Simon Sebag Montefiore, the son of a doctor, recently argued that doctors make highly effective tyrants. Is he right and if he is why might it be?

His article was not a systematic review but rather a brutal case study. The doctor tyrant of the moment is Bashar al-Assad. His regime has killed tens if not hundreds of thousands, while we see him on television as a gentle, unassuming, mildly perplexed ophthalmologist trained in London whom we would happily have remove our cataracts.

Hastings Banda, like me an Edinburgh graduate, liquidated his opponents, saying they should be “food for crocodiles,” and became a ruthless and absolute leader of Malawi.

Papa Doc Duvalier helped treat the poor in Haiti before becoming “the daddy of all tyrants,” organising the Tonton Macoute, the cruellest of secret police, who killed 30 000. “A doctor,” observed Papa Doc, “must sometimes take a life to save it,” but 30 000 is surely overdoing it.

Félix Houphouët-Boigny, a doctor from the Ivory Coast, was less into killing people and more into power and wealth. After serving as president for 30 years he legalised the opposition but won a seventh term easily at the age of 85. Although his people were poor, he was worth $7 -$11 billion with houses in France, Switzerland, and Italy. Perhaps trying to buy himself a place in heaven, he built the world’s largest church, the Basilica of Our Lady of Peace of Yamoussoukro, at a cost of $300 million.

Trained at Columbia in New York, Radovan Karadžić wrote poetry as well as committing genocide and organising the massacre at Srebrenica. While supposedly “in hiding” in Belgrade he attended Serie A football matches and practised alternative medicine for a company called Human Quantum Energy.

Sebag Montefiore notes that doctors are just as good at being terrorists close to the killing as well as presidents who remain at a distance. Dr Ayman al-Zawahari, a leader of Al-Qaeda, was the mastermind of 9/11, while another two doctors, Dr George Habash and Dr Abdel Rantisi, led suicide bombings in Israel.

Che Guevara is not mentioned by Sebag Montefiore, but is surely the best known doctor terrorist. Another reader of poetry, who could recite Rudyard Kipling’s If, Che, as we know him, is still revered and surely killed no more than is essential in the terrorism business. His saint status doesn’t fit comfortably with Sebag Montefiore’s parade of monsters.

So why are there all these doctor tyrants? The BMJ reader with a feel if not a deep understanding of statistics will first think chance. There have been many tyrants and many doctors, and so there are bound to be some who are both. There have probably as well been many tyrants with red hair, who were breastfed, or who were only five feet tall, and already we can see that many read poetry—but these things are probably incidental rather than causal. Sebag Montefiore has entertained the readers of the Evening Standard but hardly proved his case, and we doctors might be flattered that his piece depends on the world not expecting doctors to be tyrants. Nobody is surprised that soldiers, policemen, newspaper barons, tycoons, or even lawyers make good tyrants, but we expect doctors to be good.

But perhaps there is something in the hypothesis. Doctors do, after all, seem to be more likely than members of any other group to be serial killers, and doctors were among the fastest to join the Nazi Party.

Sebag Montefiore doesn’t attempt an explanation, but makes some observations that come close: “I wonder if instead of making flint-hearted murder harder, a medical training actually makes it easier?” The training certainly provides a familiarity, even a casual relationship, with death. Then, reflects Sebag Montfiore, “If the society is a body politic, isn’t a doctor perfectly qualified to purge it of the germ of opposition, cleanse it of the bacterium of treason, use the scalpel of power to cut out the tumours? Isn’t the scalpel a finer instrument than the sword, the mace, the machine gun?” This is more poetry than epidemiology.

So here are some other possible explanations.

Most of these doctor tyrants are from developing countries. If you are a clever and ambitious boy (there are no girls in our list) in a developing country, then becoming a doctor is a great step up. And once you see the dreadful conditions in which many of your patients live you might understandably, entirely rationally, become a revolutionary. With all your education and chutzpah you become leader and president if the revolution is successful. The country is not ready for democracy and so like a good doctor you tend to your flock. Then power does its work—and soon you are convinced that nobody else could do what you do. Enemies must understandably be liquidated so as not to upset your benign reign, and naturally you should reward yourself handsomely for a life of public service.

Perhaps it’s because doctors are good game players, or perhaps it is because they are used to inflicting harm to achieve net gain.

Or maybe it’s more Freudian, something to do with that deep seated idea that people become doctors because they fear death, psychiatrists because they are mad, and gynaecologists because they hate women. Perhaps people become doctors and then tyrants because they can’t tolerate mess: they want to tidy, cleanse everything.

Or perhaps they get bored with being “just doctors.”

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

• See also: When a doctor goes wrong