Introductory address on the General medical council, its powers and its work, delivered at the University on October 2nd, 1906

lister, Donald

Introductory address on the
General Uedic.nl Council, its powers
and it;

Introductory Addn

G( -a/ Medical Council

and its Work

DELIVER THE UNIVERSITY

OCTOBER 2nd, 1906

DONALD MACALISTER

"•7/y of Cambt
Medical Council of the Uniled Kingdom

ITY PR
1906

Price Sixpence net.

Manchester University Lectures. No. 5.

General flDebfcal Council
its powers anb its Work

SHERRATT £ HUGHES
Publishers to the Victoria University of Manchester

Manchester: 34 Cross Street
London: 60 Chandos Street, W.C.

Introductory Address

«

o^- rara
\

General Medical Council

its Powers and its Work

DELIVERED AT THE UNIVERSITY
ON OCTOBER 2nd, 1906

BY

DONALD MACALISTER

M.A. M.D. B.Sc. D.C.L. LL.D.

Linacre Lecturer of Physic in the University of Cambridge ; President
of the General Medical Council of the United Kingdom

MANCHESTER

AT THE UNIVERSITY PRESS
1906

3^^-^j.

o2.

.

The General Medical Council

Its Powers and Its Work.

IT happens that I have never myself had to listen to what
is called an "Opening Address." But I have read a good
many, and they have not always caused me to regret my
deprivation. At Cambridge and at St Bartholomew's,
where I was a medical student, these ceremonial orations
were not in favour. At the beginning of the session we
met as usual, and set to work at once. I hope that before
this hour is over you will not be tempted to wish that the
like custom prevailed in Manchester. It may reassure
you if I say that I do not propose to offer you a formal
exhortation. Time and temperament have precluded me
from trying to emulate the eminent leaders of the pro-
fession who in past years have discoursed to you from this
place. My aim will be humbler and perhaps more prac-
tical. I propose to speak informally, but as I trust not
loosely, on various matters concerning our common profes-
sion and its government with which at one time or another
it behoves us all to be acquainted, and about which many
mistakes are made — for want of knowledge.

When I was honoured with the invitation to address you
at the beginning of a new academic year, I was told that
my audience would consist chiefly of medical students and
practitioners — "with a sprinkling of intelligent laymen."
That information — or warning — had something to do with
my choice of a subject. For the General Medical Council
has points of interest for students, practitioners, and
laymen alike ; and my only fear is that I may fail to make
them as interesting as they really are. My chief difficulty
lies in the misconceptions that exist regarding the
Council's powers and its work. I seldom take up either a

2 THE GENERAL MEDICAL COUNCIL

professional or a non-professional paper that touches upon
medical matters without finding evidence of these mis-
conceptions. Sins of commission — more often sins of
omission — are freely laid to the Council's account j of
which, from its very nature and constitution, it cannot be
otherwise than guiltless. It is scolded for doing what the
law says it shall do. It is bitterly reproached for leaving
undone what the law gives it neither power nor means to
do. It is spoken of at one time as the parliament of the
profession ; yet it has no authority to legislate for anybody,
and it cannot make even a by-law for any but its own
proceedings. At another time it is scornfully described
as a "doctors' trade union"; yet it cannot legally levy an
annual subscription, or say a word on the matter of rates
of pay, or hours of work, or disputes with employers; it
offers no pecuniary benefits or strike-pay, and it can be
sued in the courts like any other corporation. I venture
to think that such a "union" would hardly be thought to
deserve the name by the energetic organizers of Lancashire
and Cheshire trades.

The Council is, in fact, neither a parliament for making
professional laws nor a union for protecting professional
interests. It may surprise some of you to learn that when
the Council was created, nearly fifty years ago, the
declared purpose of the Legislature was not to promote the
welfare of professional men or professional corporations —
it was not to "put down quackery," or even to advance
medical science. The object in view was simply the
interest of the public. The preamble of the Act of 1858
consists of two lines only : —

"Whereas it is expedient that persons requiring medical
aid should be enabled to distinguish qualified from un-
qualified practitioners : Be it therefore enacted . . ."

The preamble, as you see, recognizes two kinds of
practitioners, the "qualified" and the "unqualified." Up
to that time no easily-understood line was drawn between
the two, and when the public desired to make a choice,
they were frequently at a loss. The Act set up machinery

ITS POWERS AND ITS WORK 3

for, as it were, "hall-marking" the qualified practitioner,
so that he might easily he recognized when his services
were required. But the public were left free then, as they
are free now, to seek "medical aid" from the unqualified
practitioner if they like. And the unqualified practitioner
was left free then, as he is free now, to practise for gain
among those who choose to employ and pay him. He was
forbidden, under penalties, to pretend that he was qualified,
by taking a title he did not possess ; he might not use the
courts for the recovery of his charges; he could not give
a valid certificate of sickness or death : but except for
these and a few other not very inconvenient disabilities,
he was untouched by the new law.

On the other hand, the "qualified" men, as a set-off
to their new legal status and official recognition, were
subjected to a new .central control, educational and
disciplinary. They obtained no monopoly of practice
among the public in general. They were afforded no
special "protection" against the competition, not always
scrupulous or insignificant, of the uncontrolled unqualified
practitioner. Indeed, for a time those of them who were
educated and licensed by medical schools and corporations
were in a sense exposed to greater competition than before.
For at the outset all who claimed to have practised before
a certain date in 1815, whether they had been educated or
not, were enrolled among the qualified. In this way a
number of elderly practitioners, who had 110 licence or
diploma whatever, were accorded the same legal status as
the rest, and practised side by side with them. These of
course have now disappeared ; but their existence must not
be forgotten when we are considering the so-called
"privileges" of the profession which were conferred in
1858.

