The History and Controversy of Factitious Induced Illness
Factitious Induced Illness (FII), also known as Factitious Disorder Imposed on Another, and previously as Munchausen Syndrome by Proxy, is a disorder wherein a person fabricates the symptoms or medical records of an illness in another person, most commonly a child or a dependent. It is distinct from but related to Factitious Disorder Imposed on Self, in which a person fabricates their own physical or mental illness.
Although the disorder is not fully understood, it is well-known in the public consciousness. It features frequently in news headlines, as well as in films and television series. 2018-2019 alone saw the release of Paul Thomas Anderson’s Phantom Thread, HBO’s Sharp Objects, BBC’s Clique, and Netflix’s The Politician, all of which featured storylines exploring cases of FII. While the majority of these works make fairly light entertainment of the disorder, it has serious and important consequences from a medico-legal perspective. In this article, therefore, we look at the presentation of FII, as well as at some key cases in the history of the disorder. We consider what these tell us about the nature of the disorder and about its standing in the Courts today.
How does Factitious Induced Illness present?
FII can manifest itself in many different ways. In legal circles there have been cases involving smothering, poisoning, forced ingestion of toxic substances, simulated symptoms, and fabricated medical histories. A survey of the disorder noted that people with FII can fabricate almost any kind of disease in the sufferer: the victim can present “with several symptoms, including any form of bleeding… seizures, depression, apnea, diarrhea, vomiting, fever, and rash.”
While FII is not a psychiatric diagnosis, it is recognised that psychiatric disorder in the person inducing symptoms may occur. It is strongly associated with Factitious Disorder and/or Somatic Symptom Disorder, and it is commonly assumed that it stems from a need to garner attention, or from a desire to manipulate medical professionals.
Overwhelmingly, FII occurs in mothers who induce symptoms in their children. A 2017 study found that 95% of a total of 800 cases of FII involved acts of abuse carried out by mothers against their children usually infants.4 Many of these resulted in psychological disturbance including Post-Traumatic Stress, severe neglect, physical illness or even death for the child. Most typically, people who suffer from FII will bring their dependent to medical attention presenting with inexplicable symptoms that seem to have no organic cause, and that only occur when the child is with the caregiver.
The history of Factitious Induced Illness
In another post, we looked at the history of Factitious Disorder Imposed on Self, which was first described as Munchausen’s Syndrome by Dr. Richard Asher in 1951. The first case of FII, however, was reported by Professor Roy Meadow.
The diagnosis was first published in The Lancet in 1977 (the same journal in which Asher had described Munchausen’s Syndrome a quarter of a century earlier), involving a report of two cases in which parents had “by falsification, caused their children innumerable harmful hospital procedures.” In one of these cases, the parents of a young girl had provided fictitious information to medical professionals, tampered with their daughter’s urine samples, and interfered with the observations taken of her at the hospital. As a result, the girl was forced to undergo countless “investigations and anesthetic, surgical, and radiological procedures.”
The other case described involved a mother who gave her child toxic doses of salt, leading to prolonged medical investigations and, ultimately, the death of the child. The mother was deemed to be otherwise “caring,” “home-minded,” and “pleasant to deal with.” Nevertheless, it was concluded that the child had been “abused,” although Professor Meadow was “uneasy” about classing either case as an example of “non-accidental injury.”
Linking both of these cases to Asher’s diagnosis of Munchausen’s Syndrome, it was proposed that they could be considered examples of “Munchausen Syndrome by Proxy,” since they involved similar processes and practices, but the harm was done to another. It was noted that, whereas Asher had said that Munchausen’s syndrome was “a common syndrome which most doctors have seen,” FII had not been previously described anywhere in the medical literature. It was considered, therefore, whether “is it because the degree of falsification is very rare or because it is unrecognised?”
This question went on to inspire a considerable amount of research in the years that followed. As a result, many cases of child abuse, neglect, and Sudden Infant Death Syndrome (SIDS) were investigated and re-investigated in the light of Professor Meadow’s findings.
The controversy of the Sally Clark case
On account of his research, Professor Meadow was called as an Expert Witness in a number of medico-legal cases related to FII (still, at that time, referred to as Munchausen Syndrome by Proxy) during the 1990s. Many of these were cases that had previously involved instances of SIDS, but which were then re-assessed as examples of FII.
The most famous of these cases was that of Sally Clark, who suffered from Postnatal Depression and in 1999 was found guilty of having murdered her two sons. Those sons had each died (aged 11 weeks and 8 weeks respectively) while Clark was at home with them alone. Both of the children were found to have suffered from trauma, though it was argued during the trial that this was a result of Clark’s attempts to resuscitate them.
Acting as an Expert Witness, Meadow gave what was later declared to be misrepresentative statistical evidence. He claimed that the probability of two cot deaths in an affluent family was around “one in seventy-three million,” and this “statistic” was felt to be largely responsible for Sally Clark being found guilty and sentenced to life imprisonment. Clark appealed the decision twice, first unsuccessfully in 2000, and then successfully in 2002. As part of the appeal, the president of the Royal Statistical Society wrote that there was “no statistical basis” for Professor Meadow’s claim, and that it had therefore been a misleading use of evidence.
