Attack of the Killer Nurses: A look at a curious phenomenon.

In August 1975, three patients suffered cardiopulmonary arrests within 15 minutes of each other at the Veterans Administration Hospital in Ann Arbor, Michigan. An astute anesthesiologist noticed that all three patients looked as if they had been administered a muscle-paralyzing agent-which, as it turned out after much investigation, they had.

Rarely can the commencement of a tradition be placed so precisely in time-the tradition in question being that of nurses murdering their patients wholesale. Of course, it is quite possible that an underground tradition of this nature existed undetected even before the events at Ann Arbor, but from that time forth there have been epidemics, both large and small, of unexpected death at regular intervals wherever murderous nurses have taken employment. On March 26 of this year, for example, the nurse Kristen Gilbert, somewhat unimaginatively dubbed the "Angel of Death," was sentenced to life imprisonment for having fatally injected three of her patients with a stimulant to mimic heart attacks. And in November 1999, a nurse named Orville Lynn Majors was sentenced to 360 years' imprisonment for having killed six of his patients by injection of potassium chloride.

There have been outbreaks of nursing murder in many different hospitals in the last quarter of a century. They are often surprisingly difficult to detect. Indeed, many may have gone completely undetected. During the 1980s, The New England Journal of Medicine and The Journal of the American Medical Association published several articles about epidemics of unexpected cardiopulmonary arrest in hospital intensive-care units, usually coming to the cryptic conclusion that patients were 47.5 times as likely to have had a cardiopulmonary arrest while Nurse 14 (who could not be named for obvious legal reasons) was on duty as when any other nurse was on duty.

One of the most notorious outbreaks occurred in Toronto in 1980 and '81, in the cardiology ward of the famous Hospital for Sick Children. The death rate suddenly increased by four times in Ward 4A. High levels of digoxin were found in the blood of four of the deceased children, and it was estimated that, during the epidemic of sudden and unexpected death, the children in Ward 4A were 64.5 times as likely to die when Nurse A (who was a woman named Susan Nelles) was on duty as when any other nurse was on duty. She was arrested but released 45 days later for lack of evidence. The police, however, sought no other suspect.

In fact, Nurse A may have been innocent, and the deaths may have been no murder. The high digoxin level found after the deaths of the children may have been an artifact of the methods used to detect the drug. In those days, the rubber in syringes and other medical apparatus was manufactured using a potentially toxic substance that could have killed the children, either directly or by allergic reaction to it. To this day, therefore, the deaths at the Hospital for Sick Children have not been satisfactorily explained, and these doubts (which are similar to those that accompany several other such epidemics in hospitals) have been used to suggest that the very concept of mass murder by nurses is a reversion to the medieval witch mania or to the Salem trials of the 1690s. American courts have ruled that epidemiological evidence-that an excess of deaths in a hospital ward when a particular nurse was on duty-is not sufficient to convict, even when there is also evidence that a fatal substance was administered.

But there have been so many cases of undoubted murder of their patients by nurses (and hospital orderlies) that popular hysteria or mass psychosis in the public and the media is not a plausible explanation of the phenomenon. The question, then, is why should this pattern of behavior have emerged in the last quarter of the 20th century?

Do the nurses who behave like this have a deep-seated personality trait or a motive in common? It is natural to assume that they must have characteristics that distinguish them from others of their profession (after all, mass murder by nurses is still very uncommon) that would enable them to be identified in advance, and therefore tragedy to be averted.

This assumption leads to official responses that are like those of generals, who are always inclined to fight the current war as if it were the last war. For example, not long ago I was approached by a senior nurse in my hospital who was worried about the conduct of one of our nurses. She seemed in several ways remarkably like Beverly Allitt, a nurse in Mrs. Thatcher's home town of Grantham, who was given 13 life sentences for murdering three children, attempting to murder three others, and causing grievous bodily harm to six more.

In retrospect, Allitt was clearly a young woman with peculiar traits. Among them were both bulimia nervosa (binge eating followed by vomiting) and Munchausen's syndrome: the habit of presenting oneself to doctors and hospitals with dramatic symptoms of illness that are entirely spurious (it is characteristic of our age that repeatedly lying about illness should be considered itself an illness).

The young woman in my hospital about whom the senior nurse was very worried also suffered from bulimia and (if suffering is quite the term for it) from Munchausen's syndrome. And the hospital had received telephone calls making threats against her that, when traced, turned out to have been made from her own cell phone. Could she be another Beverly Allitt?

I suggested that any deaths on her ward, in the past, present, and to come, be carefully investigated (in the event, there were none that aroused suspicion). I left the senior nurse to decide whether the illness of faking illness in her spare time, and the making of nuisance telephone calls, were by themselves sufficient cause for dismissal. I am not sure I would have wanted the young woman in question to nurse me, however.

Psychiatrists suggested that Beverly Allitt, like several of the other nurse-murderers, was "suffering" also from Munchausen's syndrome by proxy. This extraordinary pattern of behavior was first described by a British pediatrician, Professor Roy Meadow, who discovered that parents, particularly mothers, sometimes induced symptoms in their children in order to gain the attention of doctors. They would put blood in their urine, provoke rashes, and in some cases (proved by covert video surveillance) asphyxiate their children to produce respiratory arrest. The most common explanation for this behavior is that the women who do this want drama in their otherwise rather humdrum lives. Perhaps not altogether surprisingly, the children of parents who "have" Munchausen's syndrome by proxy have a much reduced life expectancy.