The qualified practitioners might fairly have claimed
that it would be good for the public, as well as for them-
selves, if monopoly of practice, and protection against the
competition of the untrained, had been conferred upon
them. In other countries, and in other parts of the King's

4 THE GENERAL MEDICAL COUNCIL

Dominions, the restriction of practice to the qualified is
with general consent and approval enforced by law. Any-
unqualified person who habitually and for gain practises
or holds himself out as practising any branch of medicine
is liable to severe penalties. But in these days of
"Christian Science" and "Nature Cures" and "Bile Beans,"
it requires a good deal of optimism, and some resolute
ignoring of the signs of the times, to believe that in this
free (and easy) country legislation to that effect is either
probable or possible in the near future.

The result, foreseen or unforeseen, of Acts passed since
1858 has in fact been rather the other way. An unqualified
person can be restrained from using a title, such as
"physician" or "dental surgeon," which implies qualifica-
tion and is reserved by law for qualified men. But if he
takes to himself six other persons as unqualified as himself,
and registers the compound individual as a joint-stock
company, it is held that, in England at least, he can call
himself what he likes. He is no longer a "person," but a
corporation — with the usual and highly-convenient nega-
tion of soul or body. Thus the distinction set up by the
Medical Act is blurred in the public mind by the operation
of the Companies Act. The public may well be excused
if they think they are dealing with qualified practitioners
when they seek advice at the establishments, legally incor-
porated, of "Dr Galen Aesculapius Jones, Limited," or
"Professor Smith and Co., Consumption Specialists," or
"Tooths, Cash Dentists." Strenuous efforts have been
made, within and without Parliament, to get this
remedied, but so far without much success. The Legis-
lature is in fact very tender towards unqualified prac-
titioners of every kind — so long as they do not presume
to practise Law. The lawyers have seen to it that that
profession at least is sacred.

I have mentioned that in 1858, when medical men were
first officially registered, every one who claimed to have
been in practice some forty years before was enrolled, even
though he held no diploma or other certificate of com-

ITS POWERS AND ITS WORK 5

petency. The vested right even of the unqualified was
thus carefully respected. A similar thing happened
twenty years later, when dentists were enrolled, and to-day
the Dentists' Register is made up, to the extent of nearly
one-half, of men with no other qualification than "in
practice before July 22nd, 1878." Four years ago, as the
outcome of a bitter cry for the better regulation of mid-
wives, whose want of skill and cleanliness brought suffering
and death to countless mothers and infants, the Midwives
Act was passed. Again all women went on the roll who
applied, and had been in practice for a year — trained and
untrained together. Those who did not choose to go on
the roll were allowed two or three years more during which
they could use the title of midwife, though unenrolled or
uncontrolled. And not until 1910 will it be illegal for a
woman, who is not enrolled and has no certificate of train-
ing, to practise for gain that perilous office, perilous, I
mean, to those who place their lives in her hands.

All this care for the unqualified can, I have no doubt, be
excused on political and legal grounds. That I am not
concerned to deny. I mention it to illustrate the general
temper of our lawgivers, and of their constituents also.
We all of us in our hearts incline to distrust the rule of
the expert, and we rather admire the amateur. Most of
us flatter ourselves that in one way or another we are
something of amateurs ourselves. It is more than a half-
truth to say that England would rather be free, free even
to let itself be injured or befooled, than under compulsion
to be sober, or healthy, or secure. And so long as this
mood prevails, I do not see much chance for the Bill that
is to "put down quackery" with a strong hand. Parlia-
ment may go so far as to " distinguish " the trained from
the untrained practitioner; it will then leave you free to
make your choice — at your own risk.

The instrument which Parliament set up for the purpose
of marking the distinction is called the Medical Register.
And the making and keeping of this Register is entrusted
to the Medical Council. On the Register are placed the

6 THE GENERAL MEDICAL COUNCIL

names of those who have passed certain tests of professional
fitness. These are called Registered Practitioners, and
these alone the law declares to be duly or legally qualified.
The Council has to see that the tests of professional fitness
actually applied by the Examining Bodies to aspirants for
registration are " sufficient." The tests must ensure that
those who pass them possess "the knowledge and skill re-
quisite for the efficient practice of medicine, surgery, and
midwifery." The Council has also to see that no registered
person, who by crime or misconduct has become unworthy
of the legal status which registration confers, shall remain
on the Register. In other words, the two great functions
which the Council in the public interest discharges are,
first, to prevent the unfit from gaining access to the
Register, and, secondly, to remove the unworthy from it.
Except as to a few subsidiary matters, such as the prepara-
tion of the Pharmacopoeia, the control of Diplomas in
Public Health, the scrutiny of the Midwives' Rules, and
the like, all its powers and all its work in relation to the
medical and dental professions have reference to these two
functions. It is a Council of Education and a Board of
Regis tration .

It is a Council of Education, but it neither teaches nor
examines. It cannot lay down a code or curriculum com-
pulsory on all medical students. It cannot inspect a
single medical school. Its statutory powers are indeed
strictly limited. It can order the visitation and inspection
of the various examinations held by Universities and Col-
leges in the United Kingdom, for the purpose of testing
candidates for their respective medical degrees or diplomas-
And it can require from these bodies information concern-
ing the course of study, and the age of candidates, which
they prescribe. If, from the inspection of the examina-
tions or the information supplied as to the curricula, the
Council comes to the conclusion that either are "in-
sufficient," it has no power to disallow them or to order
that they shall be amended. It forwards its report to the
body concerned, takes note of any observations the body

ITS POWERS AND ITS WORK 7

may make thereon, and if it is still convinced that the
training or the test.is " insufficient," it brings the question
before the Privy Council.

In this and in other matters the Council is in close ad-
ministrative relation with the Privy Council. If in any-
thing the Medical Council neglects its duty, the Privy
Council may formally direct that the duty shall be per-
formed, and may in default itself perform it. In the case
before us the Privy Council has power to supplement as
well as to supersede. It can do what the Medical Council
is unable to do. If the Privy Council sees fit it can
declare that an " insufficient " diploma shall be no longer
recognized as legally registrable; and, if circumstances
alter, it can rehabilitate the diploma and make it valid
again.

