Respectful Insolence

More on doctors and terrorism

The other day, I wrote about how several of the suspects arrested in the attempted car bombings in London and Glasgow were physicians or in training to be physicians. At the time, I expressed dismay at what I viewed to be a betrayal of the very basis of our profession, that we try to help people and make them better, not kill them. The post engendered a lot of discussion (and the expected amount of doctor-bashing based on my supposed naivete in stating that most physicians go into medicine to help people, a statement that I stand by).

Now, via Kevin, MD (who apparently got this by way of Instapundit), I found a link to a discussion by Dr. Sanity that bears on the whole issue of doctors as terrorists.

In those who enter the medical profession there is almost always a curious mix of motivations. The motivation most often talked about (and believe me, I have read hundreds of prospective medical students’ essays on why they want to become doctors, and after a while they all merge into one long, treacly sentimental tract) is the desire to do good, to help people, and to ease suffering.

This is good and essential, obviously. But have you ever considered the reality that in order to do good; or to help people in physical pain, that you must sometimes (actually often) cause them even greater pain for a time? That, if you are a surgeon, you must find some enjoyment (or at least be able not to get sick) slicing people open or debriding wounds and mucking around in them? Even those of us who are psychiatrists must often lead the unsuspecting patient to experience (and hopefully to resolve) all the unbearable psychological pain that his psychological defenses have been mobilized to ward off.

This aspect of medicine is not talked about much, but it is very real nonetheless. The physician’s own cruel and sadistic impulses are never far below the surface. In the healthy person these impulses are generally sublimated and the instinctual energy derived from them can then be used to benefit society. Nevertheless, this is the dark side of altruism and the motivation to do good, and it is as human as the impulse to do good.

It is true that we as physicians must inure ourselves, at least to some extent, to the suffering of the patients that we observe and all too often cause in our efforts to eliminate whatever disease the patient suffers from. Not to do so is the path to burnout and even insanity. On the other hand, the doctor who doesn’t retain some empathy for the suffering of patients is not a doctor that too many people would want to have.

As a surgeon, I think Dr. Sanity misses the boat in his example of debriding wounds. When I “slice people open,” they are either asleep or heavily sedated and injected with as much local anaesthetic as I can get away with precisely because I do not want to cause them any more pain than is absolutely necessary to accomplish the task at hand. Indeed, it is the times when I must cause a patient unavoidable pain that are the parts of being a surgeon that I most dislike. For example, back when I used to do emergency room work, I would sometimes have to set bones or pop dislocations back in. No matter how much you dope up the patient before doing that it’s impossible, without general anesthesia, to do these things without causing considerable pain. The same is true for debriding wounds, which, I would point out, is probably the task that most surgeons enjoy least of all.

So what is the enjoyment we get in slicing into people to help them? I can’t speak for everyone, but as a cancer surgeon for me it is the ability to understand and view the anatomy well enough to remove a malignant tumor and save a person’s life. The pain that I cause my patients and how it disturbs me is, in effect, the price that I pay to be privileged to do that work. In that, I think that the “dark” side of surgery that I have to beware of would be the power. It was the love of the power to be able to act on his curiosity, I suspect, that drove Dr. Mengele to his heights of sadism. He viewed his victims as not human, as animals compared to him. I always try to remember that, alone among humans, we surgeons are granted by society the power to cut into people and forcibly rearrange their anatomy–with society’s blessings! The reward, at least in my case, is the ability to be a part of the only specialty that can cure certain cancers (breast cancer for example). Make no mistake, chemotherapy and radiation therapy are great adjuncts in treating breast cancer, but it is surgery that cures.

Consequently, upon thinking of things more since Tuesday, perhaps the reason that doctors are drawn to terrorism is the power. They are used to having power over the lives of their patients. Normally, we trust them to use that power for good and subsume that power into activities that benefit their patients and society, but I could see how the temptation might be there to become even more powerful in their own minds by killing in the name of their God, particularly if they fall into the trap of Mengele; that is, of viewing people not of their race or religion as being less than human.

