The Jolly Contrarian on Crime and Punishment
Now is the worrying time—Woe! Woe! Behold!Armageddon and the four horsemen of the apocalypse:Famine, Pestilence, Death—And the other one. … Sometimes, you know, God can be so unimaginative. The Young Ones, Interesting [https://www.bbc.co.uk/iplayer/episode/p00bfqpk/the-young-ones-series-1-5-interesting] (1982) There has recently been a bit of conflab amongst those challenging Lucy Letby’s convictions about the motivations of the “gang of four”: did the COCH paediatricians really believe she was harming babies? Opinion is split. A hard core is convinced the consultants had ulterior motives from an early stage. The more liberal fringes feel it is a bit more complicated. Some think it is beside the point. I’m in that camp. Exchanges have been testy. Even petulant. This is no doubt disappointing for those who value civil debate and want to keep the innocence campaign on the same hymn sheet, but fun for those of us who find a bit of verbal argy-bargy bracing. And it tends to rebut the idea there is some vast Letbyist conspiracy so, I’m all for it. The point at issue is how to think about the behaviour of Ms. Letby’s principle accusers — the so-called “gang of four” CoCH consultants. Were they misguided or malicious? This not worth even talking about unless it transpires she was not guilty so — apologies in advance to my many pitchforker readers — we will, for a moment, take it as a given that Ms. Letby did not deliberately harm any infants. This Substack is reader-supported. To receive new posts and support my work, consider becoming a free or paid subscriber. It’s complicated There is a continuum of possible “blame points”. At one end, the consultants were dispassionate and logical at all times but nevertheless somehow reached the wrong conclusion, and the system then swamped them. At the other, from the outset they conspired in a cynical attempt to have Ms. Letby imprisoned knowing full well she did nothing wrong. There are, naturally, a host of positions in between. As one poster put it, “it’s complicated”. This debate has an odd resonance with the public debate about Ms. Letby herself. Both extremes are highly improbable. They leave untouched a wide range of more probable, but less satisfactory explanations. We like our narratives to explain the world to us. We do not find useful ones that say, “Well, we just don’t know”. We prefer conclusions, however unlikely they may be. The situation of risk was an “unexpected cluster of medical collapses and deaths in the CoCH neonatal unit”. Since the unit is there to prevent negative health outcomes, on its face it has failed. You would expect senior professionals in that unit to be concerned, and to look for causes for its failure. An obvious one is intentional human agency. Another is unintended human failure. That may implicate the consultants themselves. Being human, they were subconsciously motivated to prefer an explanations that served their interests as well as the hospital’s. In looking for explanations, the consultants were inherently conflicted. “An undetected serial killer nurse attacked these children” was a better explanation than “these children collapsed as a result of shortcomings in the care we were responsible for providing” because it laid the blame at someone else’s door. Especially once they had identified and escalated their concerns to management. But this does not mean they were malicious. All humans act self-interestedly all the time. It is our default operating mode. We cannot attribute malice without a lot more information — information we are, at this remove, highly unlikely to get. It doesn’t matter But in any case, it doesn’t matter. What matters is that the consultants were wrong — again, assuming they were wrong — not why. If the goal is to overturn the miscarriage of justice, focusing on how blameworthy the consultants were is a distraction. For if, in forming their honest opinions that Ms. Letby was responsible, the consultants acted with clear-eyed surgical precision and the equanimity of modern saints, yet were still demonstrably wrong, Ms. Letby would be no less deserving of acquittal. If they acted as a scheming cabal she would be no more deserving. Focusing on the consultants’ motives is to make a category error. It is not the consultant’s motives and actions that determine whether Ms. Letby should be in prison, but her own. What difference does it make how malicious the consultants were? Isn’t there a ball that needs to be played here? What does it achieve to take out the man? It’s a nice explanation To be sure, “wanton malice by consultants” is a convenient, easy, satisfying explanation. It offers a clean, resolved, retributional answer. There is a heroine, some villains, a smoke-filled room, an early setback and a great final conflict vouchsafing apocalyptic justice. It cleaves nicely to the monomyth