Some of the nurses who kill are thought to want to be present at real life-and-death dramas, as if they were inhabiting a television soap opera. Moreover, by reviving the people whose hearts and breathing they have stopped, they cast themselves in a heroic light. Their fantasy is made flesh: but in the process, of course, a certain number of participants, that is to say patients, pay the ultimate price.

The motive remains a mere hypothesis, since people like Beverly Allitt rarely confess or confide their thoughts to anyone. But in any case, it is clear that other nurse-murderers have other motives: One motive does not fit all.

In another case, for example, the nurses in a ward ran bets as to which of their patients would be first to shuffle off this mortal coil. So eager was one of the nurses to win her bets (perhaps she had money problems) that she cheated a little, no doubt calming her conscience with the reflection that she was only giving a helping hand to the inevitable. As Engels remarked, what is freedom if not the recognition of necessity?

In more than one episode of serial murder, in both Canada and the United States, nurses have been moved to kill by sheer public spirit. They wished to demonstrate the need for a local pediatric intensive- care unit, and what more convincing method could there be than to bring about the very kind of emergencies that such a unit would treat? Alas, in the absence of such a unit, the babies died, but whose fault (really) was that? From a strictly utilitarian point of view, it is clear that the cause of humanity would be served by the babies' deaths: for in the long run, more lives would be saved by the intensive-care unit than were lost in proving the necessity for it.

Nurses also kill because they believe in euthanasia. The great majority of the victims of nurse-murderers are at the extremes of life (the periods of human existence that, by pure unadulterated coincidence, most concern bioethicists such as Professors Peter Singer and Ronald Dworkin). In Austria-a country with a great tradition of mercy-killing- some nurses unilaterally decided that their geriatric patients would be better off dead, and duly liberated more than forty of them from their travails.

A recent survey among American intensive-care nurses, conducted to ensure anonymity among the respondents, suggested that about a fifth of them had actively killed (or claimed to have killed) at least one patient, taking the initiative into their own hands. The survey was criticized for being unrepresentative, but it clearly demonstrated that the killing of patients by nurses was not confined to a mere psychopath or two. Likewise, one in seven of the half of the AIDS nurses in the San Francisco Bay area who responded to a questionnaire claimed to have assisted at least one patient in committing suicide.

There are many problems, of course, both ethical and practical, with mercy killing, which I need hardly rehearse. That the end of life can be a horrible and distressing process is undoubtedly true, but the question must be asked: Horrible and distressing for whom? Orville Lynn Majors-who was convicted of injecting six of his elderly patients to death, and who prosecutors alleged killed over a hundred-was said to view old people with contempt and even hatred. In a culture as fixated on youth as our own, old age is seen in itself as something terrible, cruel, pointless, and even obscene. In the circumstances, it would not be surprising if the suffering that mercy killers sought to relieve was their own rather than their patients'.

Compassion easily slides into contempt. The helpless are often not very appealing: It is all too easy to think the world would be better off without them.

Is there any characteristic that unites the nurse-murderers? And is there any explanation why such killers should have proliferated from the 1970s (I assume what I cannot prove, namely that nurses did not kill in any numbers before then)? What unites the self-dramatizers who want to be at the center of significant events, with the dispensers of mercy death and those who want to affect public policy by killing? Their motives are disparate and do not at first sight fall easily into a single category.

One possible explanation, however, is the precipitate rise of self- importance. It is one of the great characteristics of the age. The self-dramatizer believes she has a right to an interesting existence, and in an age of mass entertainment this can only mean a fast-moving drama where great events succeed each other at the speed of the videotape. The person who kills for mercy or to produce the greater good does not accept any limitation on her own power to make ethical judgments. Religious taboos are all but ineffective, however much people may say that they still believe in God. They believe that God loves them (because, of course, they are so intrinsically lovable), but not that He has forbidden them to do anything they feel in the slightest inclined to do. When it comes to making ethical decisions, they are on their own. Nor do they accept the standards traditionally laid down by their society. Why should they? Have they not learned that their society tolerated-and still tolerates-racism and other evils? Are they, then, not better placed than society to decide what they should and should not do? Are not all men created equal, and therefore equally entitled to do what they think is right?

The very word "conventional" has negative connotations. To say of someone that he is conventional is to say that he is boring and even morally deficient, since he so easily accepts what he is told. There is only one way to avoid this terrible slur: to act always upon your own unaided judgment.

There is a further matter. Nurses were traditionally the handmaidens of doctors. The Nightingale Pledge, for example, specifically stated that the nurse promised to "aid the physician in his work." In an age of equality, and thus of self-importance, this is felt as a deep and personal humiliation. What better or more decisive way to declare one's independence, and establish one's power, than to take the law into one's own hands and kill a few patients? Was it not a doctor, the psychiatrist Frantz Fanon, who said that one liberated oneself from one's oppressor by a little judicious violence?