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My Toughest CaseTreating a Contract Killer

Alice Medalia, Psychologist, Columbia University Medical Center

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I was a young doctor working in an inpatient psychiatric unit when I was assigned to a middle-aged single male with severe depression who had made several attempts to kill himself. When I met him, he was curled in a ball on his bed. He would not eat and could barely talk. He simply said, “I want to die.”

I started him on medication for depression and psychosis. His delusions diminished, and he started to get out of bed, eat, shower, and groom himself. Slowly, over the course of our meetings, I began to ask him about his everyday life. What emerged was a picture of a man who lived alone, cut off from his feelings, family, and friends. He read a lot, primarily about espionage, and collected guns. That was alarming because of the risk to himself and others. When I asked if he had any kind of criminal history, he said he had never been arrested, but he was reluctant to tell me what he did for a living. “You don’t really want to know,” he said. And “let’s not talk about that.”

All the while he was getting better, and as we came closer to discharge (at the time, a standard stay was 28 days), we began discussing outpatient treatment. I pressured him again to tell me what his job situation was so I could help him identify stressors that could hinder his recovery. It was then that he told me he was a contract killer.

It was a startling moment. It’s something that one sees in movies, but I had certainly never encountered it. And I had no reason not to believe him. He was at that point a lucid, clear-thinking person. Of course, my immediate concern was, “Is he intending to kill anybody?”

My legal obligations were clear. If a patient has homicidal intent toward a specific person, you have to notify the authorities. But if he or she confesses to criminal activity committed in the past, it’s protected by doctor-patient confidentiality. The patient assured me he had no specific intent to kill anyone. The ethicists at our hospital advised me that the patient had a right to treatment, and that I had a duty to treat him. Generally speaking, I believe everybody with psychiatric illness deserves treatment; most of my work is focused on getting people back to work or school or living independently. But this was the one instance in my career when I could not support my patient’s post-treatment goals. He had no remorse: He saw these killings as “all in a day’s work.” And he did not sound like he was done with the business. When he left the hospital a few days after his revelation, I told him that he clearly had talent and ability, and urged him to sell his weapons and use his gifts in another direction. He thanked me and said, “You are a nice lady. I told you it would be better for you not to know.”

The last time I heard from him was when we followed up to make sure he made it to his first outpatient appointment, which he did. Do I worry that he might have taken another contract, even just once? It’s definitely a concern—the case has stuck with me for three decades. The truth is, I have no idea what happened to him. I’ll never know.


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