by Cina, Joshua A. Perper, Stephen J. ; Cina, Joshua A. Perper, Stephen J.
1 In the Beginning
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Whereas this philosophy renders physicians useless, worse things have been said about doctors. For example, although the Talmud generally portrays physicians in a favorable light, it also states that even the best of physicians are headed for Gahenna (Hell). An argument can be made that while Hell is clearly the proper destination for poorly skilled physicians who inadvertently or intentionally kill, even good physicians should head there because they are under the mistaken belief that they have cured the patient when, in fact, God was the healer. This arrogance may be punishable by eternal damnation in the eyes of some zealots. While physicians of today may not face the prospect of Hell, they are constantly menaced by the specter of court and malpractice litigation.
Humankind has I long recognized that the power of healing is only one side of the magical medical coin and that the other side is the power to cause harm. Apollo, the God of Archery as well as Medicine, was said to be a bringer of death-dealing plagues. The Old Testament mentions that God punished the Israelites with a plague that killed thousands because they returned to idolatry while Moses was communing with the Lord and receiving the Ten Commandments. He also infested their camp with poisonous snakes. Job also suffered greatly due to the direct intervention of God. If one accepts the monotheistic premise that God is the Creator of everything that exists, then it is logical to infer that He also created disease, pain and suffering. This jibes with God’s promise of death to Adam and his descendents upon expulsion from the Garden of Eden. It follows then that if doctors have been blessed with the power to heal, they should also have the power to kill.
Since physicians have been imbued with the divine power of healing, these fallible humans are held to a very high, if not impossible, ethical and professional standard of perfection. Though physicians may have the near supernatural power to bring back patients from the brink of death, they also have the capacity, by failure of hands or unsound judgment, to cause great harm and death either intentionally (very rarely so) or in a failed, good faith effort. It is interesting to note that the Codex of Law, devised more than 4,000 years ago by the wise King Hammurabi of Babylon, included statutes which liberated the practice of medicine from the chains of magical practices and witchcraft. In so doing, it also set clear penalties for physicians that harmed or killed patients. The Code in keeping with Hammurabi’s philosophy of lex talionis (“an eye for an eye”) decreed: “If a physician makes a large incision with a bronze lancet (the operating knife), and causes the man’s death, or opens an abscess with a bronze lancet, and destroys the man’s eyes, they shall cut off his fingers.” It is doubtful whether a great number of pre-medical students would knock on the portals of our institutes of high learning if such penalties were in effect today.
Chapter 2
Perfect Intentions, Imperfect People
May no strange thoughts divert my attention at the bedside
of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to
preserve the lives and health of Thy creature.
– Daily Prayer of Maimonides
It is a trite fact of life that the old Latin maxim “Human erare est” (It is human to err) has lost none of its truth. For centuries, however, healers have sworn to err as little as possible in the performance of their art. As medical practice became more organized and education more uniform, most societies developed ethical and professional codes to provide their physicians rules to live and work by. It seems reasonable to assume that most young doctors would gladly swear to uphold a set of guidelines in lieu of having their fingers lopped off for a mistake.
One of the earliest and best known of the medical codes of ethics is the Hippocratic Oath. The Oath is generally recognized as the brainchild of the fifth century BC Greek physician Hippocrates, a contemporary of both Plato and the historian Herodotus. Legend has it that Hippocrates belonged to a noble family that claimed to trace its roots directly to the mythical Aesclepius, son of Apollo.
The Oath requires the physician entering the profession to honor his teachers; to give patients proper diet and cause them no harm; to refrain from giving drugs that may induce abortion or any drugs that may harm the patient; to restrict the practice of surgery exclusively to skilled surgeons; to refrain from any harmful activities; to avoid sex with anyone in the patient’s household (still a very good idea); and to keep confidential the general and medical information about a patient. Twenty-five hundred years later Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) and formalized the ancient concept of patient confidentiality. Hippocrates was way ahead of his time. In several seminal works, he began to lay the foundations of modern medical ethics. In Epidemics he states that that the first commandment of the medical profession is “To do no harm” (“Primum non nocere”). In Aphorism he wisely notes, “Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the J.A. Perper and S.J. Cina, When Doctors Kill: Who, Why, and How, 9
DOI 10.1007/978-1-4419-1369-2_2, © Springer Science+Business Media, LLC 2010
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2 Perfect Intentions, Imperfect People
attendants, and externals cooperate.” Taken literally, the modern day physician must behave ethically and ensure that insurance companies, legislators, attorneys, and noncompliant patients do the same. No problem.
