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The case of a Nazi sympathizer who entered a famed Swedish medical school in 2007, seven years after being convicted of a hate murder, throws a rarely discussed question into sharp focus: Should a murderer ever be allowed to practice medicine?

A killer turned healer might seem to be a shining example of prison rehabilitation.

And in many societies, including the United States, criminals who pursue an education during or after their prison sentence are often admired for their determination to turn their lives around.

Yet it is hard to think of a case in which a murderer should become a medical doctor.

Murder and medical practice are simply incompatible. Medical education involves more than learning from textbooks. Earning a medical degree requires a student to interview and examine patients, often in intimate circumstances.

Integrity and trust are the core of the patient-doctor relationship.

Any erosion of them could harm the healing process.

How many patients would feel comfortable being put to sleep by an anesthesiologist who once murdered?

Most medical institutions do not want murderers in their midst.

How many patients would go to a hospital where a doctor was a convicted murderer?

How many doctors and nurses would feel comfortable on the same team as a murderer, particularly a perpetrator of a hate crime against one’s own group?

The Swedish case is extraordinary, of course. But it poses questions that resonate far beyond the prestigious Karolinska Institute, where the murderer, Karl Helge Hampus Svensson, 31, began medical school last year. (Last week, he was expelled on a technical issue — apparently falsifying his high school transcript.)

Alliances like the European Union have made it easier for doctors licensed in one country to practice in another. This increases the pressure on medical schools to be ever more vigilant in asking applicants about past criminal activity.

Potential terrorists, for example, might find a medical license useful. In the Middle East, doctors have been leaders of terrorist groups, and just last July, British officials implicated four doctors and three other medical workers in botched terrorist attacks in London and Glasgow.

Mr. Svensson (he had legally changed his surname from Hellekant while in prison) was convicted in the 1999 hate murder of a trade union worker and was paroled after serving six and a half years of an 11-year sentence. The Karolinska learned of his identity through two anonymous tips last fall. Although many Swedish news organizations reported the story at the time, most adhered to local journalistic custom and did not name him.

In scores of interviews, Swedes tended to express the view that a convicted criminal who wanted to go to medical school deserved the opportunity.

But their opinions changed when they were informed that the Karolinska student was the publicized 1999 murderer. Although a few of those interviewed said they might go to such a doctor depending on circumstances, none said they would send a loved one.

Swedish law prohibits public universities like the Karolinska from asking about an applicant’s criminal past. But taxi companies and other private concerns are allowed to demand such information before hiring an individual.

What makes murder a special problem for medicine is the lengthy, costly and complex education system.

Consider the application process, which can vary among medical schools, even in the same country.

The Karolinska does not require letters of recommendation, as is usually standard in the United States. About one-third of the Karolinska students are admitted on the basis of grades without an interview. The other two-thirds are judged on grades and an interview with senior faculty members. Applicants choose whether they want to be interviewed, and Mr. Svensson was one of them.

Two faculty members, one a psychiatrist, interviewed Mr. Svensson separately. But neither asked for an explanation of the six-and-a-half-year period in his life, when he took courses through a prison-based intranet system. He did not volunteer his prison record.

Karolinska faculty interviewers are not required to keep notes of those encounters.

No one knows how many Swedish doctors have criminal records, in part because of Swedish laws and culture that emphasize personal integrity.

When Mr. Svensson’s classmates were asked at a student meeting how many had criminal records, nine other men and women said they did, according to an article in the medical student union’s publication, Medicor. No definition of what constituted a crime was given.

In the United States, the chances of a convicted criminal’s being admitted to medical school were reduced in 2002, when the standard application form from the Association of American Medical Colleges began requiring answers to questions about military discharge history, arrests and felony convictions.

Eight of the 126 medical schools in the United States do not participate in the association’s application service but may solicit the background information on their own. Six of the eight are in Texas. The 118 others may choose to receive only some of the solicited information, depending on state laws and institutional policies on privacy rights.

Each school determines which offenses, if any, would disqualify an individual for admission.

The association also recommends that all medical schools conduct criminal background checks for all matriculating students. But it is not clear how many do. From 2002 to 2006, on average, 26 of 36,000 applicants a year said yes to a felony.

Dr. Harriet Wallberg-Henriksson, the Karolinska’s president, has asked the institute’s ethics committee to address a number of questions concerning long-range policy on the issue of admitting criminals to the medical school.

Among the questions: Must educators and administrators inform patients about a convicted criminal student’s past? If so, when and how? What about a convicted murderer who was later involved in treating a patient who died under medical care?

Even if he was innocent in that death, the suspicions would be hard to erase.

Before Mr. Svensson was expelled, the Swedish medical licensing agency said that even if he graduated it would not permit him to practice. Sweden does not give medical licenses valid for only certain categories, like research.

As the Karolinska Institute struggled with the legal, administrative and ethical quandaries in the Svensson case, Dr. Wallberg-Henriksson was asked whether she would go to a doctor who had murdered. She would not say. But never, she added in one of a series of interviews in her office, would she send her children to such a doctor.

Speaking of the general problems in admitting a murderer to medical school, Dr. Wallberg-Henriksson said: “In the final analysis, it comes down to trust, because when you are a patient you are putting your life in someone else’s hands.”

Last week, she said that because Mr. Svensson’s expulsion was based on a technicality, his case did not resolve the broad issue of who is fit to be a doctor and whether a murderer forfeits the right to become one. That, she repeated, is up to Swedish legislators and government officials, who have given her mixed messages so far.

And if government officials make a legal exception for murder, they face another question: Where to draw the line for other criminal acts?

Lawrence K. Altman, M.D., reported from Stockholm last month and later added updated information. Majsan Bostrom contributed reporting from Stockholm.

[29Jan08, The Doctor’s World, Lawrence K. Altman, M.D., Stockholm,]