Comments

  1. #1 Phil
    July 5, 2007

    I don’t think Dr. Sanity was indicting surgeons as closet-sadists/psychopaths and placing them on the level as these terrorist physicians, so much as he is trying to draw an understandable parallel between people who cut people open for the hell of it and people who put on lab coats and sublimate their sadistic propensities to make a world of difference instead.

    Also, it’s feasible to conjecture that people can be drawn to medicine for the power/respect, that is, the medical/scientific authority that comes with the M.D. title and the pre-nominal “Dr.” title as well. This is certainly the reason people are so shocked to hear about the seemingly more common psychopathic doctor that offs his patients for whatever reasons he has justified.

    These terrorist physicians are nothing more than stereotypical persecution complex afflicted Muslims that went to medschool, amassed a wealth of scientific knowledge, and decided that their own extremist beliefs and values outweigh the ones they swore to uphold as doctors.

  2. #2 Dr Aust
    July 5, 2007

    I think the power-trip thing, and my previous suggestions about “wanting to prove you’re the Honcho”, are more influential in who goes into medicine than many people think.

    Interesting point about having to inflict pain sometimes. My other half is very good with kids and was a real whizz at getting them to trust her to anesthetize them. But whenever I asked her why she had never gone into paeds (she spent a lot of yrs of general internal medicine) she would say it was because she knew she couldn’t bring herself to inflict pain on little kids even when she knew it was what was medically necessary for their ultimate benefit. Adults were different, she felt, because they could comprehend why you were going to do whatever it was to them.

    Different subject: re. doctors and handling life-and-death, doctors certainly get a crash course in what I would call “hard-nosed trade-offs”. At the most stark there’s that old battlefield surgeon triage legend (which someone was alluding to on another thread) of not wasting time trying to save someone who clearly had fatal wounds if there are others around who are potentially salvageable. Or take, in the UK, the decision (made pretty routinely in UK hospitals) to NOT put a patient in the hospital’s last ICU bed if there is only a <10% chance they are going to make it, because the ICU beds are always in critically short supply and there will almost certainly be someone else along later tonight who would have a 30% shot.

    [Did you guys in the US get the coverage of the long drawn-out death of the soccer player George Best a few years back? He had three-organ failure - inc his transplanted liver - and sepsis but lingered on on multi-organ support in a private ICU for many weeks. In an NHS hospital he would simply never have made it into an ICU bed in the first place given his minimal chance of recovery.]

    And then there’s all those DNR (Do Not Resuscitate) decisions…

    Anyway, on the whole society lets the doctors take many of these decisions and turns a blind eye. But you could say it makes doctors pretty hard-nosed.

    Then think of a guy like Dr Ernesto “Che” Guevara, who had seen a lot of poverty, suffering and disease (all inextricably linked) on his road-trip round South America. After that, if a few rich people had to be shot to make the Cuban revolution and put in universal health care for the poor- well, the good of the many outweighed the good of the few, he might have said.

  3. #3 Dr Aust
    July 5, 2007

    oops – bit of the last post got lost. Meant to say (end of para 3) “..only a <10% chance they are going to make it: the ICU beds are in critically short supply, and there will usually be someone along later that night who would have a 30% shot at recovery if the bed was available”

  4. #4 Dr Aust
    July 5, 2007

    It wasn’t me, seems like the virtual mice are chewing my posts!

    I’m going to give up now, but you get the gist.

  5. #5 Koray
    July 5, 2007

    If we assume that some (many? most?) doctors chose medicine because “they wanted to help people” and believed in doing no harm, we’d have to conclude that they are nicer than average.

    I recently read about a research where they had subjects compare job ads for attractiveness. Stats revealed that subjects who claimed the sex of their coworkers was irrelevant actually gave up about $3000 in salary for a male supervisor (sorry – I can’t find a link).

    Since then I’ve become skeptical of people’s sincere statements on their intents or preferences, too. So I don’t expect doctors to be less likely to commit crime or be terrorists.

  6. #6 Phil
    July 5, 2007

    Dr Aust-

    If you think Che was involved in only a few (and only rich) people dying, naivete is much more your problem than the sadism talked about in the original post.

