§ Order for Second Reading read.
§ DR. LUSH
, in rising to move that the Bill be now read a second time, said, he must explain the circumstances attending the withdrawal of the Bill of last Session, by stating that it was in no 34 respect satisfactory to the profession generally; and since the Government had declined to bring forward a measure this Session, in consequence of the pressure of Public Business, therefore he had brought in the present Bill. The hon. Member for Leitrim (Mr. Brady) had also introduced a similar measure, so that there were two Bills now before the House. No doubt he (Dr. Lush) brought forward this Bill from a professional point of view; but the interests of the public and the profession were intimately blended together. About 50 years ago considerable alteration was made in the mode of licensing medical men, and by the Act of 1858 a general Medical Council was nominated; but in its nomination the rights of the medical profession were ignored, because the members of the profession had no influence in that nomination. The Council, further, did not possess the confidence of the profession; and really their only power was to tax members of the profession for inserting their names in certain books. That taxation they had exercised to the amount of £60,000, extracted from the pockets of the medical profession, without giving any corresponding advantage. The present Bill was not of his own framing so much as the result of considerable thought on the part of medical men engaged in teaching and in medical literature. The first principle of it was, that the existing Council should be abolished, and the second, that the members of the Council elected in their place should be fewer. Not only was the change to affect the number, but the origin from which they were to spring. The Council under the Bill would be in number 12, instead of 24, and four would be nominated by the examining bodies, four by the Crown, and four by the great body of the profession. The third, and last, provided that before any medical man could practise he should pass one particular examination, representing the minimum of qualification, instead of their being, as at present, 19 examining bodies. Some of the examinations now passed were of a most inefficient character. There were anomalies in the present system; and what reason could there be, he would ask, why the University of Durham, for instance, should have the right to send a representative to the Medical Council? He believed that the standard of medical education 35 had been considerably raised of late years; but there was still great room for improvement, which, he thought, would be likely to continue, so long as the present very inadequate examinations were suffered to exist; and for that reason, if for no other, he trusted the House would consent to-give a second reading to the Bill he now proposed.
§ Motion made, and Question proposed, "That the Bill be now read a second time."—(Dr. Lush.)
§ MR. JESSEL
said, that the present-Bill differed in a most important respect from the Government Bill of last year, which did not propose to put into the hands of the Medical Council, however elected, the right to nominate the Board of Examiners, without any security against an abuse of the power. The Bill, in fact, proposed a monopoly of examination, and all monopoly was objectionable; but if it were created, care should be taken to prevent it leading to a position of stagnation. The Bill defined in a positive manner what the examiners were to do, without having regard to the natural progress of science and learning, for an expansive and improvable system was not provided for by the Bill. Many medical men said that there was no confidence in existing examinations; and, indeed, there had been a competition downwards, so as to secure as large a number of persons as possible for examination. In some instances, also, the examiners had a pecuniary interest in the number of candidates passing the examination. Both these things were undoubtedly evils, and were only to be guarded against by making the examinations sufficiently stringent and by preventing the examiners from having a pecuniary interest in the result of the examinations. No doubt the examinations had in modern times been much improved; but what was wanted was a security for progressive improvement in examinations. The moment that you got only one examining body you would lose the probability of obtaining such improvement. He thought that the examiners should not be appointed by the body which would have the control over the examinations of the other medical corporations. If such were the case students would say that these other examinations were controlled by a body 36 which had an interest in preventing persons from entering the medical profession except by passing their own examination. The cardinal point was to secure a thorough examination, and one that would be fair to all; and, above all, the examining Board and the controlling Board should not be composed of the same persons. He thought, too, that no course of study should be compulsory, but that the examination should be so managed as to test the qualification to practise, and that if this were done, it would become immaterial whether the candidate had, or had not, attended certain classes or institutions. Such a system would lead to perfect freedom of teaching, and he believed that great improvement would follow.
