The Dark Side of Medicine: Invisible or Ignored?

Written By Girish Greedharry

Going through medical school, I find that there is something apathetically robotic in the way we get indoctrinated with the principles of what makes, in theory, a good doctor. Teachings of clinical practice encompass all the right things you should say - whether a patient approaches you with a suspected drug addiction or just wants to have a chat about how the neighbour’s new dog is the root cause of their insomnia. We get told how we should behave in the presence of a patient and what we should be feeling for them as they open up to us about their problems. We get told how we should be listening to those stories and what important things we should take away from them.

All while putting on an empathetic face that says “I want you to know that I am listening to you. I care about your wellbeing and I want to do everything that I can to help you.” We get taught and assessed on all of that, but to what end?

Simply put, are we paying medical schools bucketfuls of money to potentially get churned out as professional manipulators? At the heart of medical school, we get programmed to navigate the best way possible to involve ourselves into our patient’s lives, earn their trust and have them expose all their vulnerabilities for us to exploit, regardless of whether that exploitation is essential to helping them. And we also get taught to keep our distance from the patients - not to get personally invested in their lives. That, ipso facto, exalts us to a position of power over those who seek our help. While having that distance is deemed as fostering a professional rapport with a patient, it also makes me think that there is perhaps a Machiavellian element to the establishment of such a doctor-patient relationship, whereby they trust you considerably more than you do them.

However, there is a paradox in the way that you, as a doctor in a position of power, must convince a patient that you have their best interests in mind, so they should wholeheartedly trust you, and yet, at the same time, cast the illusion that they harness all the power. It seems a bit sociopathic, doesn’t it, that artificial production of forced feelings towards a patient? Even more ironic, is the emphasis laid on the importance of developing an organic relationship with a patient, one based on mutual respect and equal footing. Well, in that case, how can you distinguish if your behaviour is being dictated by compulsion from years of tireless rehearsal or by a bona fide interest in helping the person? Maybe it is both, maybe it is neither. The line between conservation and abuse of that acquired trust is very fine.

I think that this is precisely the reason why serial killers like Harold Shipman have been able to claim so many lives. One can only speculate about his motives, but I am convinced that the manipulation of his patient’s trust has been instrumental to him successfully murdering his victims. At that point in his career, Dr. Death must have been an expert in the art of deceit to have gone undetected for so long. But that does make me wonder – how much of it was due to his innate sociopathic character and how much of it was instilled throughout his training?

Admittedly, the loss of his mother to lung cancerand his own struggles with substance abuse must have played a major role in the cultivation of his obsession with opioids and the ideas of controlling death with it. That would explain why he conducted the killings and his choice of weaponry, but not how he targeted or approached his victims. What if his formative medical years were key to him learning how to tap into his murderous potential? What if, again ironically, his training was the very thing that cemented his fate as a killer? Indeed, he could have seen those teaching moments as being a vital lesson in keeping up a façade of normalcy, while simultaneously equipping him with the social tools to enact his murders. That could also shed some light over the circumstances under which Shipman became the sole heir to the estates of so many of his elderly female patients, following their demise.¹ I would imagine that he would derive much more pleasure out of coercing them into signing their whole lives over to him rather than simply forging some signatures on a piece of paper, thereby making his victims bend to his will and asserting himself as a master over his dominion. That is why I find it very hard to digest that he would write with red in his ledger merely for monetary pursuits (granted, that would be a welcome bonus).

According to the first report published by Dame Janet Smith, who was appointed as Tribunal Chair for the Shipman Inquiry, the former GP was found to have killed at least 215 of his patients between 1975 and 1998, with the actual number being higher (lack of evidence proved some investigations inconclusive).² It is a baffling number, but it just demonstrates how easy it was for Shipman to kill. He managed to entrench himself so robustly as a pillar of the community in Hyde that he was able to undertake the murders, unbeknownst to everyone. He was so respected and dignified that patients would go as far as to claim that being accepted on his list was equivalent to “winning the lottery.”³ This just illustrates how adept he was at wearing his mask and evading suspicion because he was excellent at making his patients feel heard. The son of one of Shipman’s victims even attested : “I remember the time Shipman gave to my dad. He would come at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father.”³ So, could it be fair to say that being a good doctor and a prolific serial killer are not necessarily mutually exclusive things?