Not only did this lead, ultimately, to Professor Meadow being struck from the medical register by the General Medical Council, but it also produced widespread suspicion within political spheres regarding the nature of FII. Speaking in the House of Lords after Clark’s appeal, for example, the opposition spokesman for health, Lord Howe, described FII as:
One of the most pernicious and ill-founded theories to have gained currency in childcare and social services in the past 10 to 15 years. It is a theory without science. There is no body of peer-reviewed research to underpin Munchausen Syndrome by Proxy.9
Such an opinion of FII would go on to be fairly influential during the early 2000s. However, this opinion is nowadays disputed by medical professionals, as there have been many cases that have come to light over the course of the twenty-first century that suggest that FII is in fact a very real disorder. Indeed, in 2006, the decision to strike Professor Meadow from the medical register was overturned, and while many believe that his use of statistics within Sally Clark’s trial was questionable, they nonetheless maintain that his diagnosis of FII was necessary and important. It has, in fact, gone on to be very influential in cases relating to child abuse and neglect, particularly in cases where there is a risk of a person displaying a repeated pattern of FII.
The risks of repetition
FII’s “high risk of repetition” is one of the reasons why it receives such considerable attention. Indeed, one of the main reasons why Professor Meadow was called to provide assessments in so many medico-legal cases was precisely because they involved the abuse and death of multiple children. This phenomenon has led to the formulation of what is known as Meadow’s Law, which is based on a principle of repetition. It states: “One sudden infant death is a tragedy, two is suspicious, and three is murder, unless proven otherwise.”
This came to be particularly important in a recent case from 2017, in which a woman was accused of attempting to murder her child by closing their mouth and nostrils. She was caught on surveillance cameras preventing her child from breathing in order (she claimed) to help cure or “exclude” their illness. When the case was investigated, it was found that her two other children had also died after she had closed their nose and mouth when they were suffering from an illness.
The woman underwent Forensic Psychiatric Assessment, where her cognitive functioning was found to be normal and she showed no psychopathological symptoms. She stated that her children had died from undiagnosed epilepsy. Given the apparent competence of her mental state, she was found to have been mentally and criminally responsible for the murder and attempted murder of her children.
The case shows that FII presents significant risks to vulnerable dependents, as it is likely to lead to a repeated pattern of behaviour. At the same time, though, the case also raises questions regarding the mental capacity of the persons who suffer from the disorder, so careful consideration must be given to the legal responsibility of those who suffer from it. In this case, the Courts found that the mother was fully aware of the possible consequences of her actions, but cases of FII must invite us to consider whether or not the sufferer believes that they are helping, rather than harming, their victims. This seems particularly true given that reports on FII tend to suggest that sufferers do not actively intend the abuses that they enact.
Victims and violence
Perhaps the most infamous case of FII to come to the public attention in recent years has been in the American Courts concerning Gypsy Rose, who was sentenced to 10 years in prison for second-degree murder after stabbing her mother, Dee Dee Blanchard. Dee Dee, who is thought to have suffered from FII, had subjected Gypsy to years of physical and psychological abuse by making her undergo unnecessary courses of medication. From an early age, Dee Dee insisted on Gypsy’s poor health, forcing her to use a respiratory machine and shaving her head to make it appear like she had cancer. She forced her to use a wheelchair and allowed her teeth to rot out, possibly as a result of unneeded prescription drugs. Gypsy internalized much of her illness, taking it on “blind faith that a mother knows best,” and used a wheelchair for all of her life, even though she herself knew that she could walk.
Dee Dee’s and Gypsy’s circumstances exhibited many of the hallmarks of FII, with doctors noting that there seemed to be no underlying organic cause for Gypsy’s symptoms and that Dee Dee’s accounts and medical histories of her daughter would often be vague and unclear. A Pediatric Neurologist who examined her, for example, could find no reason for Gypsy’s muscular dystrophy, but was not convinced of the need to report the case to social services.
Later on, Gypsy began a relationship with a man she met online, named Nicholas Godejohn. Godejohn, who had a criminal record for public exposure and had been diagnosed at various times with varieties of Autistic Spectrum Disorder, eventually met with Gypsy in person. A year later Godejohn came to Gypsy’s and Dee Dee’s house and, in an attack seemingly planned with Gypsy, stabbed Dee Dee to death while she slept.
When the couple were arrested and their cases came to trial, the prosecution declared the case to be “extraordinary and unusual” on account of the abuse that Gypsy had received and the subsequent violent murder that she assisted with. While no formal diagnosis of FII was made, it was claimed by experts they “were confident in saying Gypsy Blanchard was a victim of Munchausen by Proxy.” The case is remarkable for its violent outcome; there are “no other cases to draw on in the criminal environment where there has been a murder charge in a Munchausen by Proxy case.”
Several studies have suggested that the victims of FII are likely to suffer from psychological distress including Post-Traumatic Stress Disorder, and may therefore exhibit violent tendencies or struggle to discern between what is real and what is not. Given that she was responding to years of abuse, Gypsy’s actions raise interesting medico-legal considerations regarding her capacity and her responsibility.
Moreover, the case is all the more complicated from a medico-legal perspective since the solicitors for Nicholas Godejohn put in an appeal for diminished mental capacity. As mentioned, Godejohn had been diagnosed with Autistic Spectrum Disorder, and his lawyers argued that it had been Gypsy who had instigated and organised the attack. While Gypsy and Godejohn were ultimately both charged with second- and first-degree murder, respectively, the levels of abuse and the mental disorders that both of them suffered from highlight the significant dilemmas faced by the Courts in trying to establish guilt and responsibility for actions committed by the victims of FII, as well as their associates.
Conclusion
As this article has shown, FII is a complex disorder that is difficult to diagnose. Its causes, symptoms, and impact are not always easy to understand. The disorder raises medico-legal questions relating to the responsibility and mental capacity of the person who induces the Illness (normally the mother) . It also, however, raises questions about the responsibility or capacity of the victims of FII, particularly if they react to their abuse with grievous or even fatal violence.
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