17 March 2015

Munchausen by proxy: getting attention by making someone else sick

Cybershrink discusses the condition 'Munchausen by proxy' where people fake illness in others under their care, usually their own children, to gain attention and sympathy for themselves.


In 1977, a British paediatrician, Roy Meadow, was recognizing a variation of Munchausen syndrome he called Munchausen syndrome by proxy. This was, he explained, where people faked illness in others under their care, usually their own children, to gain attention and sympathy for themselves.

Special form of child abuse

This curious condition hit the headlines recently when an American mother was convicted of killing her son by overloading him with salt.

Read: Mom found guilty of killing 5-year-old son with salt

After some initial doubts, the concept soon became accepted by doctors and social workers, as it seemed to explain some otherwise deeply puzzling cases. It was a special form of child abuse. Meadow, however, overreached himself in a parallel issue when he became sure that many cases of “cot death” or SIDS (Sudden Infant Death Syndrome) were due to physical abuse also being disguised as illness.

SIDS was beginning to cause alarm at that time, and was little understood. It was especially not understood that it can indeed occur more than once in a family. Meadow declared that cot deaths do not run in families, and became associated with the rule that "unless proven otherwise, one cot death is tragic, two is suspicious and three is murder".

Sadly, his alarming ideas in this regard became an obsession, which obscured his important and original observations on Munchausen by proxy.

Lawyers love an acknowledged expert who speaks convincingly about an issue they can use in court, and Meadow began to be used as expert witness in too many cases.

Notably, in the trial of Sally Clark, he claimed he had found 81 cases of “cot death” which were actually murder, but that he had, peculiarly, disposed of the data. In his evidence, he insisted that the odds against two cot deaths happening within the same family were 73,000,000 to 1. By a majority of 10 to 2, the jury found Clark guilty. 

A very different conclusion

The trouble was that Meadow was wrong and had miscalculated the odds hugely, making a number of false assumptions. Others have estimated that the true odds may have been more than 2 to 1 in favour of the death NOT being murder, a very different conclusion.

The case was appealed on various grounds including his bad mathematics, but the Court of Appeal considered the evidence “overwhelming” and dismissed the appeal. Meadow wrote a paper dismissing his critics and opposing the waste of time on further investigating of the case.

But a skilled lawyer found new evidence, and it was shown that another expert witness had not revealed important evidence, i.e. that other tests showed another, infectious, cause for the death of one of the children. On a second appeal, Clark’s conviction was overturned in 2003. 

Read: Steps to prevent cot death

The judges had also examined Meadow’s statistics, and in their ruling declared that they would probably have granted the appeal on this basis as well. Sally Clark never recovered from both the loss of her children and being convicted of their murder. She died only four years later of acute alcohol intoxication.

Soon afterwards, Angela Cannings, a mother also convicted of murdering two of her three babies on the basis of Meadow’s evidence, was set free on appeal. This time, Meadow was himself investigated by the British General Medical Council.

He had testified that the mother suffered Munchausen by Proxy, and that two cot deaths within one family was extremely unlikely. The prosecution also argued that there was no family history of cot death. Investigation by the BBC found at least two of her ancestors had lost a large number of infants without explanation, making it very plausible to consider that there was indeed a genetic predisposition to cot death. Considering this, the Court of Appeal declared the conviction unsafe, and Canning was released on appeal. 

Wary of providing expert evidence

The Deputy Chief Justice, the aptly named Lord Justice Judge, discussed the appeal and was contemptuous of the theories about Munchausen by Proxy and Cot Death, calling it a “travesty of justice”.  Indeed, the law was changed to prevent anyone from being convicted on the sole basis of expert evidence and opinion.

In 2005, Meadow was brought to a GMC tribunal, which found his evidence in the Clark case has been wrong and misleading, and found him guilty of “serious professional misconduct”. They decided to remove his name from the Medical Register. There was concern, though, that this decision might make experts wary of providing expert evidence.

Meadow appealed, and a High Court Judge agreed and ruled that although it was correct for the GMC to have criticized him, this did not amount to “serious professional misconduct”, and that he should not have been struck from the register.

In 2009, however, he voluntarily gave up his registration with the GMC, and was no longer able to practice medicine.

Meanwhile, there had been another very troubling case. In 2005, Ian and Angela Gay were tried for the death of their adopted son Christian, and the prosecution leaned heavily on Meadow’s 1993 paper on “non-accidental salt poisoning”.  The judge was clearly impressed and quoted from it five times in his summary. They were found guilty of manslaughter, but after 15 months in prison, their convictions were quashed.

Read: Reduce your salt intake

In the media, other professors had challenged the conclusions of this paper, and suggested that in similar situations the well-recognized disease diabetes insipidus had to be considered as a more likely cause of high salt levels in the body than deliberate poisoning.

Despite misjudgements and mistakes in these cases, the syndrome definitely does exist, and causes genuine suffering in children at the hands of the person in the world they trust most. It is one of the many possibilities a doctor needs to bear in mind when assessing puzzling clinical situations. 

Read more:

Munchausen syndrome: why people fake illness

Social media can feed Munchausen by proxy

SIDS: co-sleeping the culprit

Image: Empty baby cot from Shutterstock

Professor MA Simpson is Health24's CyberShrink. A South African psychiatrist, he qualified in medicine and in psychiatry in Britain. He has been a senior academic, researcher, and Professor in several countries. Read more of his columns.


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