archetype. It sees Ms. Letby’s ordeal as discrete: a one-off, freak occurrence that no-one saw coming but that we have nobly resolved, restoring order to the universe. It appeals to the would-be hero, riding in on a charger, saving the damsel clearing out some some bad apples and returning home in triumph. The world is left in situ: everything, and everyone else can remain in place doing exactly what they were doing. This is justice as a surgical strike. Everyone else in the system gets a pass. For, if this really was a wantonly malicious action — if the system is otherwise ship-shape and coming up to brief — it should not happen again, and should not have happened before. But it’s a bad explanation But since we know it has happened before, and since, “wanton malice” is also a bad explanation. The “healthcare serial murder” pattern, whereby nurses are convicted of retrospectively constructed crimes on next to no direct evidence over their insistent denials, keeps recurring. If it keeps recurring and wanton malice is the cause, then the system is vulnerable to wanton malice, and needs to be fixed. Rooting out bad apples is, at best, a game of whack-a-mole. They will keep popping up as long as the system is configured to produce them. But it isn’t likely to be wanton malice, for two reasons: firstly, the criminal justice system is pretty good at identifying vexatious complainants and disingenuous witnesses and excluding their evidence. Secondly, the healthcare system is pretty good at screening out vexatious people so you don’t get truly malicious complaints in the first place. Taking these in reverse order: The medical profession is comprehensively regulated and governed. Its practitioners are systematically enculturated, trained and credentialed to eliminate wantonly malicious people. Over the 15 or so years it takes to qualify as a doctor in the UK, candidates are exhaustively vetted for fitness to practice. The profession weeds bad apples out. For the same reason, even compared against the already low rate of murderousness in the general British population, we should not expect many nurses to be murderers. That incidence would be far lower still. rNo system is perfect, and it might not catch all malicious professionals — it is, of course, not impossible that a senior medical professional would wilfully railroad an innocent nurse to prison — but the incidence of that kind of behaviour should be extremely low. We should not expect to find four malicious professionals colluding in the same hospital. If we do, then the problem is predominantly with the system, not the bad apples. The Cheshire Triangle But the “healthcare serial murder” pattern repeats, almost identically, all over the world — Brazil, France, America, the Netherlands, Italy, and in the UK. It happens a lot in the UK. It happens, in fact, in a small patch of the English heartlands I call the “Cheshire Triangle” where there have been nine alleged cases in quarter of a century, including Beverley Allitt (1991), Anne Booth-Grigg (2002), Colin Norris (2002) Barbara Salisbury (2002), Ben Geen (2003), Rebecca Leighton (2011), Victorino Chua (2011) and of course Ms. Letby. The geographical and temporal clustering is striking, as is the modus operandi: seven of the nine involve allegations of insulin poisoning. The Cheshire Triangle — yes, it is a terrible name: you are welcome to suggest alternatives — is unusual not just for its spatial and temporal sequence. The juridical strike rate is also uncommonly low. Of the nine cases, one has been overturned, two were dropped before trial, one resulted in no murder convictions, and four are the subject of active, ongoing challenge. If there really are vindictive hospital administrators, then there are a lot of them in a small area. If there really are nurse healthcare serial murderers, there are a lot of them in a small area too. Maybe it isn’t the apples All this points away from bad apples. For either: * There have been many serial murderer nurses in and around Cheshire, who were all correctly identified by their colleagues. * There are many malicious hospital consultants in and around Cheshire, who have each railroaded innocent nurses to prison. * There is some odd combination of the above, where some were genuine nurse serial murderers but others were malicious vilifications of known innocents. * Or something else is going on: there is, instead, some kind of latent system error — a recurring failure mode in how doctors, hospital managers, police, lawyers and courts interact with unusual clusters of medical misfortune. In this case, perhaps cognitive biases, institutional and financial priorities and conflicting personal incentives — and not outright malice — are at work. Unless there is compelling direct evidence to corroborate them, scenarios 1 and 2 are equally unlikely, and scenario 3 is even less likely: the first two each require