The Medical Council is also a Board of Registration.
In fulfilment of this function, partly by the force of neces-
sity, and partly in virtue of the interpretation of the law
by Judges, it has become a professional Court of Justice, a
domestic forum for the trial and determination of grave
charges brought. against registered practitioners in their
professional capacity. By successive judicial decisions it
has been laid down that in its procedure the Council,
sitting as a Tribunal, must as nearly as possible follow the
forms and rules customary in other courts. But it has no
authority to compel the attendance of witnesses, to ad-
minister oaths, or to call for the production of documents.
It has only one judgment to give when a charge is proved
to its satisfaction, namely " guilty of infamous conduct in
a professional respect"; and only one sentence when
judgment is given, namely "erasure from the Register."
From this sentence and judgment, given after proper
inquiry and without malice, the High Court of Justice has
pronounced that there is no appeal. In the earlier years
of the Council's life its decisions were frequently called in
question before the ordinary courts of law. The results
were on the whole fortunate, for while its actual findings
as a professional court were never reversed, the judgments

8 THE GENERAL MEDICAL COUNCIL

delivered on these appeals not only denned, but in effect
expanded, the jurisdiction of the Council. They laid down
its procedure, they interpreted broadly the meagre language
of the Statute, and they settled beyond dispute the finality
of its decisions on all causes within its competence.

All the Act says is : " If any registered medical prac-
titioner shall be convicted in England or Ireland of any
Felony or Misdemeanour, or in Scotland of any Crime or
Offence, or shall after due Inquiry be judged by the
General Council to have been guilty of Infamous Conduct
in any professional respect, the General Council may, if
they see fit, direct the Registrar to erase the name of such
medical practitioner from the Register" In 1863 the
Lord Chief Justice and his colleagues of the Queen's Bench
laid it down that this clause " makes the Medical Council
sole judges of whether a medical practitioner has been
guilty of infamous conduct in a professional respect; and
this Court has no more power to review their decision than
they would have ... of determining whether the facts
had justified a conviction for felony or misdemeanour
under the first branch of the section. . . . The Council is
the tribunal to whom the Legislature has left the decision,
as being the best judges in the matter, and this Court can-
not interfere."

In another appeal Lord Justice Bowen declared that,
provided "due inquiry" had been made by the Council,
"the jurisdiction of the domestic tribunal, which has been
clothed by the Legislature with the duty of discipline in
respect of a great profession, must be left untouched by
Courts of Law."

Referring to the language of the Statute, Lord Justice
Fry added: "'Inquiry/ and 'judgment,' and 'guilt' are
all words which express and which are relevant to a proper
form of judicial proceedings, and therefore, although this
body proceeds by different rules of evidence from those on
which Courts of Law proceed, I cannot for a moment doubt
that the Council were proceeding judicially; nor can I
help adding that the manner in which the Council has

ITS POWERS AND ITS WORK 9

proceeded on this inquiry, as on all other inquiries, shows
that the Council ate fully aware that they are performing
judicial duties, and endeavour evidently to perform them
in a very admirable manner."

These and like judgments settled the jurisdiction and
the procedure of the Council sitting as a Tribunal. The
meaning and scope of the statutory verdict of the Council
— "guilty of infamous conduct in a professional respect "-
were given by the definition of the Court of Appeal in
1892. " If it is shown that a medical man, in the pursuit
of his profession, has done something with regard to it
which would be reasonably regarded as disgraceful or dis-
honourable by his professional brethren of good repute and
competency, then it is open to the Council to say that he
has been guilty of 'infamous conduct in a professional
respect.' "

I have given these important decisions at length for
two reasons. They show, in the first place, the position
assigned by the law to the Council's judicial inquiries and
the range of its jurisdiction. In the second, they illus-
trate the process of legal development by which three
words in the Act of 1858 — "inquiry," "judged," and
"guilty" — have inevitably led the Council to become a
Court of professional discipline, with duties and powers
which were certainly not explicitly set forth in the
Statute, if, indeed, they were implicit in the intentions of
the Legislature. The guardianship of the Register and of
its accuracy, then committed to the Council, had in it the
potentiality of a wider and weightier stewardship. The
Council of Medical Registration had no choice but to grow
into the High Court of Medical Conduct ; and observe that
the development came about as the result of a series of
judicial interpretations. A study of the earlier minutes of
the Council shows how tentative, how hesitating, how half-
unconscious were its first steps towards the assumption of
judicial functions. It hardly knew that it was a judicial
tribunal in posse; it scarcely realized what precautions as
to procedure were necessary to make its inquiries " due "

10 THE GENERAL MEDICAL COUNCIL

within the meaning of the Act. The course the evolution
actually took is, however, exactly that by which the
Common Law of England has reached its present form.
As Sir Henry Maine (Ancient Law, chap, ii) reminds us :
"We in England are well accustomed to the extension,
modification, and improvement of law by a machinery
which, in theory, is incapable of altering one jot or one
line of existing jurisprudence. The process by which this
virtual legislation is effected is not so much insensible as
unacknowledged . . . We do not admit that our tribunals
legislate; we imply that they have never legislated, and
yet we maintain that the rules of the English Common
Law . . . are coextensive with the complicated interests
of modern society."

The development of the germ provided by the Legisla-
ture has been from within as well as from without. The
decisions of the Courts of Law have caused the Council to
expand into a recognized and independent Tribunal. Its
own judgments in a succession of actual cases, decided by
it after due inquiry, have gradually built up a body of
precedents and rulings which may fairly be described as
forming the Common Law of Medicine. I said at an earlier
stage that the Council had no power to legislate or to make
by-laws, except for its own proceedings. That is strictly
true of the Council considered as an enacting body. It is
equally true of the ordinary Law Courts ; we do not regard
them as parts of the Legislature; they do not frame new
statutes. But, as we have seen, they do in effect develop
law if they do not claim to make it. And the developed
law may be, and indeed is, more comprehensive and more
adaptable than the statute law, of which it professes to be
no more than the interpretation.

