The doctor-patient relationship is widely regarded as pivotal in the effective delivery of health care. Its unique features make it a prime example of a locus of confidentiality and trust between professional and layperson. It has symbolic properties that highlight the almost sacrosanct quality of medicine in the public imagination. Breaches of trust in any confidential relationship can generate a distinctive unease. But no matter how cynical we may be regarding the likelihood of deception or corruption in human affairs, the problems that have occasionally afflicted the doctor-patient dyad are cause for particular agitation. When those to whom we entrust our health act utterly against our interests and cause harm or even death, it is unsettling in the extreme. That some have done so deliberately and repeatedly is the stuff of nightmares. For these and other reasons, the subject matter of this book is, to put it bluntly, about as sensational as it gets. Dr. Iserson's timely book cannot fail to grab our attention as he collates details of the murderous careers of doctors whose victims were (predominantly, though not exclusively) their patients. The result is a catalogue of malevolence that would make for singularly chilling episodes in any documentary about the human capacity for cruelty and disregard for others' lives. That the protagonists were persons who had sworn an oath of beneficence only makes their behavior all the more perturbing. That they were able to act with impunity, being in a position to cover their tracks for lengthy periods and evade not only detection but even suspicion, makes the revelations contained in this book seem exponentially more horrific. The litany recited here includes infamous individual cases as well as accounts of the collective and conspiratorial use of medical power in the service of vicious political regimes. Among the individual cases figure the callous misdeeds of Dr. William Palmer, whose crimes were committed primarily for pecuniary motives, and those of Dr. Thomas Cream, who killed patients on both sides of the Atlantic. Possibly the most sinister of these infamous physicians is Dr. Herman Webster Mudgett (alias Dr. H.H. Holmes), whose prodigious sexual appetite and morbid preoccupation with his wish to develop a race of giants led him to torture, kill, and cremate his victims in the basement of his vast Chicago "consulting rooms." Although "Holmes" confessed to killing 27 people, the author estimates that he is more likely to have had as many as 150 victims, justifying his designation as America's "first and most prolific serial killer." Then there is Dr. Linda Hazzard, who transformed an initial idea of "therapeutic fasting" into a lethal starvation diet leading to the death of at least 18 patients and probably many more. More recently, there was the case of Dr. Harold Shipman, who was convicted of 15 killings through the administration of morphine and is now believed, after a thorough inquiry into his activities, to have been responsible for an estimated 215 deaths and potentially dozens more. His case has caused extensive trauma in an already deeply troubled British National Health Service. Alongside the perpetrators of some of the horrors recounted here, even the notorious Dr. Hawley Harvey Crippen, the first criminal ever to be caught through the use of radio communication, amounts to no more than a minor player. In systematically compiling information about the types of cases described in this book, one must tread a fine line between pursuing legitimate inquiry and dwelling on the luridly absorbing content of the stories themselves. In painstakingly assembling this material, Dr. Iserson has performed a remarkable service, and his style is, for the most part, appropriately measured. Each chapter provides a mainly narrative account of the lives, circumstances, and crimes of the various doctors it covers. Yet, despite the intrinsic fascination of this material, I was left with a sense of dissatisfaction regarding his investigations, and I regret to say that, on balance, the book appears to favor recitations of the stories over more searching scrutiny of causes and potential remedies. There are two principal reasons why the book leaves the reader with a sense of disproportion and possibly lost opportunity. First, the book is limited in its analysis of the psychological, criminologic, and forensic aspects of homicide. Admittedly, some of the events described here occurred many years ago, and some of the perpetrators were arrogantly uncooperative with their interrogators. The reasons for their barbaric actions often remain forbiddingly remote. Nevertheless, the account presented in the final chapter of the possible motivations for acts of this kind is limited, given the considerable volume of forensic research material concerning serial murder that is now available. Second, given the considerable import of these cases, I would have welcomed some discussion of the ethical, organizational, and other important dimensions of the degree of power wielded by doctors. That these practitioners were able to continue their deadly practices unchecked for so long raises formidable questions regarding deficiencies in our systems of oversight and accountability.
James McGuire, Ph.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.