of nationalism or ideology. While Joseph Mengele and Radovan Karadzic stand out, most doctors involved in political murder would be described as no more than time-servers, opportunistic careerists making the best of the situation and rationalizing it in the name of a good cause.19 Systematic participation of doctors in state terror commenced in 1915 with the Armenian genocide in Turkey.20 Medical personnel were directly involved in the killings, often participating in torture. Dr Behaeddin Sakir and Dr Mehmett Nazim played pivotal roles in the establishment of extermination squads staffed by violent criminals. Utterly unrepentant to the end of his life, Nazim was thought to have committed a million murders. Dr Mehmed Reşid was involved in the ‘‘deportation’’ of 120 000 Armenians from his province. Reşid’s brutality was extraordinary, including smashing skulls, nailing red-hot horseshoes on the victim’s chest, and crucifying victims on makeshift crosses. The template for the Nazi holocaust provided by the Armenian genocide set the ground for the most notorious examples of medical complicity in state Australasian Psychiatry . Vol 15, No 4 . August 2007 Dr Ronald E. Clark had bipolar disorder. Practising in Farmington Township, Michigan, Clark sexually assaulted and killed patients in his rooms from 1954 until 1967, despite being admitted to a psychiatric hospital several times.15 Each time after offences were reported, Clark was allowed to continue working. After killing his secretary, he went on the run, was hunted down in the snow by bloodhounds, and finally jailed. fiery personality, drank heavily and developed vascular dementia. 301 Downloaded from apy.sagepub.com by guest on January 12, 2012 abuse
Nazi doctors who participated in euthanasia and genocide, and Japanese doctors who practiced biological warfare. Included among the former were psychiatrists, who in carrying out Hitler’s euthanasia programme on their patients, appear to have been in a state of complete moral disarray. Japanese medical abuses were as bad as those of the German doctors. Unit 731 of the Japanese Imperial Army carried out bizarre, hideous and unspeakably cruel experiments on thousands of people from Manchuria.21 Abuses included the freezing of limbs of chained prisoners, infecting hundreds of villages with anthrax, plague and cholera, and performing live vivisection
for example, cutting out the heart or brain from living victims. Some victims were slowly burned alive with repeated jolts of 20 000 volts of electricity. Doctors referred to the hapless victims as ‘‘logs’’, on the egregious grounds that killing a prisoner was no more than cutting down a tree. The involvement of doctors in state repression and abuse has, if anything, escalated since 1945. One among many examples from apartheid South Africa is charmless cardiologist Dr Wouter Basson.22 Basson headed Project Coast, which was involved in assassinations of the members of anti-apartheid movements, established a chemical and biological weapons programme and investigated putting contraceptive agents into the water supply to the black population. Basson continues to practice as a cardiologist. Psychiatrist Dr Radovan Karadzic, who led the Bosnian genocide from 1992 to 1995, used his training in group therapy to formulate terror tactics and had troops shell the hospital where he worked, killing both patients and colleagues.23 He remains on the run, protected by a network of Serbian sympathizers. Driven as he was by nationalist objectives, it is hard to accept that Karadzic was not perverting both the skills and ethics that were implicit in his role as a doctor. Australasian Psychiatry . Vol 15, No 4 . August 2007 Going back to the murderous course of Dr Marat during the French Revolution, the gloomy fact is that political medical murder is, if anything, a growth industry likely to continue in the future. DISCUSSION Clinicide is at the pinnacle of institutional murder by health carers, a phenomenon known as carer-assisted serial killing (CASK), or alternately the ‘quiet killing’ epidemic. CASK is a homicide growth area, dwarfing statistics of the well-publicized serial killers. Caring for vulnerable charges in a place with easy access to potent drugs is an open invitation for a murderer to operate. Such crimes are difficult to detect and harder to prosecute. The killings occur quietly; they are not violent, there is no sign of a struggle, no wounds or blood is evident. In the USA, 13 health workers have murdered at least 170 patients in the past 20 years.24 Of 34 female serial murderers in the USA, six were nurses. One of the reasons that CASK and clinicide reach