The Judges' definition of professional misconduct, like
their definition of the province and jurisdiction of the
Council itself, contains within it a principle which is in
essence evolutionary and progressive. Whatever may be
reasonably regarded as disgraceful or dishonourable by
professional men of good repute and competency, is "in-

ITS POWERS AND ITS WORK XI

famous conduct " in the technical sense. As the standard
of professional competency becomes higher, as the con-
science of men of good repute becomes ethically more
exacting, so the area within which the Council can exercise
its discipline expands. And thus it has come to pass that
practices which, forty or fifty years ago, were so common
and so lightly regarded that they excited little notice and
less reprehension, are now repugnant to the general sense
of the profession, and are sternly repressed by the Council.
I may take two instances to illustrate my point.

Formerly, in certain parts of the country, it was
customary for a qualified man in large general practice to
employ a number of unqualified persons as his assistants.
These, as they acquired a certain amount of rule-of-thumb
experience, were gradually entrusted more and more with
the sole care of patients. The practitioner sometimes did
not see the patient until it was time to sign a death cer-
tificate in order to avert an inquest. Individual cases of
gross abuse were one by one brought before the Council
and condemned. Others, in which various forms of evasion
were attempted, iollowed upon these; and as they arose
these ingenuities were severally met and dealt with. At
length it was made clear to those who clung to the evil
tradition, that their practice was too dangerous to be
profitable, and that the "unqualified assistant" must go.
Having accumulated a sufficient body of experience re-
garding the mischief which had to be eradicated, the
Council summed up all in a "warning notice" respecting
the professional offence of "covering." All qualified
practitioners were notified that the abuse of their qualifica-
tions, whereby an unqualified person was enabled to treat
patients as if he were qualified, under " cover " of his
employer, was in its nature fraudulent and dangerous to
the public, and that such an offence rendered them liable
to be judged guilty of infamous conduct. The result was
remarkable. Unqualified assistants were dismissed whole-
sale, often no doubt at the cost of some hardship to in-
dividuals, but in the end for the good of the public and of

12 THE GENERAL MEDICAL COUNCIL

the profession alike. The evil, from being almost endemic
in particular districts, became sporadic, and is now fast
passing away. The general conscience, which tradition
had somewhat dulled, is now alert. Cases of "covering"
by medical men have almost ceased to be reported to the
Council ; though in the dental profession, which is still in
the stage of transition, they are somewhat more frequent.

The " warning notice " was not in form a law or regula-
tion made by the Council ; it was merely a condensed state-
ment expressive of the successive judgments of the Court.
But it served its purpose, and its authority has not been
impugned.

More recently the practice of issuing objectionable
advertisements, or of employing or sanctioning the employ-
ment of canvassers, with the object of procuring patients,
was brought before the Council in connexion with par-
ticular flagrant cases. Each case had to be dealt with on
its own merits — or demerits. The character of the
objectionable advertisements varied; in some cases the
canvassing or touting was direct; in others it was carried
on through the agency of a club, or association, or dis-
pensary. Sometimes the case was strenuously fought, in
others the accused practitioner preferred to discontinue the
practice complained of, and submitted himself to the
clemency of the Council. Once more when the time was
ripe, and the various forms assumed by the mischief were
fully apprehended, a "warning notice" was issued as
before. This pointed out the public detriment and pro-
fessional discredit attaching to such unworthy methods of
attracting practice, and gave notice that practitioners who
employed them, or sanctioned their employment, were
liable to the penalty of erasure from the Register. A
similar notice had already been issued to dentists, as the
result of a series of cases duly heard and determined. In
this instance the Council had the support of the Court of
Appeal, given in certain important judgments relating
to an advertising dentist of some notoriety.

These examples — and I could add to their number —

ITS POWERS AND ITS WORK 13

illustrate my statement that even with its apparently
limited powers as'-a Court, and notwithstanding the ap-
parent inadequacy of the Statutes that govern it, the
Council does in fact formulate, and by formulation makes
explicit, fresh applications of the law to the growing com-
plexity of modern conditions. And, what is more im-
portant, in doing so it carries with it the consensus and
approval of "professional men of good repute and com-
petency." The average conscience is quickened, and what
was once tolerated is in the end repudiated and dis-
countenanced.

The experience of the Council on the judicial side of its
work has been singularly paralleled on the educational side.
There, too, though its positive powers seem meagre and
inadequate, it has not been prevented from developing
an influence which is real and potent.

Its powers only enable it to visit and inspect examina-
tions, and to call for information as to courses of study :
it is not authorized to prescribe or to amend either. It
cannot itself disallow an " insufficient " curriculum or an
" insufficient " test : it can only report its opinion to the
Privy Council. These are the limits imposed on its educa-
tional action by the terms of the Medical Acts, and at first
sight they are narrow enough. But in practice they have
proved to be more efficient than they seem in theory; and
the "long result of time" has gone far to make them
adequate for the purpose. This result has been reached,
as in the other case, by a gradual process of evolution, and
by the exercise of moral as distinguished from legal
pressure. It is dependent in great measure on three
factors, one the constitution of the Council itself, another
the loyalty and conscientiousness of the teaching and
examining bodies, and the third the publicity of the
Council's minutes and proceedings.

Let me say a little first about the Constitution of the
Council. As you all know, the testing of students in
medicine, and the granting, to those who pass the test, of
medical diplomas and degrees, have been entrusted by

14 THE GENERAL MEDICAL COUNCIL

the State to Universities and to certain professional
Colleges and Societies within the United Kingdom. Some
of the Universities are of great antiquity and repute, like
Oxford and Cambridge; others are modern, and filled
with high ambition, like Manchester and Birmingham.
The professional Colleges of Physicians and Surgeons are
all of considerable age, with traditions of service to the
cause of medicine that extend over centuries. Altogether
there are now twenty-four bodies which are legally entitled
to test candidates and to confer diplomas. In England
and also in Ireland two of the bodies, and in Scotland three,
have combined for examination purposes to form three
Conjoint Boards, one in each division of the Kingdom.
But for all other purposes the bodies preserve their
autonomy, and make their own regulations. To the fifteen
Universities it is probable that a sixteenth, namely the
University of Wales, will shortly be added.

