Angels of Death: The Doctors

Since the motives for murder by a medical professional are all over the map, it's instructive to narrow down the types of killers to serial killers who happen to be doctors and doctors who kill repeatedly for gain or power. Situational murders, such as killing one's wife, are generally easy to explain, as are mercy killings. Doctors who kill over and over, or who kill in some utterly brutal manner, are more difficult to understand.

According to Lawrence Miller, a police psychologist in West Palm Beach, Florida, there's a neurological facet to predatory killing that is linked to the typical hunting behavior of males. While serial killers tend to act out of some intense fantasy, their hunger for violence is on the extreme end of a continuum linked to the stalking and predation that characterize many normal social activities of human life, such as hunting, romantic pursuit, entrepreneurial enterprises, and group combat.

"It is pathological," says Miller, "only in terms of degree, not the nature of the act." In other words, it's not a brain disease that sets them apart in kind. They act out, feel empowered, and continue to want that energy, just as males in battle want the thrill of victory. Some feel better after a murder, others feel better during it.

From the idea that such behavior is on a continuum with normal human behaviors arise theories like that from Robert Jay Lifton. To participate in evil, doctors must possess the psychological mechanism that allows it. He proposes the notion of "doubling" as an explanation for the Nazi doctors, and then generalizes this as a possibility for any other medical practitioner. There's a prior self---the original person before doubling takes place---and the doubled self---the one that emerges from some dark place.

Lifton calls doubling the "Faustian bargain," because one sacrifices something of oneself to gain something one thinks one needs. Doubling is "the division of the self into two functioning wholes, so that a part-self acts as an entire self."

This is not to be confused with a dissociative identity disorder in which the person has two functional personalities, nor a schizoid type of psychosis. Doubling is in fact an adaptive mechanism in the human psyche that under certain conditions helps us to survive, but it can also be stretched too far. The doctor that doubles in order to kill learns to use his ability to adapt as a way to form a self-structure that encompasses all of his behaviors. That is, he can redistribute his sense of morality to accommodate his killing by having one part of himself disavow the other. He's aware of what he's doing but doesn't have to consider the meaning of it.

The doubled self is responsible for what it does—which often involves altering what murder means---and whatever the prior self gains from this shift reinforces the doubling behavior, ensuring more of it in the future.

The doubled self can act autonomously but can still be connected to the prior self from which it arises. That is, a doctor can view himself as a compassionate, humane person and still go out and kill. The killing self provides a means for the prior self to survive as much as possible without guilt. The killing self is the one doing the deeds, not the "real" self.

However, there's always the danger that the killing self can take over and become the dominant self, as seemed to have been the case with H. H. Holmes and many of the Nazi doctors. The killing self may so violate the prior self that it gives way, finally, to evil. Nevertheless, to call forth the evil in the first place was a moral choice, so the prior self is still morally responsible if not actively feeling guilty.

Depending on the personality involved, several types of doubling can occur:

1. The limited doubler: This person kills only under certain circumstances that he can somehow allow, such as in response to great financial or personal need. In Auschwitz, many doctors did what they were told in order to stay alive.
2. The enthusiastic doubler: This person is pleased to know that he can kill, get away with it, and still function normally. He has an adaptive affinity to it.
3. The conflicted doubler: Both parts of the self retain their power, so that killing produces guilt but the person cannot imagine resolution, so the killing continues.

Lifton believes that doctors as a group may be more susceptible to doubling than others, because they're used to skeletons and corpses, and because they learn to develop a "medical self" with a professional demeanor that may hide many things. They become inured to death and learn to function under many diverse demands. Add to that a heroic vision such as that offered by the Nazis and you get a lot of psychological support for doubling. They can be the paradoxical healer/killer, living in associated but separate realities.

Looking back on the cases, the idea of doubling seems to cover them all, although it still doesn't explain why a person would choose to double as a killer in the first place. To adapt to Nazi conditions is one thing, but to kill one's entire family or a succession of vulnerable patients is quite another. Doubling may be more insidious than adaptive, more an acceptance of the capacity for evil than a way to survive.

At least some countries are responding, however, by instituting more agencies to monitor death rates in hospitals and nursing care. Hopefully these safeguards will detect people like Shipman and Swango before they harm many people.