  7. #7 factician
    July 5, 2007

    I agree that many (most?) MDs get into the business out of a sense of doing good. For that reason, I am not at all surprised that there are terrorists who are MDs. You forget, the terrorists who are blowing shit up actually think that they are doing good. They are being righteous, in their own minds (and in the minds of their peers). They are doing God’s work (in their minds). I think it’s not surprising at all to find young, idealistic people willing to blow some shit up for God.

    We’d like them to be evil and diabolical, but they’re just gravely mistaken about what is righteous.

  8. #8 Joseph j7uy5
    July 5, 2007

    FYI: Dr. Sanity is actually Patricia Santy, so the feminine pronoun would be more appropriate.

    I know that what she says about sadism being “under the surface” is a standard formulation in psychodynamic terms (in which the two fundamental motivations are sex and aggression). However, I don’t buy that formulation.

    The physician’s own cruel and sadistic impulses are never far below the surface.

    For one, I don’t think the notion of there being only two motivations is correct. Granted, there are still many adherents of that notion, but it lacks empirical validation. Cloninger’s notion of dividing motivation into reward dependence, harm avoidance, and novelty seeking, has (at least some) empirical basis, and (at least some) way of mapping the abstract concepts onto a neurobiological substrate.

    I think it would be more accurate to say that physicians, as a group, are characterized by the ability to act decisively, with determination. After considering the risk-benefit equation, a physician must be able to act even when the risk or cost is considerable. There are times when that might appear cruel or sadistic, but it is not the same thing. Most humanistically- oriented physicians will act within a framework that respects the patient’s own values regarding risk tolerance.

  9. #9 Phil (the Phil who made the first comment)
    July 5, 2007

    Koray, I don’t see the correlation to that study and your criticism of doctors supposedly being “nicer than average” unless the offending “they” in the study are doctors. Please tell me this is not the case.

  10. #10 Calli Arcale
    July 5, 2007

    Personally, I think it’s very simple. Horrible, but simple. On this blog, courtesy of Orac, we have seen doctors who have gone so far down the primrose path of woo that it seems inconceivable that they had any kind of formal education at all, much less a medical degree. It seems odd to us that a group as well educated as doctors could possess so many apparently ignorant people (even ignorant on topics highly relevant to medicine, such as biochemistry; I can understand a doctor not grasping the special theory of relativity, but frankly they have no excuse for getting suckered into homeopathy).

    So we know doctors are just as gullible as the rest of us, no matter our stereotypes of wise, benevolent doctors. It really shouldn’t be inconceivable that they may also be just as prone to other misguided beliefs, such as the opinion that the ends justify the means.

    These physician terrorists appear to have been led astray not by pychosis or a desire to get Britain out of Iraq or anything like that. Rather, they have been led astray by Islamic fundamentalism, and the dream of a world-wide Islamic caliphate. There was an old perception of the world being split into two domains: the Islamic world, and the world of unbelievers. Peace was to reign in the Islamic world, but the rest of it was fair game. If one believes in that sort of thing, today’s world is horrifying because there really is no Islamic world now. The closest thing would probably be Saudi Arabia, and of course it doesn’t really satisfy the fundies, who feel that it has made a deal with the devil (the unbelievers, which includes the West but is not limited to it). There are also attempts underway to create fundamentalist Islamic states, such as the attempts by the Taliban to recover Afghanistan, and then of course the horrors being committed by the janjaweed in Sudan.

    The world will have peace once it is united in Islam, or so fundamentalist Muslims believe. Ergo, the sooner this happens, the better. Ergo, it is justifiable to take extreme measures to hasten it. In fact, their doctrine actually endorses doing so — it is unacceptable to kill believers, but unbelievers are fair game, and the worst of all of course are heretics.

    The decision of these doctors can be likened to “the good of the many outweighs the good of the one”, but I think that gives them too much credit. Truthfully, they simply believe that this is what they are called to do. For doctors, I’m afraid, are no more immune to religious idiocy than the rest of us. Oh, their extensive education helps — it gives them a chance to learn critical thinking. But it is certainly no guarantee.

