The New Statesman Essay - Professionals who lost their virtue
Doctors and lawyers base their right to self-regulation on their moral superiority. The claim no lon
The professions have become increasingly prone to professional fouls. Trust, competence and moral integrity - the conventional trademarks of "the professions" - have evaporated. Hardly a day goes by without horror stories involving doctors, dentists, lawyers, accountants, even members of the clergy. We are beginning to realise that George Bernard Shaw was not just joking when, in The Doctor's Dilemma, he declared: "All professions are conspiracies against the laity."
The laity, we ordinary citizens, find ourselves at the receiving end of the untender mercies of professionals. Consider, for example, the doctors. There is the case of Dr Harold Shipman, who murdered his patients unsuspected and undetected for decades. Then we heard of the doctors at Bristol Royal Infirmary hoarding body parts from dead infants without parental knowledge or consent. Now we read of the consultant gynaecologist Rodney Ledward, whose botched operations over 16 years have left a trail of more than 400 maimed women.
But our dilemma is not just with doctors. We learn that 90 per cent of dental work performed in Britain falls below international standards, that the profession is littered with "cowboy dentists" who are destroying patients' teeth with impunity. Complaints against lawyers are increasing exponentially. According to the Law Society, there is a backlog of 13,000 complaints against solicitors that will take decades to investigate. The Office of Fair Trading is looking into the huge fees and probably unfair profits being made by the professions - surveyors, architects, accountants. And we all know about the scandal at Lloyds where a businessman's word is no longer his bond - but someone else's money down the drain.
Nothing new here, you may say. Many of Dickens's novels turned on the villainy of a member of the professions. But, in Dickens's day, the bad egg was no more than that: public trust in the professions generally was maintained, and the social opprobrium that greeted the transgressors was considered a sufficient sanction to uphold standards. In these postmodern times, when moral certainties have dissolved, the principles that govern professional behaviour are less clear. Our dilemma is that the very professions we need to trust in good times and rely on unreservedly in times of personal distress now incite our distrust, suspicion and even fear.
Professions evolved and consolidated their positions during the Victorian era, and they are deeply entrenched in the morality of the period. Originally, the term was reserved for such "gentlemanly pursuits" as law, medicine and divinity. In pre-industrial Europe, these occupations gave those who lacked a private income the opportunity to make a living without troubling themselves with commerce or manual work. Eventually, officers in the army and navy were also included in the professions.
Most conventional definitions present an idealised picture of the professions as selfless public service. The classical definition is provided by A M Carr-Saunders and P A Wilson in their 1933 study, The Professions. The profession, they claimed, "exhibits a complex of characteristics" which are absent in other vocational pursuits; the main being the "ethical imperative" to render "altruistic service" to the public. Later, in his much quoted 1964 book, The Qualifying Associations, Geoffrey Millerson provided a compact list of the most frequently mentioned characteristics of professions, as enumerated by a host of writers and commentators: a skill based on theoretical knowledge; a requirement for training and education; the need for the professional to demonstrate competence by passing a test; a code of professional conduct; the performance of a service for the public good; and a professional organisation.
Such formal definitions leave out a number of other, perhaps more important, aspects of the professions. Their members once had the same public standing as "officers and gentlemen" and hence all the social privileges that went with this status. Further, by virtue of their knowledge and training, as well as their code of honour, professionals were said to be equipped with a higher moral aptitude. They were both socially and morally superior to the public. In its turn, the public was obliged to give the professions both due respect and unquestioning trust.
Moreover, like the armed forces, the professions worked as a closed society - or rather, as a gentlemen's club (female professionals being, until quite recently, very rare). Rising to the top in the professions was not solely about competence and skill or knowledge and technique. It was largely about being a certain sort of person. Entry into the professions required you to be groomed in the mindset and outlook of the professional gentleman. Candidates recruited into the professions were taught that "the first public schoolboy was born in Galilee and his name was Jesus Christ". The gentlemanly code of honour inbuilt in professional sensibilities and transferred from generation to generation symbolised a mythic "laying on of hands". It confirmed both privilege and responsibility: hence the rites that attended entry to the Bar, such as the need to eat a certain number of dinners at the Inns of Court; hence, too, the open preference in medical schools, until very recently, for the offspring of doctors.
It was always bad theology; social changes have turned it into a disastrous sociology. When did we lose that instinctive sense of morality that went with privilege, the idea we associate so particularly with England?
Back in Victorian times, that cranky but enormously influential thinker, John Ruskin, identified the crux of the matter. For him, a "profession" was a calling for which a man is prepared to give up his life. Otherwise it is just a job, or a business, or a racket. Giving up one's life was also the gentlemanly ideal that shone through empire- building. It was all part and parcel of taking up the white man's burden. The professional ethos became another way of talking about Victorian nationhood, the nation of the few who led the rest. It found its fullest expression in the renewal of the old Roman maxim dulce et decorum est pro patria mori.
Yet there was nothing sweet or fitting in leading your men over the top in Flanders fields. It was here that a morality based on privilege crumbled into the dust. Arrogance and incompetence at the top, marshalling slaughter and waste, exposed the old fallacies. Privilege, it turned out, guaranteed neither morality nor ability. The code of the public school junior officers and gentlemen, their ideals of honour, service and patriotism, were sacrificed before the enemy machine-guns as callously as those of the common Tommy Atkins. Those who returned thought differently about themselves, the men they had led and those who gave the orders.
Then came the Second World War. Britain's working class ate better on wartime rations than on peacetime dole. The middle classes got a glimpse of working-class lifestyle. The great collective endeavour introduced everyone to the horrors of rickets, slum neighbourhoods and children infested with lice. The general levelling of wealth and income in postwar Britain further exposed the professions as privileged, infested, closed societies.
The response of the professions was to launch a fierce defence of their privileges. The consultants, for example, successfully stalled the establishment of the NHS until their dominance was secure. They demanded and got the right to maintain private beds in NHS hospitals and pocket the fees. Their moral integrity and professional competence could not be questioned and they continued to be gatekeepers to the profession. These very privileges have been identified as complicit by reports on both the Bristol baby scandal and the Ledward case. Indeed, in the latter case, the entire repertoire of preserved privileges are clearly identified: a hospital culture that treated consultants as gods; an old boys' network; a climate of fear and retribution that prevented colleagues reporting concerns about skills and standards.
The next major assault on the professions was launched by Margaret Thatcher. The "politics of envy" has always been ascribed to Labour (old, rather than new). But Thatcher hated the old Tory classes even more intensely than she hated the old Labour bureaucrats. She saw the professions as a corrupted aristocracy, and wherever she could tear them down, as in the old NHS, she did. But she did not replace what she destroyed with democracy (admittedly a hazardous venture), but with open plutocracy. The makeover was for money, and money became the only medium that mattered.
And that's where we stand today. The professions still operate on the basis of a Victorian morality. But the social milieu in which the balance of gentlemanly privilege and idealism is supposed to function does not exist any more. As a society, we recognise competence and expertise, but we no longer accept institutions claiming innate moral superiority. Technical expertise does not, in the modern view, equal moral enlightenment. We are no longer ready automatically to accord "due respect" to professions or to accept that they have a god-given right to higher social status.
As the social status of the professions has been eroded, their idealism - the "ethical imperative" to render "altruistic service" to the public - has collapsed. However, it is not the hard-working rank and file of the professions who are to blame; doubtless most of them want to give a decent day's work for a good day's pay. But it is the professionals' professionals, the elites who run their governing bodies, that reveal the rot most openly. These are the ones who are most jealous in clinging to the privileges of hierarchy, and who are the most zealous in covering up incompetence and corruption.
The fundamental privilege that professional bodies such as the General Medical Council guard most jealously is that of self-regulation. Originally, the whole idea of self-regulation was based on the moral superiority of the professions - as people far above the mundane level of the public, the professionals had the right to regulate their own affairs. Later, self-regulation became a vehicle for defending "professional standards" and purportedly a means of quality control. The justification is that only qualified members have adequate knowledge to understand the complex issues involved in regulating a profession. The public and the politicians are just too ignorant to deal with the complexities associated with modern medicine or contemporary law.
Self-regulation is the hallmark of professional status. It is the aspiration of those occupational groups whose claims to professional status would once have been regarded as marginal - social workers, the police, even estate agents. Many have succeeded in largely regulating themselves, through such bodies as the Police Complaints Commission. But they mostly lack even the pretence of an ethical imperative.
In practice, self-regulation was always an instrument to protect the self-interest of the members, to maintain a closed shop, to restrict recruitment, to preserve exclusivity and to shield the incompetent and unconscionable from public scrutiny. This is why it is the rarest of occasions when the Law Society actually finds a solicitor culpable, despite the avalanche of complaints against the profession. The GMC has systematically refused to examine many allegations of misconduct against doctors. In a recent case, the council was rebuked by a High Court judge for "serious and disturbing failures" in investigating allegations against an Oxford-based GP. The GMC also systematically turns a blind eye to doctors who have been struck off; doctors who have harmed patients are normally allowed to resume after a very limited career break, and incompetent doctors and consultants are allowed to continue to harm their patients with impunity. The recent cases of the unsound 78-year-old pathologist James Elwood and the consultant gynaecologist Richard Neale, who was struck off in Canada and botched operations on 14 women in North Yorkshire, are only the tip of the iceberg. Even the British Medical Association, at its annual conference last month, recognised that self-regulation is a recipe for public abuse.
But the self-evident failure of self-regulation is not the only reason to insist on radical reform of the professions. Most professions have no notion of retraining. Once you qualify and join the elite, closed society, you qualify for life, even though theoretical knowledge, techniques and technology now change rapidly. This is why we have a constant stream of horror stories about doctors who fail to diagnose cancers, who cannot spot a tumour when they see one, or who make a hash of operations because they do not know how to use the latest equipment.
In other words, we need a new definition of what it means to be "qualified". Even regularly retrained professionals will not be "qualified" to deal with the complexity of social and ethical problems that their practices could generate. Contemporary advances in knowledge and the problems they generate are no longer confined to fixed boundaries. The social and ethical complexities of medicine, for example, are now way beyond the art of being a doctor. A medical qualification gives you no special knowledge of the moral and ethical issues involved in gene therapies or fertility treatment, although it may give some technical knowledge that helps to illuminate them. The ecological or social effects of a company's decisions, often on a global scale, are far beyond the specialist knowledge of the lawyers or accountants who are called upon to advise.
The case for participation by both lay people and elected politicians in regulating the professions is therefore overwhelming. If we cannot trust the politicians, that is a fault in our democracy which we should work to put right; certainly, we already know that we do not trust the professionals themselves.
We must all become the gatekeepers and referees of the professions. Plenty of mistakes will be made; but the old myths are dead and there is no other way.
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