The Hippocratic Oath, now well established as the cornerstone of the medical ethics edifice, took centuries to catch on in European medical schools. The first major institution of medical learning to include it in the curriculum was the University of Wittenberg in Germany in 1508. In 1804, the Oath was first incorporated into commencement exercises at a medical school graduation in Montpellier, France. This custom spread sporadically on both sides of the Atlantic during the nineteenth century and early 1900s but relatively few American physicians formally took the Oath. According to a survey conducted for the Association of American Medical Colleges in 1928, only 19% of the medical schools in North America included the Oath in their commencement exercises. It was only after the Second World War that it became much more frequently utilized. Today most medical schools in United States administer some type of professional oath to the 16,000
men and women entering the field each year. In many schools, the Oath has been revised to compensate for changes in the practice of medicine and fluctuations in societal values. Many medical schools administer an Oath that has deleted references to Greek deities, statements advocating obligatory teaching of medicine to physicians’ sons, and the prohibition for general practitioners to perform surgery, abortion and euthanasia. In fact, according to a 1993 survey of 150 U.S. and Canadian medical schools only 14% of modern oaths prohibit euthanasia, 11%
preserve the covenant with a deity, and 8% forbid abortion. Interestingly only a mere 3% forbid sexual contact with patients. It is safe to say that Western society has a more liberal attitude than the Greeks with respect to medicine; rumor has it that the ancient Greeks had their less conservative sides as well.
The Hippocratic Oath and its various permutations are not the only codes of ethical behavior available to novice physicians. The Oath of Asaph, also known as the Oath of Asaph and Yohanan, is a code of conduct for Hebrew physicians dating back to the sixth century AD. Maimonides, a great Jewish philosopher, rabbi, and renowned physician of the twelfth century also devised an Oath and Prayer that is still used in a number of medical schools. Ali ibn Sahl Rabban al-Tabari, the chief Muslim physician in the ninth century AD, described the Islamic code of medical ethics in his book Firdous al-Hikmah stressing the desirable character traits of the physician and the physician’s obligations towards his patients, community, and colleagues. The modern Oath of the Muslim Physician was adopted at the first International Conference on Islamic Medicine held in Kuwait in January 1981.
This Oath requires the physician to protect human life in all of its stages, respect the body of the patient, pursue knowledge, and live in faith in piety and charity. In 1997, the Islamic Medical Association of North America adopted a somewhat different oath that included the Quranic verse stating: “Whoever killeth a human being, not in liew [sic] of another human being nor because of mischief on earth, it is as if he hath killed all mankind. And if he saveth a human life, he hath saved the life of all mankind.” Strict interpretation of this verse suggests that the physician would be in great trouble if he killed a patient unless it was through an act of mischief or in lieu of killing another person. In reality, physicians can also get in a lot of trouble by killing people through acts of mischief.
2 Perfect Intentions, Imperfect People
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Just as some cultures pre-date the Greeks, some ethical codes existed for centuries prior to the Hippocratic Oath. The oath of the Hindu physician, also known as the Vaidya’s Oath, was an oath taken by Hindu practitioners dating back to the fifteenth century BC. This ethicoreligious code requires physicians not to eat meat, drink, or commit adultery. Further, the Vaidya’s Oath commands physicians not to harm their patients and to be solely devoted to their care, even if this put their lives in danger. A Chinese Hippocratic-like oath was devised by a famous traditional Chinese doctor, Sun Simiao (581–682 AD), of the Sui and Tang Dynasties. The code is included in Simiao’s book “On the Absolute Sincerity of Great Physicians” which is still required reading for many Chinese physicians.
The Seventeen Rules of Enjuin, for students of the Japanese Ri-school of medicine in the sixteenth century, emphasized that physicians should love their patients and that they should work together as a family. Physicians were also instructed to respect their patients by maintaining confidentiality of their medical records. This commitment to patient confidentiality stated in both the Rules of the Enjuin and the Hippocratic Oath is alive and well today.
The Declaration of Geneva was adopted by the General Assembly of the World Medical Association in 1948 and it was subsequently amended in 1968, 1984, 1994, 2005 and 2006. It was created to remind physicians that their calling and primary professional mission was to provide service to humanity. The first draft was largely prompted by the painful recollection of medical crimes recently committed in Nazi Germany. It was intended to modernize and adapt the moral directives of the Hippocratic Oath to the realities of modern medicine. The Declaration of Geneva, as currently amended, states:
At the time of being admitted as a member of the medical profession:
• I solemnly pledge to consecrate my life to the service of humanity
• I will give to my teachers the respect and gratitude that is their due
• I will practice my profession with conscience and dignity
• The health of my patient will be my first consideration
• I will respect the secrets that are confided in me, even after the patient has died
• I will maintain by all the means in my power, the honor and the noble traditions of the medical profession
• My colleagues will be my sisters and brothers
• I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient
• I will maintain the utmost respect for human life
• I will not use my medical knowledge to violate human rights and civil liberties, even under threat
• I make these promises solemnly, freely and upon my honor
The amendments to the Declaration have been criticized on the grounds that they are intruding on the inviolability of human life. Hippocrates made “health and life”
the doctor’s “first consideration” whereas the amended Declaration removes the words “and life.” The original Oath demanded respect for human life “from the time of its conception” whereas the Geneva Declaration replaced this with “from 12
2 Perfect Intentions, Imperfect People
its beginning” in 1984 prior to deleting it entirely in 2005. These changes have been criticized as departing from the Hippocratic tradition and as a deviation from the post-Nuremberg concern of respect for human life.