  11. #11 Vern
    July 6, 2007

    …we try to help people and make them better, not kill them.

    LOL. What a joke, Orac. How does blogging about stupid stuff all day and night “help” anybody?

    You guys care are about money, prestige, reinforcing the status quo, not getting sued, in that order. You do not try to help people or make them better. Nobody believes this, perhaps it is a comforting lie you tell yourself.

  12. #12 Cam
    July 6, 2007

    To everyone who perpetuates that “doctors are in it for the money” myth…

    There are many easier ways to make a bunch of money than to spend 36 hours in a row at the hospital trying to keep someone from dying. If I was in something for the money, I would’ve become an investment banker. Or a lawyer. Or an accountant.

    Of course, if I were in it for the money, I certainly wouldn’t be practicing family medicine in Canada.

  13. #13 Koray
    July 6, 2007

    Phil #1: The study subjects were not just doctors. What I meant is that even when a doctor sincerely says he became a doctor to help people and do no harm, I don’t necessarily believe it.

    For me there’s no problem for a person to study and practice medicine because he thinks he’d be good at it, make a good living and have a good standing in society. These are perfectly acceptable and sufficient for every other profession. If you assume that doctors are less likely to commit acts of terror then it immediately follows that they are better people than the rest of us.

  14. #14 Legal Eagle
    July 6, 2007

    Doctors kill over 100,000 people a year through mistakes, and if you try to talk to someone like Hoofnagel about it they make exucuses.

    Not to mention the million and a half babies aborted each year by doctors.

    So this bullshit about “doing no harm” was out the window long ago.

    Who ya kiddin?

  15. #15 Orac
    July 6, 2007

    Oh, goody. I wondered when the doctor-bashing “doctors kill 100,000 patients a year”-type trolls would come out of the woodwork. It only took them two days from the original post…longer than I expected.

    Guess it must have been the holiday.

  16. #16 Dianne
    July 6, 2007

    For whatever the anecdote is worth, here are my reasons for going into medicine. They may or may not be what I told the med schools I applied to. To tell the truth, I no longer remember what I told them. But the actual main reasons were:

    1. Curiosity. An MD allows one to experiment on people (with their consent and IRB oversight, of course) and find new things out about how the human body works and how to fix it when it doesn’t work. This was the main attraction for me. It’s not particularly noble. Sorry.

    1b. Curiosity. MDs are allowed to ask strangers questions that would normally get them slapped. Still not noble.

    2. Helping people. Yep, now we’re getting to the treacly stuff. It’s so often hard to know whether one is really benefitting others or not. Giving a street person money may simply be enabling their drug habit. Outlawing FGS may cause social chaos in societies that have traditionally used it. Overthrowing a dictator can…see Iraq. But curing someone’s illness or easing their pain is nearly always a good thing, at least for that one person. Yes, I know, it can go badly wrong, but at least in principle medicine is always meant to help.

    3. Power? Well, power. But I stand by my earlier statement that creation and preservation are power and destruction is the refuge of the incompetent wannabe. Actually, while I might find the whole power-status thing appealing in principle, there is nothing I find more embarrassing than a patient saying something like “whatever you say, doctor.” Still, I enjoy beating a cancer into remission as much as the next person. Nothing like being able to give the finger to death, even if we all know it is only temporary, to make one feel better.

    Sadism? No. I can’t imagine committing sadistic acts on patients. I can’t stand seeing people in pain and not doing anything about it. Literally. I get panic attacks. One reason I could never be an ob/gyn is that I can’t watch women in labor suffering and not do anything about it. Even when they don’t want anything done and are doing perfectly well on their own.

    The potential dark path for me is not sadism but depersonalization: seeing the patients as test subjects, not people. When I read about some of the things the Nazi doctors did, I find myself horrified not just by their inhumanity, but by their poor experimental design. I wouldn’t sacrifice a mouse, a cell culture, to some of the experiments they were performing: they were simply so poorly designed that nothing would be learned. If you’re going to kill people you could at least learn something from their deaths. Killing them in badly designed experiments seems such a waste all the way around. This is probably not the optimal humanitarian response. So I’m really quite greatful for IRBs, even if I do hate the paperwork involved in getting a protocol approved.