one rare event (genuine murderers or malicious consultants) and the third requires both. From everything we know about how complex organisations operate, how the people in them behave, and how prone the combination is to failure, scenario 4 is totally plausible. It is, in essence the “Post Office Horizon” scenario. It looks bad: it looks like systematic malice up and down the county — take your pick by whom — but it is nothing of the kind. Translating that last scenario to the Countess of Chester: these are not serial murderer nurses or malicious consultants, but a strange combination of circumstances, events and interacting social structures that creates scenarios that lead the consultants to mischaracterise an innocent nurse as as a murderer, and this intersects a latent vulnerability in the criminal justice system, such that these cases are not seen for what they really are. This happens. We know it happens. This is not to say that the consultants — or for that matter the implicated nurses— are entirely without sin, or above stern criticism, but they are not the root cause of the problem. They are, in a way, its symptom. Something else is driving this. If the system were working properly it would intervene on time: it would identify the sins and failings of nurses and consultants and stop them: they would get the censure they deserved at the time, not years later, after rectification of a terrible injustice. This is a far more plausible explanation. It does not satisfy the wish for a quick clean resolution. It does not satiate the bloodlust for retribution. It points instead to hard yards: this is a far less tractable problem. The goal should be to fix the system, not defenestrate bad apples. Even if they are bad apples, the system tolerated them. Rid the system of its defects. Make it immune to malicious doctors — and for that matter serial killer nurses! On either account, the system has repeatedly failed. Why the system failure points away from malice The UK’s criminal justice system has, of late, had its moments, but on the whole, its remarkable achievement over centuries has been to evolve techniques to counteract malice. It is good at isolating liars and rooting them out. This is another reason these doctors were not probably not outright malicious: if they were, the justice system would have found them out. Its weakness here may be exactly that they weren’t outright malicious: they were, instead, accepted as experts expressing sincerely-held views. The system has a weak spot with expert evidence. Again, this is not a secret: the Law Commission has been warning about it for years. Experts who are simply mistaken are harder for non-experts to gainsay. They are resistant to cross-examination. They are harder to falsify. Of course, sincerely-held views can become more tendentious as contradicting information emerges. But once we commit to a position, we are motivated to cling to it long after it is tenable. We should expect buried conflicts of interest, methodological errors, cognitive biases and so on—the ordinary artefacts of imperfect humans interacting imperfectly, in other words—to cause this sort of thing. Attributing malice—or, for that matter, even blame—is to be distracted from the far important issue of understanding the interlocking system effects that cause these outcomes and fixing them. It is surely better to reorganise the system to stop these miscarriages happening—isolating root causes of the clusters themselves—rather than embarking on a witch-hunt against (perhaps) below-average doctors. The system should be designed to cope with ill-advised acts from below-average doctors, because literally half of all doctors are below average. There’s another reason to prefer the systems explanation over malfeasance: that way you create a route by which incumbents can, without personal prejudice, accept there is a problem and work to fix it. If you back accusers into a corner they are bound to be defensive. Attributing blame is to take sides and entrench positions, rather than to diagnose the problem and resolve it. In other words, if you really want to fix a problem, as a first step, don’t blame people who may be, in their own way, as much victims of the system as anyone else. Sure: the consultants may not be in prison, but if Ms. Letby is exonerated their reputations are unlikely to recover. Their errors were, at first, understandable: this happens a lot, after all. If the system worked to catch and remediate an early error, rather than entrenching it, the consultants would not be in the place they are now in. Fix the problem. Thanks for reading! This post is public so feel free to share it. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit jollycontrarian.substack.com/subscribe [https://jollycontrarian.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]
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