Intended for healthcare professionals


The rule of ignorance: a polemic on medicine, English health service policy, and history

BMJ 2011; 342 doi: (Published 03 March 2011) Cite this as: BMJ 2011;342:d997
  1. John V Pickstone, research professor
  1. 1Centre for the History of Science, Technology and Medicine, University of Manchester, Manchester M13 9PL, UK
  1. john.pickstone{at}

A good health service needs evidence based policy making as well as evidence based medicine, says John Pickstone

Over the past two centuries dogmatism and quackery have been substantially reduced in clinical medicine, albeit unevenly. Over recent decades especially, British medicine has learnt to use clinical evidence well and to respect the wishes of the treated. Quite the reverse seems the case for NHS policy in England—as the present blind “revolution” underlines. Though the lessons from clinical medicine are manifestly available, political leaders see no need to learn. In the absence of democratic, evidential, or professional controls to effectively protect the public interest, policy dogmatism and quackery flourish as never before.

How medicine learnt

In 18th century Britain, in the reign of mad King George, there were two main schools of doctors. Some tried to sell remedies that had seemed to work in similar cases; they were called empirics, or often “mere empirics.” Some doctors of higher status tried to apply first principles or dogmas—hence the dogmatists. But neither approach was reliable: it was hard to know which cases were similar, and dogmatists could choose from several sets of competing principles. The medical pamphlets promoting rival theories or expensive cure-alls would have sold well in modern airports, somewhere among the self help books, the management pot boilers, and the discussions of whether national economies should be inflated or deflated.

In other technical enterprises at that time, a potential buyer or investor might have asked to see previous work or whether the engineer himself had invested, but neither test was easily applied to medicine. Worse still, some of the doctors who sold “heroic” remedies or dangerous operations were itinerants; and when the bandages came off and the pathological chickens came home to roost, the quack doctors had left town.

Victorians had other answers to …

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