Academic Medicine:
doi: 10.1097/01.ACM.0000352385.31906.d9
Medicine and the Arts

Commentary

Flood, David H. PhD; Soricelli, Rhonda L. MBBS

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Dr. Flood is professor of health and society, Drexel University, Philadelphia, Pennsylvania; (df37@drexel.edu).

Dr. Soricelli, a former internist and nephrologist, now teaches and writes on issues in clinical ethics and medical humanities.

It shocked the medical establishment on both sides of the Atlantic to learn that one of its own was “the most prolific serial killer in British criminal history.”1 Dr. Harold Shipman, an English general practitioner, was convicted in 2000 of murdering 15 of his patients, a number later revised to 218 known victims, during his more than 25 years in practice. But how and why could such a situation happen? In a later New England Journal of Medicine commentary, Aneez Esmail speculated that “[Shipman’s] profession provided him with the opportunity to kill, and the lack of safeguards and controls allowed him to avoid suspicion.”2 But the “why” still remains a mystery: “How could a GP [general practitioner] who was trusted and respected by more than 3,000 patients also be a serial killer who struck time after time with no obvious motive?”3

While these questions remain unanswered for Shipman, Chet Williamson’s 1996 short story “Dr. Joe,” about a general practitioner who becomes a serial killer of his trusting patients, gives a chillingly detailed portrait of how—and why—a good doctor can go bad. Struggling to establish a small-town practice during the Great Depression, Dr. Josiah Waters’s goal is to become the ideal family physician, “the man on those Norman Rockwell covers.” Through civic service and dedication to his patients, he achieves the respected status of “Dr. Joe” after barely two years in clinical practice. When he paternalistically decides not to tell Aunt Esther that he suspects she has terminal cancer, Dr. Joe, himself, identifies the first step of his long slide down the ethical slippery slope. It is his discomfort with this well-intentioned transgression that leads to the second step, a breach of confidentiality when he discusses the situation with his cousin Randall, an insurance salesman.

Unbeknownst to Dr. Joe, Randall takes out a fraudulent life insurance policy on Esther. He then offers to split the death benefit with Dr. Joe. Acknowledging that the situation is “awfully wrong, and certainly unethical if not illegal,” Dr. Joe nonetheless accepts. After all, he hadn’t intended to profit by her death, and the money would help all his patients by keeping his practice afloat. Although we might wonder whether this small-town physician essentially operating in a vacuum would have developed a healthier perspective if he could have approached professional colleagues as sounding boards, Dr. Joe’s decision to split the insurance money is his third step down the slippery slope.

Randall buys policies on other terminal patients about whom Dr. Joe now knowingly informs him while concealing the diagnoses from the patients. Initially, to preserve his sense of being an ethical physician, Dr. Joe selects as insurance candidates only bachelors or spinsters with no families. After some years, however, when he has difficulty finding a suitable victim during another period of financial duress, Dr. Joe decides to sacrifice a “family man,” justifying his actions by sending the man’s son, “a Joe, too, like me” to medical school—something the boy’s father would not have been able to afford. Eventually, he begins to “play God,” selecting “people who wouldn’t be missed too much, or who were causing other people more grief than happiness”—the boy who beat the rape charge, the wife beater, the daughter who abused her mother, the cutthroat businessman.

Through it all, Dr. Joe salves his conscience by putting the money back into his practice. Earlier, being the empathic, dedicated physician was enough. Now, technological advances in medicine drive him to purchase ever more high-tech equipment to demonstrate to his patients—and himself—that “Dr. Joe” is still the best. The material trappings of medicine now compensate for his ethically damaged self. Dr. Joe and Randall finally end the insurance scheme not because of any ethical awakening but because computers have made detection too risky.

Whether or not the end justifies the means is the subject of perennial debate, and perhaps in the early stages of Dr. Joe’s career, an argument could be made in favor of such consequentialist thinking. As the story progresses, however, “Dr. Joe” unmasks multiple other contemporary themes that must be addressed in ethics and professionalism education: conflicts of interest in all their overt and subtle forms; the power differential between physician and patient; the risks of rationalizing our behavior when cognitive dissonance raises ethical red flags; and the seductive power of fame, be that in the delivery of clinical care or played out in the annals of national research and development. “Dr. Joe,” an unlikely parable for us all, reminds us that each is fallible, that reflection on one’s acts in medicine is essential, and that the profession must police itself while providing its members with a guiding hand.

At the conclusion of Williamson’s story, the police who discover Dr. Joe’s body and his record of his deeds determine that a suicide has not occurred here. Rather, a murder has been committed, most likely by the younger Joe, whose medical education Dr. Joe had funded after selecting his father for the insurance scheme. Now a prominent lung specialist who makes a surprise visit to his benefactor, he has apparently discovered the truth and wreaked a terrible vengeance. In an ironic twist, the police decide to destroy the evidence and suppress the truth about Dr. Josiah Waters and his protégé. After all, “[those] families have suffered enough.” Unwittingly, they have now embarked on the same downhill ethical slope of secrets and lies that have plagued Dr. Joe for more than 60 years.

Harold Frederick Shipman committed suicide while in custody in 2004.

David H. Flood, PhD

Rhonda L. Soricelli, MBBS

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References

1Dyer C. Tighter control on GPs to follow doctor’s murder convictions. BMJ. 2000;320:331.

2Esmail A. Physician as serial killer—The Shipman case. N Engl J Med. 2005;352:1844.

3Harold Shipman: The killer doctor. BBC News. January 13, 2004. Available at: (http://news.bbc.co.uk/2/hi/uk_news/3391897.stm). Accessed February 20, 2009.

© 2009 Association of American Medical Colleges

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