  17. #17 Orac
    July 6, 2007

    Bingo, and that’s what I was trying to get at but in retrospect perhaps didn’t do as good a job as I could have.

    The reason Dr. Mengele was able to do such horrific things is because he did not view his test subjects as human beings. This, of course, was helped by the Nazi ideology that demonized Jews as subhuman, but it’s nonetheless a danger in any physician. Forgetting that patients are as human as you or I is indeed a danger, particularly for academic physicians. Thankfully, we have many safeguards in place to prevent horrors like Mengele or the Tuskegee experiments from happening again. Abuses occur, but I don’t think abuses on the scale of the Nazis or the Japanese biomedical “experiments” during World War II is likely, at least not in western Democracies.

  18. #18 factician
    July 6, 2007

    In it for the money? There aren’t that many doctors that make good money (except for a few of the fancy specialties like cardiac surgery). You’d be smarter to become a real estate agent if all you wanted was money. Or a dentist. My dentist friends pull in $200K a year working 4 days a week, and taking loads of vacations.

    If anyone goes into medicine for the money, that person is very, *very* stupid (and therefore, not that likely to get into medical school).

  19. #19 Dr Aust
    July 6, 2007

    The financial rewards of medicine differ widely in different countries, factician. In the UK the consensus would be that mid-level doctors (typically still in specialty training) earn the same as mid-level lawyers, CPAs, actuaries, etc, but that consultants (attendings) – at least those working in the state medical system – probably don’t earn as much as other really top-end professionals. There are exceptions, and people in medical or surgical specialties where there is a thriving private sector (which enables patients with add-on insurance or hard cash to “leapfrog” the waiting lists in the state system) can make big $$$ “moonlighting” to do private work part-time (early mornings, evenings, w/ends, afternoons off). A lot of surgeons in particular do this.

    In the UK specifically, people with jobs in finance (of almost any kind) out-earn all other professions comfortably. But the docs do pretty well. A UK family physician who is a partner (part owner) of a medical practise and works a 5-day week with no “out of hrs” call-outs now earns about US $ 200 K on average. Investment bankers still earn more, but you can also earn a lot less. For instance, a 40-something tenured University Associate Professor in the sciences, with a Ph.D. and many years training and experience, would be on about half that much.

    Re. comments above, agree the “dehumanization” of people, including patients, is a key concept. Doctors do have to guard against the dehumanizing mindset. It lies behind some of those jokes like:

    “How did the trial of your anti-angiogenic agent X1-06B go?”

    “Really promising, we got 95% tumour cell kill at day 6 with xy mg/kg.”

    “And how’s the patient doing?”

    “Oh… unfortunately the drug regimen gave them pulmonary oedema and they died. But we’re really looking forward to the next case so we can try a different dosing schedule…”

    PS You may be gratified to hear that real estate agents in the UK earn comparatively little, and are universally regarded as even less trustworthy that journalists or politicians (who trail almost all other professions, even lawyers). To make money in property in the UK you need to be a real estate developer rather than just an agent.

  20. #20 Vlad
    July 6, 2007

    Hey Lawyer parrot,
    So 100,000 people are killed by doctors mistakes? Not really my feathered friend. Yes about 100,000 people die that could have been prevented because someone screwed the pooch. First you have some of those deaths from experimental procedures. The person under the experimental procedure is screwed anyway, otherwise it’s unlikely they would try it, unless it’s an Altie thing. The reason most doctors won’t touch experimental stuff is because feathered disgrace for a lawyers (not all just some) go after every penny they can get regardless of the actual merits of the case. Also the people that die in the hospitals are already sick or injured so they have a higher chance of dieing any way. They also have a much higher chance of dieing if left to their own devices. As far as abortion, when all the bible thumpers clear out the orphanages and the DSS holding tanks then you get to question the behavior of doctors. Take a peak at all the suffering incurred by the unwanted children. DSS survivors have high suicide attempt and success rates. The term “do no harm” is open to interpretation, to me it means minimize the suffering. The bible thumpers constantly and creatively re-interpret the bible to suite their prejudices. If one chooses to truly do no harm (taken in the absolute) then one can not touch a patient at all because there is always risk of doing harm.

