David Zigmond is a retired GP and psychiatrist in London. He has written and campaigned on problems within the NHS for several years. His website is at http://www.marco-learningsystems.com/pages/david-zigmond/david-zigmond.html
The most shocking destructive human acts are designated by the State – and in our minds – as either wilful criminality or insanity. In the final event the law will decide. How much do these categories help?
It is now twenty years since Dr Harold Shipman was convicted of the incomprehensible and (then) almost unbelievable crime of deliberately killing at least 215 of his patients over three decades. At the time almost no-one thought such a crime to be possible within the motivational repertoire of any doctor, so it was not part of our mindsets. And as we tend to perceive and pattern only those things that we have thoughts for, so we did not perceive the pattern of Shipman’s extraordinary murderousness … because we had not yet conceived of it. Subsequently we have learned rapidly about what can happen if we are not vigilant, even with those we need to trust the most.
Maybe to mark the twenty years of Shipman’s conviction the BBC commissioned a three-part documentary The Shipman Files: a Very British Crime Story that was broadcast 28-30 September 2020. The director, Chris Wilson, had grown up in Shipman’s South Manchester locality and describes feeling ‘haunted’ since the revelations. The Commissioning Editor defined the film’s mission: ‘to reveal the systemic failings and cultural attitude that allowed Shipman to go undetected for such a long time and at such terrible human cost.’
What can we learn?
What do we learn from this long documentary film? Well, let us begin with the Commissioning Editor’s two stated aims.
First, the ‘systemic failings’. From our current knowledge this now seems undoubtedly true: the film documents many events and interviews with police, colleagues and patients all indicating their (then) oblivion to what can now be clearly seen, and described in this film, as ‘murder in plain sight’. Yet such retrospective clarity can easily obscure the obscurity of the time and The Shipman Files manages this with Olympian earnestness. The narrator’s tone is of righteous mournful remonstration: How can they not have seen? The loop-themed music is by turns creepy, poignant, lugubrious: Surely they must know what’s coming?! But the film slips easily past this other truth: they did not see and they did not know because, at that time, no-one had, until then, described such an event or possibility.
They did not see and they did not know because … no-one had … described such an event or possibility.
Now – post-Shipman – we do, and certainly should, know better. Any such blindness or oblivion would rightly be judged as lax, flagrant incompetence or even collusive indifference. That is because of what we now know, what we have learned. But, surely, such moral judgements can make sense only in the context of contemporaneous common knowledge of the time. If we retrospectively moralise adrift from this principle what do we demonstrate apart from our own virtue-signalling?
What about the second main theme, ‘the cultural attitude that allowed Shipman to go undetected for such a long time and at such terrible human cost’ (my italics)? This insinuated judgement runs into similar difficulties. We usually use the word ‘allow’ to mean to let something pass with our full sentience and understanding. Did the ‘cultural attitude’ do that, when no-one yet knew what they did not know? Was society in the 1970s and 1980s so much more uncaring about the plight of the elderly than we are now? Certainly we are more alert to the possibility of rogue healthcarers, but that is significantly different. We also need to remind ourselves that Shipman’s victims died, mostly, in a pre-computer world: data-patterns that are now so easily discerned could not be in that world of paper files and ledger books. Such patterns could then be collated only with much time and labour: that would only happen if we knew what we were looking for. We didn’t know of such a pattern so, for a long time, we didn’t look for one. Yes – again – such ignorance or oblivion would now be unconscionable.
Shipman’s victims died, mostly, in a pre-computer world.
There are other factors that expedited Shipman’s serial killings that have nothing to do with any ‘cultural attitude’. Shipman’s era of practice was one where the GP’s work included much that is now the responsibility of other community and nursing services: for example, opportunistic home-visiting by the better erstwhile family doctor to the newly-born, the bereaved, the vulnerable elderly, the mentally ill, and the dying. All were common then as part of committed GPs’ pastoral healthcare. Mostly such visits were warmly welcomed and positively regarded; many would say this kind of personally engaged care has not been matched since. Indeed, in the film one couple, now probably in their late sixties, say: ‘We trusted this doctor [Shipman]. When Mum was declining he was wonderful with her. We hoped that when it was our turn to be old he would somehow still be there for us.’
Such experiences among Shipman’s patients were common and then responsible for a remarkable resistance among them to any kind of investigation or impeachment of ‘their’ doctor. In these ways Shipman represented a deep and occult perversion of an otherwise caring culture. That perversion is certainly very serious, but it is a very different problem to an absence of care. Shipman’s tragic and rare perversion probably tells us a lot about how complex are our often conflicting needs; for example, for strength vs vulnerability, for trust vs concealment. Yet Shipman’s rare and extraordinary convolutions signify little about the ambient healthcare culture from which they arose.
It is certainly true that Shipman operated in a culture of much wider forms of care and trust. But caution is needed here with interpretation: the fact that he so cleverly and exceptionally abused that culture of care and trust need not impugn the culture he eluded and excepted himself from.
There have been, in any case, developments in technology and services that would make Shipman’s actions now so conspicuous as to be impossible. No current GP goes to attend patients needing that doctor to administer injections of Diamorphine because there are now Community Palliative Care Teams who administer such powerful drugs. Coincidentally, with this change of working roles, has come advances in these drugs themselves and their delivery systems: this has meant that potentially lethal ‘bolus’ injections are much less required. The possibility of another Shipman has therefore been massively reduced by such changes, together with our newly-fashioned vigilance harnessed to IT capability: we know it happened before, and it could happen again. So cultural culpability – a kind of insouciant care-lessness – the moral Leitmotif of this film – seems to be of little, if any, relevance.
The Shipman Files
The Shipman Files does not, therefore, tell us that much about our culture: we are left with a strange individual, a grotesquely paradoxical outlier: diligent-carer-harbouring-murderer.