§ DR. BREWER
said, that he must confess to a feeling of astonishment at the strange misconceptions which the hon. and learned Gentleman the Member for Dover (Mr. Jessel) appeared to entertain on the objects contemplated by the Bill brought in by the hon. Member for Salisbury (Dr. Lush). The hon. and learned Member for Dover charged the promoters of the Bill with the design of perpetuating the abuse whereby the 19 Universities or corporate bodies, who had the legal power of granting degrees and licences to practice in medicine or surgery, were all found competing with each other for candidates; and he rightly attributed to the pecuniary interest involved in securing the largest share of students, a direct inducement to lower the standard of efficiency demanded for obtaining a degree, and thereby lessening the security of the public and depreciating the test which an examination ought to supply. He (Dr. Brewer) could hardly account for the wondrous misapprehension of the object and scope of the Bill which this representation exhibited. Surely the hon. and learned Gentleman had omitted to road the Bill, and had so fallen into the error of attributing to it the very blots of the Act of 1858, at which the Bill before the House aimed, and which it was the special object of its promoters to remove. It had become patent that the actual constitution of the Medical Council was too restricted, and that the unrestricted competition between licensing bodies for the fees and the patronage of students was dangerous to the future success and advancement of me- 37 dical science, no less than unsatisfactory to the great body of practitioners throughout the country. It was patent that the Council had failed to regulate and control this state of things, and whether the defects were wholly attributed to the constitution of the Council or not, the medical practitioners of the country generally believed that a re-modelling of that body would be required in order to make it harmonize with the other provisions which must form the subject - matter of any good Medical Amendment Act. The Bill provided that the Council should be diminished in number, and that whilst the Government should be empowered to nominate one-third, the old corporations should be represented more as a body of mixed constituencies than by individual representation. But the chief modification in the constitution of the Council would be found in the provision for the direct representation of the medical practitioners throughout the United Kingdom. The hon. and learned Member for Dover rightly apprehended that his suggestion to trust simply to any examination as the test of knowledge, without taking cognizance of the educational training of students, whether that training were picked up in by-lanes and in a helter-skelter manner, or in obedience to a prepared and well-considered system, would not meet with the concurrence of the profession generally, and he (Dr. Brewer) would take leave to point out to the hon. and learned Member one of the most obvious reasons for this dissent. The science of medicine was not a certain science. It was unlike chemistry, astronomy, and mathematics, and it formed one of a group of uncertain sciences, requiring more of the invidual and affording less assistance from positive knowledge than any of the certain sciences supplied. Consequently the instrumentation of the mind—so to say—the excellence of the result of training on the individual was of greater consequence than any mere technical knowledge or special train of facts. The reliability to be placed in the medical practitioner arose far more from the flexibility of his mental operations, the use he had of the processes of thought, the exercises of his mental faculties, than on any mere glibness in answering medical queries, or even in knowing the physical framework, or symptoms of morbid 38 structures of the body. It was, in fine, the instrumentation of the mind rather than the mere knowledge of facts which made a great physician. Therefore, it was of no slight and secondary consequence that a good course of study and a competent body of professors and teachers should form a prominent part in any scheme which aimed at elevating the standard of medical education. He was not sanguine enough to believe that the Bill before the House would or could pass as it stood. He was not prepared to say that there were not some serious defects, and more serious omissions in its provisions; but the object the promoters of the Bill had in view, was to pass the second reading with the express understanding that it should subsequently be referred to a Select Committee upstairs, where evidence might be invited into the undoubted defects of the law as it existed—into the proposed constitution of the new Council—into the best method of forming an examining board—into the nature of inspection required to secure a due care in conducting the examination, and, in fine, to show by what modification of its provisions, or by what additional precautions or suggestions, material might be collected for the preparation of a Bill for medical reform, which should secure what the hon. and learned Member desiderated—that which the Government Bill of last year failed to assure—aud that which must be the common aim of the promoters of this Bill and of all earnest medical reformers, a better supply of competent practitioners, through the means of a higher standard of excellence in medical study and medical examinations. If the hon. and learned Member were sincere in his deprecation of the abuses to which he pointed, and desired the reforms which he had suggested, he would undoubtedly succeed in both these objects far better by sending this Bill to a Select Committee upstairs, than by the course, which through misconception of the aims of the Bill, he had foreshadowed.