Each of the twenty-four Licensing Bodies, as they are
called, appoints a member of the Medical Council. Five
members are appointed directly by the Crown, on the
advice of the Privy Council, and five members more are
appointed by direct election, under a universal suffrage, by
the registered practitioners resident within the Kingdom.
The total number of members is thus at present thirty-
four. Of these, fourteen only are required by law to
be medical practitioners themselves. The Crown and
the Universities may appoint lay men if they like.
They have not chosen to do so; but the freedom
reserved to them illustrates what I have already re-
marked on, namely, that Parliament in creating the
Council had in mind the safeguarding of general public
interests, not of professional or scientific interests. In-
deed, it was at one time proposed that one of H.M.
Secretaries of State should be the President of the
Council. One of my predecessors, Sir Henry Acland, used
to maintain that the Crown should appoint to the Council
lay members of the House of Lords, such as the late Earl
of Shaftesbury, as being persons of knowledge and ex-

ITS POWERS AND ITS WORK 15

perience of public affairs who were independent of transi-
tory politics (Royal Gommitsion Blue Boolt, 1882, page 5).
The Peers would, in his opinion, increase the administra-
tive efficiency of the Council, correct its tendency to pro-
fessional bias, and be always at hand to bring forward in
Parliament measures of medical importance. You will see
how remote from Sir Henry's mind was the conception of
the Council as a mere union of doctors for professional
ends. We have travelled a long way from his point of
view ; whether for better or worse it is not for me to say —
at least on this occasion. But the original idea on which
his view was based is not without significance, and it sur-
vives in this, that in the Universities generally it is not
the medical faculty that appoints the member but the
academic body, whatever that may be. In my own
University of Cambridge, the member is elected by the
Senate, more burgensium, that is, as the members of
Parliament are elected. The Senate numbers over 7,000
graduates in all the faculties, and each has his voice and
vote. When I was first returned to the Council I had, like
better men, to pass through the ordeal of an election con-
test.

The five members directly elected by the practi-
tioners of the three countries were added in 1886. In 1882
a Royal Commission had reported as follows : " While we
insist that the reason of the existence of the Medical
Council is the interest of the public, we cannot but re-
cognize the vital interest of the whole Medical Profession
in the Constitution of that Body. It seems to us highly
important that the Profession should have full and com-
plete confidence in the Council, and seeing that the govern-
ing Bodies of the Medical Corporations, which now elect
members of the Council [and which alone, be it re-
membered, are required to elect medical men] can hardly
be said to represent the great majority of practitioners, we
think it advisable to give the general practitioner an
effective voice in the Body which will be the principal
authority of the Medical Profession. We see no reason to

16 THE GENERAL MEDICAL COUNCIL

suppose that the members elected by direct representation
will be less eminent than those nominated either by the
Crown or the [proposed] Divisional Boards " [of the three
parts of the Kingdom]. The Commission accordingly re-
commended that four members should be directly elected,
two for England and one each for Scotland and Ireland.
The Act, when it came, was framed on a somewhat different
basis, and gave three members to England instead of two.

Please observe the main reason alleged for the intro-
duction of the directly elected members : it was " highly
important that the Profession should have full and com-
plete confidence in the Council." Exactly the same reason
may be assigned for the arrangement, also sanctioned in
1886, by which each one of the Licensing Bodies was
granted a separate voice in the counsels of the principal
authority. For in their case also it was important that
they should have such "full and complete confidence in
the Council " as would make them ready to co-operate with
it in matters of medical education. The new Act conferred
no new coercive powers on the Council. Its numbers were
increased, the extent of the qualifying examinations was
enlarged and better defined, the scope and method of the
inspection to which they were subject were more fully ex-
pressed. But the Council as before could only in the last
resort report to the Privy Council any deficiencies it dis-
covered. The law in fact contemplated that reasonable
uniformity and stringency in the existing tests were to be
brought about not by autocratic compulsion but by
common action for a common end. To use the language of
a recent Bill, "peaceable persuasion in a reasonable manner"
was to be the main motive force entrusted to the Council,
so far as Medical Education was concerned. Ardent re-
formers cried then, and have often cried since, for speedier
and more drastic powers. But after all is not the
method adopted by Parliament characteristically British?
"Government with the consent of the governed"; "freedom
limited only by necessary checks on the abuses which
would destroy the freedom and efficiency of others." These

ITS POWERS AND ITS WORK 17

are general maxims of our statecraft in regard to other
departments of our corporate life. And the State thought
well to apply them to the regulation of our profession also.

By its new Constitution then, in which (1) the State on
behalf of the people, (2) the medical profession itself, and
(3) the several bodies which educate, test, and maintain the
repute of the profession, possess each of them an effective
voice, the Council became better adapted than before for
its purpose of regulating the training of medical men. It
became in fact a better Council of Medical Education.
The duty and responsibility of appointing not obedient
delegates but good members were imposed on each of its
constituent bodies and sections. Their corporate credit
rather than their narrower interest was involved in the
selection they made. For the influence wielded by any
member of the Council within its walls ultimately de-
pends on his character and capacity as a man among his
brethren, and not on the dignity or power of the body
which sends him. His personal influence is instantly
weakened if he comes burdened with a mandate or ham-
pered by a pledge. He must be a voice, and not merely
an echo.

I need not labour this point. Its importance must be
obvious. But I would add two remarks before I leave it.
However important may be the essential independence of
the members considered as components of a Council of
Education, it becomes more than important, it becomes
vital, when we view them in their judicial capacity. In
Scotland the Judges of the Supreme Court are finely
described as Senators of the College of Justice. In our
medical Tribunal the Councillors must also be regarded,
and regard themselves, as for this purpose members not of
this or that College, University, or Association, but of
a "College of Justice" only. "Clothed by the Legislature
with the duty of discipline," as Lord Justice Bowen
expressed it, anything like fear or favour, partiality or
ill-will, mandate or pledge, becomes more than a defect,
it amounts to a disqualification for judicial functions.

18 THE GENERAL MEDICAL COUNCIL

And, in the second place, I would bear testimony that
during the twenty years which have elapsed since the
Constitution of the Council was readjusted, and over which
my knowledge of it extends, the electing bodies have been
singularly successful in realizing the idea I have indicated.
The special gifts of the members chosen have varied, and
fortunately varied, as much as their individual opinions
and experience ; but all have contributed elements of value
to the corporate life, and to the corporate character which
is its essence. Projects have often been framed for altering
the Constitution of the Council, so as to give less or greater
preponderance to some fancied " interest " or other. What
is always undemonstrated in these schemes is that they will
bring about the appointment not merely of different
members but of better members, having regard to the one
supreme interest — the interest of the public. It is with
this essential question that our people and our Parliament
are primarily concerned, and yet this is the very question
on which, in my opinion, no clear evidence has yet been
vouchsafed.

I have said above that the Constitution of the Council
was a factor in the development of its educational influence.
I have given you a sketch of what the Constitution is.
Let me next consider briefly how it reacts upon the
Council's work.

As regards education, the principle sanctioned by the
Legislature is that laid down by the Royal Commission of
1882. "It would be a mistake to introduce absolute uni-
formity into medical education. One great merit of the
present system, so far as teaching is concerned, lies in the
elasticity which is produced by the variety and number of
educational Bodies. Being anxious not in any way to
diminish the interest which the teaching Bodies now take
in medical education, or to lessen their responsibility in
that respect, we desire to leave to them as much initiative
as possible. In certain matters of general importance,
such as the duration of study, and the age at which a
student should be permitted to practise, common regula-

ITS POWERS AND ITS WORK 19

tions ought, we think, to be laid down; but we wish to
record our opinion tljat nothing should be done to weaken
the individuality of the Universities and Corporations, or
to check emulation between the teaching institutions of
the country." In other words, competition between a
multiplicity of teaching bodies, as such, tends to the
advancement of education. The institution which, caeteris
paribus, affords the most efficient teaching will have the
best reputation, and be the most resorted to. The interest
involved in the competition is the interest of improvement.
As regards examination, to put it mildly, this interest
is not so clear. I put it to the unregenerate instincts of
the students before me. If, as they will probably be ready
to declare, all examinations are essentially evil, would it
not be wise to choose the least ? Will not the most popular
Examination Board be that which offers the easiest test?
If the same hall-mark is impressed on 9-carat gold as on 22,
why waste precious metal in working up to the higher
standard? Reasoning of this somewhat crude kind com-
mends itself to the natural man, and many of the criticisms
that we hear are based on nothing more profound. It
takes little account of other facts of professional economics,
which are nevertheless of decisive importance. Thus, the
supposed hall-mark is not the same in the two cases.
Examining Boards, no less than medical schools, in the
end depend for popularity on their reputation for efficiency.
If a Board is notoriously easy-going, not students only, but
their teachers, and their parents, and the profession, and
the public, know it. The practitioner finds that he can
only get a 9-carat diploma from that Board, and he pretty
soon learns that he starts on his career with the stamp of
a 9-carat man. Conscious as we are of each other's im-
perfections, we are all sure that our own merits deserve
more than the minimum of recognition, whether in this
imperfect world they receive it or not. And so the easy-
going Board becomes the object of resentment instead of
loyalty among those it has licensed, and loses not only its
public prestige, but the corporate backing and support of

20 THE GENERAL MEDICAL COUNCIL

its licentiates. In its own interest the Board has to
recognize that it is hurtful, not helpful, to have the reputa-
tion of being over-lenient ; and I may add, as a matter of
statistical fact, that even in older days, before the full
operation of this law was observed, the easiest examination
was not the one which attracted the most students.

In so far, however, as the primary tendency of com-
peting examinations might be regarded as downwards
rather than upwards, the State has established a check. It
has affirmed the principles (1) that a certain minimum of
stringency shall be required; (2) that the minimum shall
always be such as to secure efficiency in the practice of
the essential branches of medicine, surgery, and mid-
wifery; and lastly (3), that to admit of the gradual
rise of the minimum with advancing needs and advancing
knowledge, the practical definition of it from time to time
shall be left to the General Medical Council with the
concurrence of the Privy Council.

It is here that the Constitution of the Council tells in
favour of these self-acting — or, as I called them just now,
economic — forces which tend to raise the standard of both
teaching and examination. Every Board has its member
on the Council. The Council informs itself by inquiry
and inspection of the actual requirements of each in respect
of training and of testing. If it appears, let us say, that
England is at a given moment too lax in any particular,
and that students are in consequence tempted to pass to
England from Scotland and Ireland, the members from
these sterner regions are at once on the alert. They are
not usually deterred from speaking their minds by any
overmastering awe of the majesty of English Universities
or Corporations. They have a common interest in urging
that the alleged laxity shall be remedied. The English
Boards, even if they were united in a solid conspiracy of
Saxondom, have only 12 votes out of 34. If the case against
them is made out to the satisfaction of the members elected
by the Government and the practitioners respectively, the
English combination is powerless to prevent the carrying

ITS POWERS AND ITS WORK 21

of a resolution that the fault ought to be amended. And
so far as a resolution of the Council can do it, amended it
would be. This is an imaginary instance : I don't say that
anything exactly like it has ever happened, though,
changing "names and numbers," examples not unlike it
could be cited. I am concerned only to give you what the
engineers call a "force-diagram" of the Council's Con-
stitution, as it operates, and was no doubt intended to
operate, in questions of the kind.

Unrestricted individual competition, to continue the
mechanical metaphor, would as some think make all
examining bodies gravitate to the lowest possible position.
By bringing all the bodies together, in the persons of their
chosen members, round the Council table, the play of
forces is so altered that the position of normal and stable
equilibrium is now somewhere about the centre of gravity
of the whole. The average standard of all replaces the
former minimal standard, and the average tends to be that
which "men of good repute and competency," having
regard to all the circumstances, think reasonable and
"sufficient." If it is not so high as some might think
attainable, it is a good deal higher than what, without our
machinery, would actually be attained.

