Breivik's trial now focuses on victims

Breivik's trial continues - but the attention is no longer on the killer.

The court lecture played faithfully into the absurd image he has constructed for himself – Commander Anders Behring Breivik, the gallant defender of Norway.

"If anyone wants to throw something, you can throw it at me,” Commander Breivik admonished the Olso court after the brother of one of his victims hurled a shoe.

The accused gunman and bomber murdered 77 people on July 22 last year, most of them teenagers executed at close range. But they were legitimate targets. Vibeke Hein Bæra, hit gently by footwear aimed at him, was an innocent bystander. Commander Breivik was honour-bound to intervene: “Don’t throw things at my lawyers.”

It was one of several opportunities he has taken to try to regain the attention of a court which has moved on despite him, and attempt to re-establish himself as the hero of his own trial. The contrast with the genuine heroism of some of the survivors from his rampage on the holiday island of Utoya last year could hardly be starker.

Tonje Brenna, 24, terrified, under fire, watching her friends die around her, picked up and carried a wounded 14 year old girl to the relative safety of a steep cliff edge. She slid down to shelter only after guiding others, then held the wounded girl in her arms, willing her to stay awake, while Commander Breivik stood at the top of the rock face, letting out yelps of joy as his bullets found their teenage targets.

Faced with this story of heroism - one of many heard by the court over the last three weeks - Commander Breivik smiled contemptuously and shook his head.

Beneath Ms Brenna, in the shallow water of the lake, a 17 year old boy, Viljar Hanssen, shot five times, felt for his eye. He couldn’t find it. Instead he reached through the gap in his head and touched his brain. While trying to take stock of his injuries – the three fingers dangling by a thread from his hand, the wounds in his shoulder, arm and leg, and the bullet hole in his head – Viljar could only think of his brother. He had kicked him to safety when the first shots found his own flesh and ordered the younger boy to swim to safety.

Disfigured now, unable to run and ski the way he could before and still unsure about the effects the missing part of his brain might have on his life, Viljar made the court laugh by saying that at least missing an eye meant he didn’t have to look at his would-be killer while he testified. When he described his delight at discovering his brother was unhurt then spoke unselfishly, with stirring fraternal compassion, about the younger boy’s own island ordeal, several in the court cried. Almost nobody was left unmoved.

Commander Breivik took notes. Nothing he has seen so far has shaken his belief that he is the only real hero at the trial. He is defending Norway against “Islamic colonisation” by striking at the heart of the “leftist” establishment. Presumably that is why he was screamed, “today you will die Marxists,” at the unarmed children he was gunning down on the island, and why he was satisfied enough at his work to call the police and proclaim, “this is Commander Breivik... Mission accomplished.”

He is not a commander in the established sense.  He’s not been in any of the forces; never even served his normally obligatory year’s national service. He is, however, part of an imagined pan-European chivalric order, The Knights Templar, similar to the online guilds he was so familiar with from playing World of Warcraft 16 hours a day for a whole year.

He also has a uniform. There are camp pictures of him wearing it in the manifesto he emailed to hundreds of supposedly like-minded right-wingers in the hours before the slaughter. But he has dropped his demands to be allowed to wear it in the court – presumably on the advice of his defence team who would argue that in seeking to be sentenced as a sane man, he should ditch anything which might make him look anything but.

There must be disappointment. The uniform was supposed to have been part of the propaganda front Mr Breivik believed he would be able to sustain throughout the course of this ten week trial. But the media have largely been and gone. He has already been given his legal opportunity to preach his ideology and has now been pushed aside. Now, try as he might to wrestle back some attention, as brave witnesses to the Utoya massacre relive their island nightmares, he has been relegated to a sideshow in his own show trial.

Mark Lewis tweets @markantonylewis

One of the survivors of Breivik's massacre Photograph: Getty Images
Christopher Furlong/Getty Images
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Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide