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A warning to the GMC

BMJ 2001; 322 doi: (Published 17 February 2001) Cite this as: BMJ 2001;322:439
  1. Iona Heath, general practitioner
  1. London

    The history of the political subversion of medicine is long, dishonourable, and continuing. It includes the active participation of doctors in the “racial hygiene” policies of Nazi Germany, the involvement of doctors in covering up deaths in custody under apartheid in South Africa, and the current use of doctors to medicalise and thereby sanitise the death penalty in the United States. The extent of the social construction of disease means that medicine will always be political and therefore at risk of political coercion.

    It is not impossible to imagine extremists seeking to marginalise the healthcare needs of minorities or dissidents

    In the United Kingdom, the General Medical Council (GMC) is considering the responses to its recent consultation process on its future constitution. The primary responsibility of the GMC is to regulate doctors and thereby assure the maintenance of professional standards. There is no doubt that lay people have an essential role to play in this process. However, the new constitution of the GMC must also provide a robust defence against the ever present possibility of the political abuse of medicine and the political coercion of doctors. In this role, the current systems of appointing lay representatives may represent a serious threat. Successive governments have exploited the democratic deficit within the health service and appointed lay representatives to positions of power and influence at every level. It is no coincidence that in 1995, the Nolan Committee on Standards in Public Life directed 22 of its 55 recommendations at NHS trust boards and other quangos (www.official-documents.

    There is great danger in the assumption that the atrocities and obscenities of the past were in some way unique and unprecedented and will not recur. We believe in the continuation of a relatively benign political context to our work at our peril and that of our most vulnerable patients. In a Europe already capable of supporting the career of far right Austrian politician Jörg Haider, it is not impossible to imagine an extremist administration, of either right or left, seeking to marginalise the healthcare needs of particular minority or dissident groups or extending the scope of psychiatry as an agent of malevolent social control.

    At present, the doctors on the GMC are elected by their peers and are democratically accountable to them. Low levels of participation weaken this accountability but none the less fundamental democratic safeguards remain in place. The lay members are appointed, and that process of appointment has been subject to political influence in the past and is highly likely to remain so. At present, the lay representatives are accountable to no one but themselves and those who appointed them. Under the current modernisation proposals, the GMC seems likely to become much smaller with a larger proportion of lay members, and the potential for political placement and influence will be proportionately greater. The adoption of the seven Nolan principles—selflessness, integrity, objectivity, accountability, openness, honesty, leadership (—in making appointments introduces some safeguards but, once appointed, individuals remain unaccountable.

    There is no question but that lay people must be involved in the regulation of the medical profession and in the workings of the GMC at every level and no doubt that lay people have hugely valuable insights to offer to the processes of assessing and regulating doctors. But how should these lay people be selected and should they be regarded as representing patients or citizens? To date, the vast majority of lay people involved have come from a relatively narrow, relatively affluent, and relatively well educated section of society. Are the views of those who fall outside this group necessarily less valuable or important? We know that the capacity to exert a degree of control over the context of one's life is in itself health promoting, and the relative exclusion of poor, marginalised, and chronically unwell people from the regulation of the health service and health professionals is an important dimension of health damaging social exclusion.

    This statement in Deutches Arzteblatt, a leading medical journal, heralded the collapse of medical ethics in Nazi Germany in 1933: “Never before was the medical profession so intimately linked with the wisdom and aims of the state as today.”

    In 1996, the Nuremberg issue of the BMJ warned of the dangers whenever political forces directly enlist the medical profession in an agenda of social and economic transformation (1996;313:1413-5). If we are to heed this warning effectively, a mechanism must be found to make lay representatives democratically accountable to the wider public—and not just to the politically powerful. This will not be easy but it remains essential.


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