Suppose now that the Council has passed a resolution for
the improvement in some particular of the requirements
of one or more of the constituent bodies. The resolution
does not come as an order from an autocratic bureau —
sic volo, sic jubeo. It comes from a Council on which the
body concerned has as much voice as any other. It is
like the utterance of the International Conference at the
Hague, in which all the nations are represented, and in
whose proceedings all take a part. You, as one of the
nations, may not wholly agree with the utterance : but you
feel that you can give it the most careful consideration and
even embody it in your own national practice or legisla-
tion, without derogating one whit from your proper dignity
or sacrificing a jot of your rightful independence. You
act on the impulse not of servile submission, but of noblesse

22 THE GENERAL MEDICAL COUNCIL

oblige. You gave the Council the highest sanction in your
power by sending a member to represent you; you would
expect the minority to respect its decisions had you been
in the majority : you can do no less yourself even if you
for once are in the minority. *

From the point of view of the Council as a corporate
entity, it is also of inestimable advantage that each of its
constituent bodies is represented upon it. Its members,
in one aspect of their functions, are so many envoys from
the Universities and Corporations. Each is in immediate
touch with his Governing Body : he is by hypothesis in
good standing and influence there, or he would not have
been chosen. While he is an envoy of the body, he be-
comes in turn an envoy of the Council to the body. From
his own knowledge of the course of the discussion, the
arguments used, the examples proposed for imitation, he
is in a position to explain and commend the Council's
decision to his colleagues at home. He can make clear the
scope and bearing of resolutions that are not always, I
regret to say, self-explanatory.

It is, I am convinced, largely owing to the representation
of the bodies upon the Council, and to the potent motives
which, with our British temperament, we deduce from that
representation, that the influence of the Council with the
bodies so far outmeasures its actual powers. The only
compulsion to which the bodies have been subject is the
internal compulsion of a high self-respect, which makes
them unwilling to do less than their compeers for the
common good. In a multitude of instances, even this com-
pulsion has been eased of all constraint by the fuller
sympathy with the Council's motives and objects which
the loyal mediation of its members has induced.

Whatever may have been assigned as the reason for it
in past times, the fact is worthy of mention here that
during its forty-eight years of existence the Council has
only once had to express its final verdict of "insufficiency"
with respect to any one of the licensing boards, and to
report that verdict to the Privy Council with a view to

ITS POWERS AND ITS WORK 23

judgment. The board in question no longer exists. It is,
therefore, only just to give full credit to the loyalty and
conscientiousness of the bodies, in setting forth the factors
which have facilitated the Council's task of maintaining
the educational and examinational standard of the pro-
fession.

The third factor I propose to mention to-day is the
publicity of the Council's minutes and reports. About
twenty years ago, in a notorious case, an attempt was made
to restrain the Council from publishing its proceedings in
relation to a penal enquiry. The attempt failed utterly.
The "privilege" of the report in question was amply sus-
tained. The Lords Justices of Appeal said : —

"The report is a report of proceedings which actually
took place; proceedings within the jurisdiction of the
Council ; a report of proceedings where the facts had been
ascertained; a bona fide true report without any sinister
motive ; a report of a matter of a public nature ; a report of
proceedings in which the public are interested, and in

respect of which they are entitled to information

We have come to the conclusion that the publication of
these proceedings, being true, accurate, and bona fide, is
privileged."

Now, if it is for the public advantage that proceedings
relating to the character of a particular person should be
published, it may well be held that it is still more for the
public advantage that reports and proceedings relating to
the action of a responsible corporation in the exercise of
its public functions should have the like publication.
Thus, when one of the examinations has been inspected,
the Inspector's report, with the remarks of the body con-
cerned, and the remarks of the Examination Committee on
both, are presented to the Council, and when duly received,
are printed in its public minutes. The report is full and
detailed, the strong points and the weak points of the
examination are described and commented on, ample
materials are furnished whereon to base the judgment of

24 THE GENERAL MEDICAL COUNCIL

the Inspector, the Committee, and the Council as to its
sufficiency or insufficiency. The whole is discussed in the
presence of the public and of the reporters of the various
journals, and the decision can thus be criticized with know-
ledge of its grounds. The net result is certainly beneficial.
If a body is commended for some new and valuable feature
in its methods, for an examination-experiment which has
proved successful, the commendation is public, and the
credit of the body is enhanced. The other bodies have the
opportunity of learning from the success of the pioneer
body, and of adopting the improvements themselves. In
this way a virtue is not only praised, it is propagated. It
is twice blessed ; it blesses the bodies that (thanks to their
free initiative) were wise enough to discover or invent it ;
it blesses also the bodies that offer it the sincere flattery of
imitation.

On the other hand, if a clear defect or insufficiency is
revealed, the body concerned hears of it, the profession
hears of it, the public hears of it. The criticism it calls
forth is echoed and re-echoed; and the criticism is not
always over-tender or under-pungent. It may in fact be
so irksome to self-complacency, so disturbing to con-
ventional dignity, that even a dignified and self-complacent
body of men, who are convinced that they are "not as
other men," and are persuaded that they "need no re-
pentance," will generally find it expedient to take serious
account of it. The forces called into play thus tend to
eliminate the defect, or even to convert it into a re-
dundancy of merit, before the next inspection. Please
remember that I am not trying to hint at particular
examples. I am only, as before, showing how the
machinery may be expected to work, and illustrating my
thesis that by its intrinsic construction it works for the
advancement of professional education and the upward
development of the minimum standard.