Now, the parameters of trust are not limited to just the doctor and the patient. It also extends to the patient’s family, friends and to the members of the multidisciplinary team. With more people involved, there are more opportunities to establish that dynamic and, consequently, even more chances for that trust to be abused and breached. This is where it gets messier. As a whole, you (as a patient) are left with almost no choice but to rely on that team to cater to your needs, but how many of them can you individually trust? And what is the guarantee that they can also fully trust each other? I think that Lucy Letby perfectly encapsulates this dilemma. As part of the neonatal care team, she was entrusted with the responsibility of tending to babies and expected to deliver the utmost standard of care but this resulted in an earth-shattering tragedy. She is currently serving fifteen life sentences on the count of seven infanticides and attempted murder on seven others, but her conviction still remains a highly debatable subject.⁴

Her case highlights that there are several layers to this patient-profession relationship which make it so susceptible to abuse and even harder to identify. It could also be the blind optimism that everyone who decides to pursue a medical venture can only mean well for others, or exhaustion from being stretched to your limits that precludes you from caring enough to notice when things are seeming sketchy. Or it may well be a simple case of denial to believe that someone you know and work with every day could be capable of such unspeakable atrocities. But all that does is enable the wrongdoers to persevere. Who will take responsibility for when things go astray then? Is it the people who failed to notice what was right in front of them or is it the people who have failed to train them to recognise such signs and come forward with their thoughts? Or perhaps it is all due to the system that has tried and failed to implement policies to stop these crimes before they are even committed. It is believed that it is better to prepare and prevent rather than to repair and repent. But I still wonder, how far is that viable in the medical profession?

I do also think that a career in healthcare can potentially corrupt and a failure or reluctance to acknowledge this daunting possibility contributes to gangrenous elements in an otherwise already flawed system. Exposure to lethal drugs and easy access to the vulnerable can breed temptation. Giving in to that temptation in a clinical setting could be just as voluntary as inadvertent. Coming back to the Shipman Saga, another reason he could have chosen to kill with diamorphine overdoses may have been because he had easy access to it. The inquiry on his practice revealed that he used to overprescribe the potent analgesic and, being the compassionate and caring practitioner that he was, he used to collect the drugs from the pharmacist himself to deliver to his patients.³ Of course, at the time, no one had a clue that he was keeping the surplus for his personal arsenal. Furthermore, if we explore his drug addiction while working at Todmorden Health Centre in West Yorkshire (this was prior to his move to Hyde), he was found to be falsifying prescriptions for pethidine to feed his own needs and was subsequently sacked.³ Shipman again exemplifies just how easy it is to start abusing power.

In the case of Letby, she decided to be a bit more resourceful. Her murderous repertoire consisted of intravenously introducing air emboli in the babies, insulin poisoning via adulteration of their drip feeds and overfeeding them with milk, just to name a few.⁵Perhaps her hope had been that these mishaps would pass off as coincidences. But little did she know that, ever since the first few incidents, suspicions had started to rise. Dr Stephen Breary and Dr Ravi Jayaram, two consultants at the unit, dissatisfied with the sheer inexplicability of the situation, decided to conduct their very own informal review. Unfortunately for Letby, the common denominator in this sudden rise in infant deaths was found to be her, marking the beginning of the end of her avocational activity.⁵ But what if those two consultants had not picked up on those signs, however inconsistent? When these sorts of things occur, it really puts into perspective the vicissitudes of a medical career and how although it can be a rewarding path and all about helping those in need, you will also encounter endless pain, suffering and loss.

Not being aware of this dark aspect of the medical profession can be just as catastrophic as being aware of it and consciously exploiting it, if not more. You can try to stop a driver who knows they are about to drive off a cliff but what can you do if the driver has no idea that the cliff is even there? This is where I think the difference can be made. Acknowledging and talking about the nuances in medicine is paramount, even if it makes you sound like an absolute sociopath. At least it will start a conversation. Only then can the root causes be properly examined, and solutions can come into play. Everyone, indubitably, has intrusive thoughts that drive malicious temptations, but how can they be prevented if no one wants to talk about them?