§ DR. LYON PLAYFAIR
The cognate Bills of the hon. Members for Leitrim (Mr. Brady) and Salisbury (Dr. Lush) have a double purpose—they aim at reforming the constitution of the Medical Council, and they desire to give a national security for the theoretical and practical knowledge of licentiates in 39 medicine. Their purposes are not new to this House, for it is now a period of 40 years since our attention was first directed, to the subject-matter of these Bills. After numerous and vain attempts at legislation, the Act of 1838, founded on compromises, was passed. By that Act the Medical Council was instituted, its object being to enable "persons requiring medical aid to distinguish qualified from unqualified practitioners." Its primary object, as thus defined, was for the protection of the public, and yet, by an anomaly, the public were not called upon to pay for their own protection, but the expense of working the Act was thrown upon the very qualified practitioners, against whom the public required no protection. Such an Act could not work without friction. The general practitioners of the country, on receiving the licence to practice, were taxed for the support of the Medical Council, on which, in defiance to all principles of taxation, they were not directly represented. The Council was composed of representatives of medical corporations and Universities. The representatives are selected by their executive Governing Bodies, and not by the licentiates or graduates, as they might even now be without new legislation. In the fact that the only entrances into the medical profession are through 19 portals leading out of the medical corporations, there is a slight, though not a popular, representation of the licentiates of medicine. But if, as these Bills propose, all these corporation portals are to be closed and entrance to the profession is only to be attained by a single portal, guarded by a national board, or by three portals of a like kind, every kind of representation, close or open, is cut off between the future licentiates and the Medical Council. My hon. Friends have seen this, and have been forced by this circumstance to include in their Bills two objects of a different character. The constitution of the Medical Council is one thing; the mode by which the qualifications of medical practitioners is to be ascertained is another. Both subjects were important; but each is so large and affects so many existing interests, that it would less encumber the path of medical reform if they were dealt with in separate Bills. At all events, past reformers have been unable to secure such support, for both, subjects as to en- 40 able them to carry their measures. Even Government last year found the necessity of asking our attention to one part of the question—the admission of licentiates—leaving the constitution of the Medical Council for future consideration. I feel the difficulty even in addressing the House. I cannot resist, and have no desire to resist, the claims of the medical practitioners to a direct representation on the Medical Council, and I even grant that they should have a preponderating representation upon it, so long as they are taxed for its support; but it is a question of public policy whether they should be so taxed. The Medical Council is primarily established—not to protect members of a profession in their class interests, but to protect the public from unskilled medical practitioners. If the protection of the public be the real raison d'étre for this Council, its expenses should be borne by the public and not by the profession. But if this be done, then the constitution of the Council should have more of a public and less of a professional character. In such a case there ought to be a lay element in the Council, because the representation of public interests becomes a more important question than the representation of professional interests. The latter should, no doubt, be represented also, but in a subordinate degree to that which they have a right to ask as long as the cost of the Council is met by the taxation of new entrants into the profession. There are other important questions involved in this part of the subject, to which I can only allude. One is, how much or how little representation should be allotted to the medical corporations and the Universities. The two Bills before us treat this part of the subject in a very different fashion; the Bill of the hon. Member for Leitrim (Mr. Brady) leaving the representation of corporations in its present position, while that of the hon. Member for Salisbury reduces it to very diminutive proportions. My own feelings are in favour of an efficient representation of the corporations. I think they have acted beneficially on the recognition of medical men as a distinct and independent profession. Without them there would be as little coherence and as little esprit de corps as there is among officers of the mercantile navy, who, though all certificated men, want 41 centres of junction to make them a recognized profession, and to give them the strength of combined unities. Any scheme of medical reform which weakens these bonds of union, I feel satisfied will weaken the influence of the profession as a whole. I have said enough to show that there are large and leading principles connected with the constitution of the Council that require careful consideration, apart from the other subject embraced in the Bills before us—the securities for the proper qualifications of medical practitioners. There is no doubt that there is a need of reform here also; less need, indeed, than when the agitation for it first began, because the effect of that agitation has been to force upon some of the examining bodies the necessity of ascertaining the practical and clinical knowledge of the candidates, both in the arts of medicine and of surgery. Still the main fact remain that there are 19 licensing bodies in the kingdom, with from 12 to 20 examiners to each, and