such levels in hospitals or nursing homes is that deaths are expected to occur there and attract little attention. Typical victims are vulnerable: too sick, too old, too young to communicate, or terminally ill. The extreme susceptibility of demented or frail patients with limited involvement of family members makes them ideal targets. Among the motives listed in those who were charged were acting out a sexual fantasy, impressing a boyfriend, exercising power over life and death, overcoming feelings of inadequacy, and responding to requests for assisted suicide. Offenders included both medical and non-medical personnel, occasionally even hospital visitors. There are good reasons for maintaining a distinction between CASK events and clinicide. Compared to nurses and other health workers, the clinicidal physician is in the most powerful position to kill vulnerable patients and almost invariably will use the euthanasia defence when discovered. Doctors have a prolonged professional gestation and a leadership role in health care. Both groups have easy access to drugs and have the means of killing patients, but the physician is not merely a unit in the group or team caring for the patient, but responsible for treatment decisions and outcome. They have the elite status as well as the legal responsibility when things go wrong. Why do doctors kill their patients, or use their medical skills to participate in horrendous experiments, torture or genocidal murder in the service of the state? And are they different from other healthcare workers who kill patients? It is an extreme paradox, considering the extraordinary effort and discipline it takes to become a doctor and the devotion, since the times of Hippocrates, to medicine as a calling to save lives. The answer is that murderous doctors are different from their colleagues and from other lethal healthcare workers and, if it can not be always known with certainty why they kill, there are explanations to be found in many cases. Peter Smerick, former FBI criminal profiler, describes two types of medical killers:25 (1) The hero killer doctor would put a patient under great risk. If they save the patient, they are a hero. If the patient dies, the killer will say, ‘‘so what?’’. (2) The mercy killer doctor will rationalize that they are concerned about the suffering of this patient and put them out of their misery. They count on the fact that an autopsy is not usually performed when a terminally ill patient dies. Medicine attracts a certain kind of personality who is lured by the power of life over death. Many clinicidal 302 Downloaded from apy.sagepub.com by guest on January 12, 2012 doctors have extreme narcissistic personalities, a grandiose view of their own capability and inability to accept that they could be criticized or need assistance from other doctors. Such doctors develop a Godcomplex, getting a vicarious thrill out of ending suffering and by determining when a person dies. But can it be mere incompetence
hapless, feckless or witless
when there is a recurrent pattern of deaths through neglect, treatment failure, disinterest or by putting financial gain above patient care? From Petiot to Bailey and Shipman, there was a fatal hubris, permitting these doctors to perceive themselves as supremely dedicated, if not heroic, and any criticism of their work was responded to in paranoid terms. This narcissism explains the most puzzling aspect of clinicide, the doctor who cannot step back at an early stage from the casualties of treatment and seek assistance or stop what they are doing. The inability to admit they could be wrong exemplifies the ancient Greek sin of hubris. Such individuals, while not necessarily psychopathic, go to extraordinary lengths to get what they want. One issue that will not change is expecting medical colleagues to monitor their own kind with due vigilance. By definition, medicine is an autonomous activity often conducted in group settings. Most practitioners are acutely aware of the shortcomings of what they do. This results in a ‘‘there but for the grace of God go I’’ mentality, an inner resistance to be overcome before reporting a colleague. And, as the example of Sir Roy Meadow’s involvement with Munchausen’s syndrome by proxy has shown, medical over-zealousness has its own perils.26 Of all the clinicidal doctors, Shipman killed the greatest number of patients, and his zone of operation causes the most concern. Swango killed in hospitals, others in nursing homes. However, this is nothing compared to the risks that lie in the suburbs, doctors’ rooms, units and houses of the community when a doctor who derives a thrill from