Physicians, heal thyselves

The biblical injunction takes on new meaning as British doctors struggle to regain public confidence.

Published March 23, 2000 5:00PM (EST)

The conviction of Dr. Harold Shipman last month for the murder of 15 of his patients has sparked a major crisis of confidence in British medicine. Now we hear that the bearded, outwardly respectable doctor may have killed as many as a thousand more. And since his conviction, British newspapers have carried at least one story of medical malpractice every day.

The lead story Saturday in the London Times was "Rogue Doctors To Be Struck Off For Life," revealing that the country's health secretary, Alan Milburn, is "incandescent with fury" that Shipman, 54, was permitted to go on seeing patients long after he had been accused. He wants the British Medical Council to change its rules to ban doctors from ever practicing again after being found guilty of a medical offense. At the moment, a doctor can apply to be reinstated after 10 months, and 1 in 5 is successful.

Friday's Guardian reported "New Organ Scandal Forces Hospital Chief To Quit" after staff at Alder Hey hospital in Liverpool disposed of the heart, brain and lungs of 10-day-old Stephen White by mistake, on the day they were to have been handed to his parents for burial. This follows the revelation that the hospital had removed the organs of 893 dead children without informing their parents.

The day before, the Daily Mail had a story titled "Baby Died After Junior Hospital Doctor Sent Him Home." This was the case of newborn Callum Wright, diagnosed with Group B streptococcus but released from Norfolk and Norwich Hospital, only to worsen a week later. When his parents took him back, a junior doctor, on her first day there, told them they were being "overprotective." He died at home 24 hours later.

And Sunday's Observer capped a disastrous week for the National Health Service when it led with "Private Care Bonanza as Sick Spurn NHS." It revealed that the number of people paying for private operations in order to avoid the long waiting lists has risen by 40 percent since 1997.

What is going on in the country once so proud of its National Health Service for providing free and efficient cradle-to-grave medicine for all? Is there a real breakdown in the system or is it a hysterical press reaction? Has the Shipman case revealed too great a reliance on the family doctor as an unquestioned fount of wisdom?

An avalanche of scandals is forcing Britain to debate these questions. These include:

  • The arrest in February of Dr. John Gordon for the manslaughter of five patients following the exhumation of a body in Carlisle. Keir Hamilton, 18, died from suspected methadone poisoning. Police launched an investigation into the quantity of methadone Gordon was prescribing to addicts to wean them off heroin.

  • The case of Graham Reeves, a 70-year-old Welshman who went into Prince Philip Hospital, Llanelli, to have a diseased kidney removed. Four doctors, now suspended, took out his healthy kidney instead. On March 1 he died. Continuing the bungling, Robert Fletcher Deane, leader of the Royal College of Surgeons' official inquiry into the blunder, turned out to be in the midst of being sued for wrongfully extracting the healthy kidney of a woman in Glasgow three years ago. "If we'd known, we would have asked someone else," said an RCS spokesperson.

  • The striking off the medical register of surgeon James Whiseheart of Bristol in February for continuing with open-heart operations despite warnings from other doctors after 29 children died in 53 of his operations and four others suffered brain damage. He told an inquiry, "The problems we experienced are a microcosm of what is happening all across the National Health Service -- experienced surgeons battling against difficult circumstances, with inadequate resources and in a culture where the finding of scapegoats appears to be put before the finding of solutions."

  • The inability of the hospital service to cope with this winter's flu epidemic. Dying patients were left on gurneys and a third of patients waiting for urgent operations were sent away because there were no beds available. At East Surrey Hospital, near Gatwick Airport, a 71-year-old woman with angina was left on a trolley for 49 hours although government guidelines say no one should be left on a gurney for more than four hours. The hospital also left a 73-year-old woman with a broken leg on a trolley for 45 hours, and a 56-year-old man with pulmonary edema for 32 hours. Chief executive Isobel Gowan blamed an acute shortage of staff, which has forced her to close 30 hospital beds. "Low pay has left the hospital with a shortage of 350 nurses," she said.

    But it was the conviction of Shipman in Lancashire on Jan. 31 that brought all these scandals into focus. Although prosecutors had open-and-shut cases on the 15 murders they charged him with, they had many more in reserve. Coroner John Pollard revealed "the police are looking into another 130 deaths, bringing the total under investigation to 175. You could speculate on a possible thousand deaths over 30 years."

    Shipman's preferred victims were old and female. His chosen method was diamorphine, injected under the pretext of curing them of whatever it was they were suffering from, which quickly brought collapse and death. He watched them die, and never undid one button of their clothing.

    As the judge told Shipman when he imposed 15 life sentences (the death penalty has been abolished in Britain), "I have little doubt that each of your victims smiled and thanked you as she submitted to your deadly ministrations. None of your victims realized that yours was not a healing touch. None of them knew that you, in truth, brought them death -- death which was disguised as the caring attention of a good doctor."

    The effects of Shipman's exposure will be far-reaching. At 30, he had been fined $1,000 for illegally procuring the drug pethidine to feed his own addiction. But due to lax regulations that are still in force, he was still able to get a senior post.

    Only now is the General Medical Council revising the rules that let Shipman go on practicing. But any system to monitor the performance of doctors will take years to set up, warns RCS president Barry Jackson. It turned out that the General Medical Council had no powers to suspend Shipman while he was being investigated by police.