    No I’m not a doctor parrot

  21. #21 emily sheffer md
    July 6, 2007

    Couldn’t help but agree with previous comment by Cam. There are far less rigorous endeavors by which to make money than 12 hour shifts in an urban ER, up to my elbows in various unsavory bodily fluids, assaulted and cursed at. In point of fact, I earn less than half of what my contemporaries earn in finance. Still, I love what I do and consider it a tremendous privilege.

  22. #22 S. Rivlin
    July 6, 2007

    I still believe that the main reason a few doctors (apparently very few) resort to terrorism is no other than religious brain-washing. Throughout human history, only religion has ever managed to twist people minds so badly.

  23. #23 trrll
    July 6, 2007

    Whenever a horrific event (or in this case a near miss) occurs, it is hard to avoid the temptation to draw broad generalizations from a singular event. Such generalizations are particularly dangerous, both because they are so often wrong and because their association with said event causes them to “stick in the mind” and bypass rational consideration.

    I think that it is almost certainly an error to seek some particular vulnerability to terrorist thought in the soul of the physician. It is not as if there is some long-term trend of physician involvement in such crimes. The fact that so many of the attempted perpetrators in this case were physicians is very likely a nucleation phenomenon–i.e. a consequence of the pattern of associations of the specific individuals involved in this particular instance rather than something to do with physicians per se. If the guy who started building the cell had been an auto repairman recruiting acquaintances that he knew to be sympathetic to his cause, we might now be wondering what it is about auto repair that predisposes one to terrorism.

    I suspect that the basis of terrorism here is the same as anywhere else: dehumanization of the enemy, the belief that nobody is truly innocent, the belief that the end justifies the means, and that “God will sort them out,” anyway. All this tells us is that physicians are not any more immune than anybody else to these malign notions.

  24. #24 grasshopper
    July 6, 2007

    From the British Medical Journal, Dec 23rd, 2000

    … medicine has arguably thrown up more serial killers than all the other professions put together, with nursing a close second.
    Dentistry too has had its notorious characters, yet among veterinarians homicide seems to be almost unknown.

    One of the perquisites of being a veterinarian is to deliberately end the life of an animal that is suffering. Doctors are not permitted to act in a similar way for humans.

    Vets get to play God every day.

    Some doctors think they are God, perhaps.

  25. #25 Samantha Vimes
    July 7, 2007

    Those who bring up abortion as an example of doctors not caring about human life, do not count pregnant women as human.

  26. #26 hoary puccoon
    July 8, 2007

    The odd thing I noticed about this is the ‘doctors go into medicine to do good,’ mantra– as if that distinguished them from other professions. In my experience, almost all people feel that their occupation does good. Do you think that farmers grow crops in order to increase American obesity, or that truckdrivers’ main goal is to increase global warming? Actually, both groups think they’re out there keeping the population supplied with food and other necessities. It’s the doctors’ bias that they’re somehow special which could lead them into the selfrighteousness that promotes terrorism.
    That said, I think we need to see how the investigation shakes out before thinking there is some great ring of doctors attacking Britain. Apparently the cell phones found at the intended bomb scenes had a lot of numbers on them. A doctor who was involved in the plot would probably also have phone numbers of other doctors whom he contacted for professional reasons that had nothing to do with radical Islam. I’m guessing when the smoke clears we’ll find there were a couple of kooks, and a lot of complete innocents who were just going about their jobs.

  27. #27 MikeB
    July 9, 2007

    I’d like to pick up on Grasshopper’s post about the number of doctors and nurses being serial killers.
    I suspect one reason is simply that they tend to have the means and opportunity. Howard Shipman showed clearly that you could knock off people for years , with relatively few questions, as long as the people you killed might die anyway, and that you used medical drugs (which could be explained away), rather than anythings else. It’s much easier to be a killer if you just have to fill out a cremation form afterwards.

    Of course the ‘Some doctors think they are God’ arguement might hold water, considering some of the surgeons I’ve come across….

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