Institutional fear of litigation, reputation damage and career consequences can create a protective shield around the small minority of doctors who commit serious crimes against patients, experts warn.
Doctors and Their Crimes: Hiding Behind the White Coat examines high-profile global cases of medical malpractice, fraud, manslaughter, sexual misconduct and murder to expose a common link – systemic failures which enable these criminals to stay hidden.
“Fear is the weapon so effectively wielded by those discussed in this book, and it is a culture of fear in healthcare that we must work to dismantle,” authors and experienced general practitioners Baroness Clare Gerada and Zaid Al-Najjar explain. “Understanding the nature of these criminal acts helps us better support victims and improve systems for detecting and reporting misconduct.”
Less than half of 1% of UK doctors have criminal convictions, compared with roughly 16% of the general population. But when medical professionals do commit crimes, the authors explain, the consequences are devastating due to their unique position of trust and access.
Between 1970 and 2006, ninety healthcare workers across twenty countries were prosecuted as serial killers, linked to 2,113 suspicious deaths. The fact that many evaded suspicion for decades, has prompted questions about why institutions repeatedly failed to stop them.
Fear culture in medicine
Doctors and Their Crimes reveals a pattern of problematic doctors routinely moving between hospitals, regions and countries to avoid detection.
The medics often leave with ‘glowing references from employers eager to see them go’, the authors say, creating a system that simply exports risk.
“Reflecting on the cases, we can see that warning signs were often evident: patterns of complaints, unusual behaviour, and poor results were frequently ignored or minimised,” the authors explain. “The very notion that a doctor might behave in such a manner was unthinkable to many, allowing perpetrators to go unchecked.”
Research cited in the book found only two-thirds of doctors with direct knowledge of an impaired or incompetent colleague reported concerns. Nearly 12% cited fear of retaliation or the belief that ‘nothing would happen as a result’.
Harold Shipman, Britain’s most prolific serial killer, murdered an estimated 215 patients. Michael Swango poisoned patients and colleagues across multiple American hospitals. Gerada and Zaid Al-Najjar argue that both exploited the same systemic vulnerabilities: institutional deference to medical authority, reluctance to investigate senior colleagues, and a culture that prioritised reputation over patient safety.
“Hierarchical and paternalistic systems mean that challenging a senior colleague might be seen as career suicide,” Gerada explains. “Silence, driven by fear, loyalty, or learned helplessness, can sustain harm over many years. When whistleblowers are nurses, they are often ignored, with gender imbalance adding to the professional disparity.”
The authors explain that there are psychological traits that drive criminal behaviour, including hero complexes and narcissism, which could be amplified in medical settings. They are clear that the institutions themselves do not cause these traits – but tighter restrictions could see them exposed sooner.
Reforms and recommendations
Gerada and Al-Najjar suggest systemic reforms are possible and many already underway. Following the Shipman case, for example, the monitoring of controlled drugs and investigation of deaths were overhauled in the UK, and electronic records now maintain audit trails that are more difficult to falsify.
“Most clinical systems enable tracking of medicines, making it easier to detect unusual prescribing patterns compared to previous years,” the authors say. “Regulators are more prompt in acting, and data sharing between agencies and across international borders has improved.”
Whistleblowing policies and the Freedom to Speak Up Guardian in England reflect growing awareness that silence enables harm.
But new vulnerabilities continue to emerge, the authors warn.
“Telemedicine, accelerated by the pandemic, broadened access but also introduced new risks of inappropriate prescribing or exploitation. Globalised healthcare makes it easier for rogue doctors to move between jurisdictions,” they explain. “The rate of medical innovation continually surpasses regulatory systems.”
Cultural change
The authors argue that preventing medical crimes requires more than policy.
“Preventing such cases is not solely about perfecting control measures, as criminal masterminds will almost always find ways to bypass them; it instead involves fostering a culture of accountability, transparency, courage, and truly listening to what our patients are saying,” they suggest. “More can be done to empower and educate patients about warning signs and to equip them with the confidence to speak to someone if they suspect a problem.”
“The qualities that make medicine a noble profession, its intimacy, authority, and promise of healing, can, under certain circumstances, become the conditions that cause harm,” Gerada and Al-Najjar explain.
They say the challenge is to preserve the trust and autonomy essential to good medicine while building safeguards against those who would exploit them.