    There has also been a widespread demand for statistical monitoring of every doctor's patient list for unusually high death rates. But amid the clamor for closer inspection, there have been words of caution. A group of doctors wrote to the British Medical Journal on Feb. 19, warning that even 30-40 excess deaths a year would not be detected as statistically exceptional. They wrote: "Shipman's practice list of 3,600 would allow 18 deaths a year above the average to pass as unremarkable, which is more than the 15 murders over three years he is convicted of, and also more than the high estimate of 175 murders over more than a decade."

    One of the writers, Dr. Stephen Frankel, added: "The best protection against lethal doctors is to strengthen the avenues for patients, relatives, other doctors, pharmacists, coroners and undertakers to inform about aberrant practices."

    But the fact is that a good five months before Shipman was arrested the police were warned by local funeral parlors and fellow doctors that a disproportionately high number of his patients were dying. They launched a low-profile investigation, but could not find any evidence of wrongdoing. Three more patients were to die before he was stopped. "The records looked all right," said Detective Superintendent Bernard Postles, "but we now know that was because he was altering them."

    His patients loved the avuncular, white-bearded, Santa Claus figure. They consulted him. They recommended him. And they trusted him. Even after he had been exposed, many of his patients insisted that he was a wonderful family doctor. Typical was Jennifer Cleary, who said on the day after he was found guilty, "He was very, very kind. Dr. Shipman was superb, and I don't think I will ever find a doctor as good as him again."

    When he prevented paramedics from resuscitating one of his victims, 81-year-old Hilda Hibbert, and said with anguish, "You don't want her bringing back as a cabbage," they took this as compassion, not guessing that it was really the fear of discovery.

    So why did he do it? Apart from the forging of one will for $617,600, which eventually led to his unmasking when the real heir smelled a rat, he didn't get any material benefits from the murders. Psychiatrists had a field day trying to answer the question.

    "He felt guilty that he had not been able to ease his mother's death with morphine when he was a teenager, so he set out to repeat her death and this time be in control of it," opined forensic psychologist Ian Stephen.

    "He was a necrophile -- obsessed not with having sex with the dead, but with the act of inducing death and controlling the moment," mused psychiatrist Richard Badcock.

    "He was driven by the thrill of having the ultimate power over someone's life and death. He also had an obsessive-compulsive disorder. He developed this ritualistic act to kill and then felt compelled to repeat the act over and over," was the view of psychologist Alan Wise.

    All the experts agreed that he craved supreme authority, and it is easy to understand how a British doctor with delusions of omnipotence could get carried away with his power over patients. There, the family doctor is still regarded as almost omniscient.

    House calls are still part of the ailing National Health Service and, in a country that has virtually abandoned organized religion (fewer than half the proportion of the population that goes to church in the United States goes in Britain), the family doctor has replaced the priest as the figure of authority.

    "A consultation with a doctor is similar to a confession in church," wrote Fred Kavalier, a general practitioner, in the Independent. "In these days of increasing complaints against doctors it may seem bizarre, but there are many patients who want their doctors to be nothing less than God-like. It is easy for a doctor to obtain lethal drugs. If a patient is elderly, everyone feels it is more humane to avoid involving the coroner. It was easy for Dr. Shipman cleanly and quietly to commit murder."

    Britain is moving only slowly toward the American model of "mini-clinics" replacing the old-style family doctor. Medical practice is strikingly casual compared to North American procedure: When you go to a doctor in Britain neither your weight, blood pressure nor any of the other basic information that is standard pre-consultative procedure in the United States is ever taken.

    In the latest twists to the Shipman saga, the convicted doctor decided to launch an appeal against his sentence, claiming that the press coverage prejudiced his trial. If by any chance he succeeds, the prosecution says it has enough evidence to try him immediately on 23 more charges of murder. And, at last, the British Medical Association has struck him off the list of doctors allowed to practice.

    While the scale of his crimes may be unique, Harold Shipman is merely the latest in a long line of British medical murderers. They are ensconced in British folklore, celebrated at Madame Tussaud's waxworks and as familiar to every schoolchild as Snow White's stepmother.

    Back in the 1850s, another doctor, William Palmer of Rugeley, poisoned a dozen of his relatives and patients. And Jack the Ripper, most famous of all British murderers who got away with it, was strongly suspected of being a doctor, so anatomically perfect was his disembowelment of his prostitute victims in London's East End.

    Dr. Hawley Harvey Crippen, who murdered his wife in 1910 (and fled to the U.S., only to be caught by the first criminological use of wireless telegraphy), is still a household name. And, in the 1960s, Dr. John Bodkin Adams stood trial for murdering his patients and forging their wills, just like Shipman, and was acquitted for lack of evidence.

    Like Palmer and Adams, Shipman was unctuously pious. He decreed in the will he forged for Kathleen Grundy that some of her money should go to an old people's home and to establish a fund for the support of women who gave birth on the anniversary of her death. The rest was to go to her kindly doctor "for all the care he has given," as he phrased her grateful thanks to him.

    As the hysteria mounts in the British press, a spokesman for the National Health Service admitted: "The service is underfunded and has too little capacity. There are too few doctors and nurses. We are trying to change that, but it takes time."

    As for policing doctors, the secretary of the British Medical Association, Dr. Mac Armstrong, says that the present regulatory system is the worst of all worlds. "The General Medical Council has lost the confidence of the medical profession, and doctors worry that it no longer has the confidence of patients." It seems to be a case for St. Mark's words: "Physician, heal thyself."

    However, a new public opinion poll by Market and Opinion Research International found that 87 percent of Britons would still trust their doctor to tell the truth. And how many would trust journalists, presumably including those who were stirring the trouble pot? Just 15 percent. Perhaps we should also be saying "Media, heal thyself."

  • By Elkan Allan

    Elkan Allan is a longtime British journalist and TV producer.

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