killing is let loose there.27 Great to see a single-handed enthusiastic GP with a rolling programme of audit-keep up the good work! 28 This quote is just 9 months before Shipman’s arrest. The paradox of Shipman’s medical role is that, as nothing else has done, it reveals the loss of the human element so crucial to the engagement of doctor and patient. Psychiatrist Humphrey Osmond described the three facets of the medical role as sapiential, authoritarian and charismatic.29 The first two are self-evident. The Illness and death are not consistent or amenable to reason. Dealing with the powerful and mysterious forces involved, doctors can not be anything but inconsistent. One explanation for this may lie in the peculiar intimacy of medical care. Patients put themselves in the care of their doctor and want to believe in the person they have chosen. Being on a pedestal feeds the need of the doctor to be a successful healer, for many the raison d’etre they took up the profession. But patients perversely insist on behaving like . . . the public. They refuse to get better, keep returning, comply poorly, if at all, with treatment and even imply that the doctor is to blame for their misery. In an age of equality, only the doctor can be held to blame; the arbitrariness of life or death is not a matter for the state. The same doctor has to be a combination of priest, counsellor, pharmacologist, horologist, talkshow host and healer
in short, the demiurge of our society. Far from being diffident, grateful or admiring, patients may bubble with entitlement, seethe with rage or demand constant approval.3 In this scenario, there is no accommodation for dissident emotions from the healer, for doctors behaving like patients. Forever linked in the treatment endeavour, the treater is as much prone to these emotions as the treated. How many doctors, if they are truly honest, seeing the same doleful face across the desk or bed yet again, have not wished for an early death to relieve them of the burden of dealing with wretched, peevish ingratitude or clinging adulation? Take that one step further: in a single unguarded impulsive moment, a patient dangling on the business end of a needle, a few air bubbles, an extra squirt of morphine . . . Like jailers with their prisoners, some doctors internalize the dysphoric impulses, where they fester and choke them. The list of miseries that haunt some is endless, in stark contrast to their public image as selfless healers. Every doctor knows colleagues who renew Walt Whitman’s observation that the majority of men (and women) lead lives of quiet desperation. How many mornings do they look in the mirror and see themselves there? For all the gloss and complacency that high-technology modern medical care involves, there is a fatal flaw, one that ignores that doctors and patients are bound together by a common cause. In most cases, this will result in a successful parting when agreed-upon goals Australasian Psychiatry . Vol 15, No 4 . August 2007 Shipman ensured that he kept up with practice requirements. He received regular approval from the auditors that he was meeting required practice standards: charismatic role accounts for the fact that doctors are not expected to be reasonable. In fact, they are rewarded for being arbitrary. All doctors have these three factors to a varying degree in their personality; when one factor is overarching, then problems occur. In this regard, one only needs to look to the cases cited above. 303 Downloaded from apy.sagepub.com by guest on January 12, 2012 are obtained; in some cases, both sink, dragging each other down under the recriminations of failure, misunderstanding, and entitlement. 10. Scott J. Serial homicide. British Medical Journal 1996; 312: 2
3. 11. John Camp. One Hundred Years of Medical Murder. London: The Bodley Head, 1982. 12. Surtees J. The Strange Case of Dr Bodkin Adams: The Life and Murder Trail of Eastbourne’s Infamous Doctor and the Views of Those Who Knew Him. London: SB Publications, 2000. Far from politically correct notions about the doctor
patient relationship, there is nothing new under the sun. In the end, doctor and patient soar together like Dedalus and Icarus: one flies to the sun, one crashes to the earth. In the words of Lord Keynes, ‘‘in the long run, we are all dead’’. 13. Bromberger B, Fife-Yeomans J. Deep Sleep: Harry Bailey and the Scandal of Chelmsford. East Roseville: Simon & Schuster Australia, 1991. ACKNOWLEDGEMENTS 16. Fitzgerald PD. The Bundaberg hospital scandal: the need for reform in Queensland and beyond. Medical Journal of Australia 2006; 184: 199
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