Not to be confused with the Geneva Declaration, the Geneva Convention governs the behavior of military members, including physicians, in wartime.
Anyone familiar with the altruistic behavior of Hawkeye Pierce and the other doctors of “M.A.S.H. ” can tell you that a military physician should impartially treat both his own troops and the enemy based solely on the severity of the wounds and accepted field triage standards. He is allowed to carry and fire a gun, but only in self-defense or to protect his patients. If a physician is captured, the Convention states that the doctor is to be treated as a non-combatant and should be “detained”
rather than “imprisoned.” In return for humane treatment, he is obligated not to attempt to escape and to treat both his comrades and injured enemy soldiers to the best of his ability. These ideas are great in concept, however many physicians and countries don’t play by this set of rules. Red Cross-labeled vehicles and tents may become military targets. Hospitals may be bombed and patients are murdered in their beds. Captured physicians may be tortured or killed. And up to 25% of U.S.
military physicians have admitted that they would not provide the same level of care to enemy soldiers as they would to their own countrymen. Perfect intentions, imperfect people.
Most every culture created deities with healing powers early in its evolution.
As humans were invested with the power to heal (in essence, the power to turn death into life) it is no surprise that each society eventually developed a code of ethics to govern their healers. All of the codes have a similar theme – physicians are to behave as honorable, good, respectable, and compassionate men and women –
and more. They are to value all life, do no harm, and to put their patients above themselves. It is easy to say an Oath; it is harder to live by it. In the 1990s, medical schools experienced a resurgence of students’ interest in taking the traditional Hippocratic Oath. Some older professors, however, were initially reluctant to administer the Oath to these graduating doctors. Some were convinced that these young physicians were not capable of understanding and reaching the high ethical standards inherent in the Oath. Although most eventually relented and swore in these neophytes, we wonder whether they might have been right after all. Would our teachers be proud of the way in which twenty-first century physicians practice medicine? Would Hippocrates?
Section 2
When Doctors Kill
Chapter 3
The Alpha Killers: Three Prolific
Murderous Doctors
Doctors are the same as lawyers; the only difference
is that lawyers merely rob you, whereas doctors rob you
and kill you too.
– Anton Chekhov
Doctors are supposed to heal people, not kill them. Murders by physicians always arouse a great deal of public interest and invariably instigate a media frenzy.
Physicians enjoy a high level of trust and respect as essential providers of life-saving medical care. The doctor is, or at least has been, viewed as a father figure by society – a source of security, safety, and comfort. When a member of the medical profession violates this important public trust, society at large experiences a psychological shock similar to that occurring when a high-ranking military officer or a respected political leader commits treason.
It has been pointed out that because of their close contact with a relatively large number of patients and their unchallenged mandate to recommend treatments with many potentially toxic or lethal side effects, physicians may injure or kill many people if they choose to do so. A physician’s knowledge of human behavior, anatomy, and physiology coupled with a familiarity with drugs, poisons, and sharp instruments may certainly facilita
te serial murders by evil or mentally disturbed practitioners. A physician, even if psychologically impaired, may put on a façade of normalcy and assume the guise of a model citizen. Internally, however, there may be an unquenchable desire to inflict pain, subjugate wills, and, ultimately, to choose between life and death for his victims. For every Dr. Jekyll there is a potential Mr. Hyde. Some studies have shown that among serial murderers a significant number are doctors. Researchers such as psychiatrist Dr. Herbert G. Kinnel have argued that medicine has given rise to more serial killers than all the other professions put together because the medical profession seems to attract some people with a pathological interest in the power over life and death. This infatuation can lead to horrific crimes.
Serial killings by medical professionals are always good for at least a few headlines.
Depending on what else is happening in the world, the stories may stay in the public eye for days to weeks. If Nancy Grace dislikes the suspect, he can be on the air for months before fading back into obscurity. But one-hit wonders are a dime a dozen.
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DOI 10.1007/978-1-4419-1369-2_3, © Springer Science+Business Media, LLC 2010
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3 The Alpha Killers: Three Prolific Murderous Doctors
It takes either a large series of victims or a cluster of cases with particularly gruesome features to permanently etch the murders and murderer into the collective mind. The Jack the Ripper slayings are a case in point.
Saucy Jack (MD?)
The most famous series of killings possibly committed by a medical professional were those of Jack the Ripper. This pseudonym was given to an unknown serial killer, or killers, active in the Whitechapel area of London beginning around April 1888 and perhaps lasting until February 1891. The sobriquet was plucked from a letter sent by someone who claimed to be the murderer to the Central News Agency.