The film certainly conveys this chimeric portrait through its interviews with many of his erstwhile patients who still echo with confused and angry pain so many years later: ‘How could he have done such things? He seemed so kind … we completely trusted him. He betrayed us!’ is a typical pained refrain about this once-idealised doctor.
Another man, now in his mid-fifties, unleashes a long-harboured yet still-raw rage: ‘Svengali, psychopath, liar, drug addict, serial killer!’. This invectived anger expresses dramatically a common fate of those idealised: their descent into vilification.
Why did Shipman kill?
‘So why did Shipman kill?’ asks the melancholically sincere voice of the narrator soon after the invector. Under public pressure, particularly from some of Shipman’s ex-patients, the government launched a long formal inquiry presided over by a veteran Judge, Dame Janet Smith. The very thorough and exhaustive proceedings certainly clearly answered the factual questions of who Shipman killed, and how he killed them, but not the more indeterminate human-philosophical question of why he did so. The conclusions and recommendations of this inquiry faithfully reflected this tightly limited frame. It said, in effect: ‘Shipman killed (at least) 215 of his patients. The trail of circumstantial evidence is certainly clear now and should have been seen at the time. The fact that it was not heeded demonstrates the hazards of a profession that is largely self-monitoring and self-regulating, Shipman is a shocking and clear indicator of just how much policed management the profession now needs.’
How exceptionally anomalous Shipman was did not figure in the long and very detailed report, or the many draconian micromanagement initiatives that followed the report’s recommendations. The profession now – twenty years later – continues to groan with dispirited fatigue from the corrosive consequences of this.
The profession now – twenty years later – continues to groan with dispirited fatigue from the corrosive consequences.
The trial process and verdict was clear that Shipman was ‘bad’, not ‘mad’: he knew what he was doing and had no other mental illness. But the trial could not address Shipman’s many paradoxes and anomalies – his ‘badness’ was an isolated island in an otherwise good life: he was otherwise a devoted, diligent and conscientious doctor, who worked also for charities and had little apparent interest in wealthy comforts. Very unusually – perhaps uniquely – his victims would have died very differently from those of other serial killers – not with terror, pain and humiliation, but with opiate-euphoria, peace and (specious) trust. This distinction does not, in any way, offer excuse or absolution, but it is worth trying to understand.
Chris Wilson’s view seems pragmatic and avoids any depth-psychology to address these anomalies. He sees Shipman’s choice of victim – almost all elderly women – as being purely opportunistic. He killed wherever it was easiest and the risk of detection was least. Why did Shipman kill? Because he was a psychopath, and that is what psychopaths do. What about the devoted and caring doctor? Well, that was a long and sinister charade, a false-self he presented to the world to conceal his real-self – the murderous psychopath. And why was he undetected for so long? Because the medical profession was hierarchically rigid and blind, complacent and indefeasible. And because the rest of society thinks old people are going to die anyway – it can happen at any time – so we don’t bother to really look out for them … we didn’t care enough to see.
This is the Shipman Files’ understanding of this painful tale of brutal paradoxes.
Just a psychopath?
But labelling Shipman as a ‘psychopath’ gives us merely a tautological so vacuous designation, but not a human explanation. [ie Why did he do what he did? Because he is a psychopath. How do we know he is a psychopath? Because he did what he did …]
Can we do better than this? Here is a start.
Wilson’s film mentions only briefly that Shipman’s mother died at home when Shipman was a teenager. Her illness was a long, gruelling and painful one from an invasive cancer. Shipman was his mother’s main comforter and carer as his father avoided those painful responsibilities. When the mother’s pain became extreme and unbearable, the family doctor would be called to inject his mother with the merciful relief of an opiate: there was no-one else to do this, Community Palliative Care Services did not then exist.
By all accounts Shipman’s public-self was guarded, circumspect, touchily self-reliant, fiercely independent and tirelessly devoted to (his perception of) the needs of others. Whatever vulnerability and complex grief he struggled with remained private, secret, silent and invisible.
For years later, it seems, that Shipman was in the thrall of a compulsion akin to a deep and rare sexual perversion. Like those other perversions it can be plausibly understood as the mind’s way of trying to reexperience, encapsulate, master and refashion earlier crucial events that were either incomprehensible, intolerable or inassimilable. With most such perversions the victim-perpetrator can neither easily explain nor cease their (usually secret) behaviour. This kind of explanation seems to accurately fit Shipman. His victims were mostly older women with whom he had relationships of professionally-framed warmth, trust and affection; they possibly saw him as a kind of caring older son. Shipman ‘gave’ them (himself) the kind of death he wished he had been able to give his mother. When he did this it brought him intense, if transient, relief and peace. He could not find this respite anywhere else, so he needed to keep repeating his terrible symbolic undoing of the past. Only others could stop him, and for that he would have to be caught. This he disingenuously arranged. But he would never admit to it or talk about it. Never. He would rather die.
This he did, by self-hanging suicide, in prison.
This kind of account depends on imaginative psychology. It cannot be subject to true/false dichotomy tests of the earlier formal government inquiry or Wilson’s recent documentary. But such human/humane speculation may help us better perceive and understand the tragic burdens that we may carry within us if we cannot find more creative and healing ways to unload and express.
Such … speculation may help us better perceive and understand the tragic burdens that we may carry within us.
Yes, it is far quicker and easier to write off Shipman as a ‘murderer, liar and psychopath’ and not look at the often painful, tragic complexity of being human. But if we can steel ourselves for this troubling scrutiny we can see so much more, not just of others, but – possibly – even more of ourselves, too.
Of course, we must look out for the strangely and unexpectedly dangerous among us. But it may be equally important to look in, to see more clearly why such things can ever happen.