A few outstanding examples will suffice to make clearer
the results which all these factors in co-operation have
gradually brought about. The successive judgments of

ITS POWERS AND ITS WORK 25

the Council in disciplinary cases made it necessary that,
for the information and guidance of the profession, it
should formulate its view of certain courses of conduct in
the so-called "warning notices." These, as we saw, were
not laws enacted, but only law interpreted and declared.
In regard to education, the Council had no authority to lay
down a compulsory curriculum applicable to all. Strictly
speaking it could only consider on its merits each curricu-
lum proposed by any one of the bodies, and pronounce it
"sufficient" or "insufficient," If "insufficient" the body
must in theory try again and again, until the Council was
ready to say "sufficient." The inconveniences of this
method are apparent, and out of them arose a virtual
appeal to the Council to say, in general terms and before-
hand, what would be sufficient. In this way the Council
was impelled to formulate a statement of what subjects
should be included in a sufficient course of study, and
how many years at least should be spent in pursuing it.
Thus, without formal enactment, yet with general consent
and assent, first the four years' and later the five years'
curriculum came 'into being. It is not prescribed by a
ukase; in form it professes to be nothing more than a
"requirement" for sufficiency, or a "recommendation" to
the licensing authorities, but for practical purposes it has
the same effect as if it were an authoritative regulation.
All the bodies observe it, yet not as of law but as of grace.
Again, there is absolutely nothing in the Medical Acts
about the general or non-professional education of medical
students; nothing about matriculation or preliminary
examinations ; nothing about a volume that nearly touches
many of you — I mean the Students' Register. I hope I
shall not undermine your respect for that important docu-
ment by making this admission. The Royal Commissioners
of 1882 thought that the preliminary education and re-
gistration of students should be made a matter of statute.
They say : "We agree in the opinion universally held by
the witnesses that every intending medical student ought
to pass an examination in general education before enter-

26 THE GENERAL MEDICAL COUNCIL

ing on medical study. . . . As the purpose of this examina-
tion is only to test the possession by the candidate of a
reasonable amount of general culture, its subjects should -

not 'be of a technical or professional nature The i

general scope of the examination should be subject to the
approval of the Medical Council, but the conduct of the
examination should be left to the Universities or such
other bodies as may be approved by the Medical Council.
.... We consider that the full period of medical study
should be passed after the date of registration. The re-
gistration of medical students ought, we think, to be
placed under the charge of the Divisional Boards [of the
three Kingdoms], and an officer of each Board should
keep a list of the names. .'. .5>

But somehow the necessary provisions for giving
statutory effect to these recommendations were not form-
ally embodied in the new Medical Act which followed the
Commission. The recommendations practically described
a system that had already grown up. As you have heard,
the plan was universally approved by .the witnesses
examined, and they were many and representative of all
shades of medical opinion. How had it grown up, and by
what authority then — and now? We searched the Acts
before for the potential germs of the Council's judicial
development, and we found them in three words —
"inquiry," "judged," and "guilty." The germs of the
quasi-legislation of the Council on students' registration
and preliminary education and professional curriculum
lie in the words "courses of study" and "ages." As to
the sufficiency of these, the Council is to form, and if
necessary to report to the Privy Council, its opinion. Let
us suppose that the Council's opinion is that no course of
study should be less than five years long, and that no one
should be licensed till he is twenty-one years of age.
That means, first, that the beginning of the course should
somehow be marked in a definite way, and, secondly, that
it should not be begun before the age of sixteen. To en-
sure that these conditions are fulfilled in the case of

ITS POWERS AND ITS WORK 27

every student who after the age of twenty-one applies
for the registration of his diploma, the Council must
either ask each of the twenty-four bodies to keep its
own register of students' names and ages, and keep it
open to the Council's inspection day by day; or, what
is vastly more convenient for everybody, it must insti-
tute a Central Register of its own. As students often
pass from one University or school to another, the
former plan would require the establishment of a
students' clearing-house for the ratification and exchange
of local certificates of registration. The latter plan
saved all this, and so it was adopted. Then arises the
question, On what conditions shall a student be entered in
the Central Register? What must he do before he is in-
vested by the Council with the rights and privileges — if
any — of a Registered medical student? At a very early
stage most, if not all, of the bodies had insisted that every
one of their own students should first show, in some way
satisfactory to themselves, that he had enough general
education to justify his admission to a liberal profession,
and to profit by 'the scientific and technical training that
prepared him for it. The Central Register had no chance
of acceptance by bodies like these unless it was based on
the same principle. Thus *the Council was impelled to
require a " sufficient " certificate of preliminary educa-
tion as a pre-requisite to registration. Again the
question of " sufficiency " led to the defining of a
minimum requirement, and to the enumeration of the
authorities whose certificates as a matter of fact ful-
filled the requirement. Without its seeking, the Coun-
cil had thus to embark on inquiries concerning general
as well as professional education, and indirectly to
exert an influence on the former as well as on the
latter. To this day the time of two Standing Committees,
on Education and on Students' Registration, is largely
taken up with this subject ; and the Council's requirements
in regard to " arts " have risen, are rising, and are bound
to rise still higher.

28 THE GENERAL MEDICAL COUNCIL

Time fails me to tell you in detail by what curious
stages, through what disputes and controversies, along
what educational bye-paths, the present arrangement has
been reached. It is still transitional, there are still
difficulties in the way, it is not yet perfect. But on the
whole it is making for progress, for the uplifting of the
educational status, and thereby of the social status of the
profession. And its improvement is fortunately the con-
cern not of the Council only, but of medical men them-
selves. It is entirely to their credit that so many of them
should be eager for a more rapid advance than the Council
finds to be practicable. The Council has to carry a large
number of bodies with it; the pace of the march has to
take account of the slower as well as of the faster of
these; and, as you know, it has no real power to drive —
it can only lead.

Let me make a last confession in closing. The Medical
Council as an instrument of professional government is
not ideally perfect. Perhaps no human organization, with
the possible exception of the University of Manchester, is
perfect. But it may be said for it that it did not start
de novo, full-armed and potent like Minerva from the brow
of Jove. Like every British institution it was built on old
foundations of tradition and vested right and sacred
privilege. It was not a creation but an adaptation. That
it had within it, however, the seed of life, the germ of
growth and expansion, my informal sketch of some phases
in its half -century of history has, I hope, convinced you.
Whether its future be one of continued evolution, or of
sudden and complete revolution, it has not wholly failed
in the task committed to it. The work it has succeeded in
accomplishing has not been measured by the scanty powers
it originally received.

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