it is impossible with such a number to prevent a certain amount of competition for candidates, or to obtain sureties that the standard of qualification will never be below a certain minimum. The two Bills before us treat this evil in two different ways. The Bill of my hon. Friend the Member for Salisbury (Dr. Lush) proposes that there shall be a single national examining board, peripatetic in the three divisions of the kingdom; whereas the Bill of my hon. Friend the Member for Leitrim (Mr. Brady) intends that there shall be three national boards—one for England, a second for Scotland, and a third for Ireland. It does not follow that because 19 licensing bodies are too numerous, that therefore they should be reduced to one. I prefer the scheme of three national portals to one portal, for reasons which seem to me to be weighty. At present the examining bodies in the three capitals enjoy the services of the most distinguished members of the profession. As long as you have an examing board, with its work circumscribed to one part of the kingdom, you may continue to enjoy the services of the chief members of the medical profession in testing the qualifications of the licentiates; but if you have a moveable board, oscillating between distant points, you cannot secure the services of men whose great experience in a practical 42 profession best fits them for performing the duties of examiners. I do not say that you could not secure the services of competent examiners, but they would necessarily be men of less position and experience than are now on the examining boards, and would be less calculated to inspire public confidence in their judgments. Besides, an absolute uniformity in examination is not desirable. Differentiation is as important in science as it is in the structure of organized beings. England, Scotland, and Ireland have always been characterized by the differences of their medical systems of education, and by differences in the practice of the arts of medicine and surgery. These differences, though sometimes loading to fierce professional contentions for a time, have redounded to the advancement of medicine. I should lament to see the characteristics of these schools merge into the sameness which must necessarily be produced by a single examining body; for just as ships must adapt themselves to the character of the harbour into which they are to sail, so must schools suit their students—to the knowledge and peculiarities of their examiners. The very differentiation of the three national boards is a great recommendation of them to my mind, and securities could readily be taken that a certain standard of knowledge should prevail in all, without a definite sameness of knowledge that would merely indicate success in the art of cramming. But whether you have three portals or one portal for licence to practice, such limited entrances must always aim at excluding the inefficient and yet admitting the moderately competent. You may by them exclude the incompetent and assure a respectable mediocrity in the profession, but you cannot by such means give an active stimulus to excellence. There are, therefore, behind this scheme many important questions which we cannot treat lightly. Do we by it injure or strengthen the Universities and medical corporations in inducing members of the profession to seek higher titles than licentiates, and thus always secure among medical men a class distinguished for literary and scientific attainments, and for high skill and prolonged experience of their profession? If your scheme fail to do this you bring down the profession of medicine to a dead level of respectable mediocrity. Take the division 43 of the kingdom with which I am best acquainted. In Scotland, the three Universities of Edinburgh, Glasgow, and Aberdeen educate about one-third of the whole medical men of the kingdom. Drawn within the walls of a University the medical students become imbued with the spirit of its teaching, and enlarge their studios in science beyond the mere prescribed curriculum of a medical education. Will these Bills encourage or destroy these University teaching's for medical students? Will they weaken or strengthen the Universities as sources of notional education for the people, by crippling or augmenting their resources? These are grave questions as affecting the public interest, and especially grave to me, who represent the largest medical school and medical constituency in the kingdom. I do not intend to discuss them now, for I cannot think that my hon. Friends propose to push these Bills through their various stages at this late period of the Session. My own constituents certainly do not believe that the time for actual medical reform has been reached in these efforts of two private Members. My right hon. and learned Friend the Member for the Universities of Glasgow and Aberdeen (Mr. Gordon), and myself certainly possess the largest medical constituencies in this House; but with the exception of a single letter, which was in answer to one from myself, I have not received any communication in regard to either of these Bills. Is this because medical men are indifferent to medical reform? Certainty not that. There is very nearly unanimous feeling that changes are required in the mode of licensing' medical men, and in the constitution of the Medical Council. Nor is it because the Bills before us are unworthy of attention. Both of them are well-considered Bills, and present their own views with care and elaboration. But the indifference to their fate depends on the fact that they aim at reforms beyond the power of private Members to effect. If the medical graduates of my Universities, amounting to several thousands, believed that medical reform depends on the fate of these Bills, my life would be a burden to me in the amount of correspondence which it would entail. My complete immunity in this respect is owing to the belief that Parliament, while it treats these Bills with the respect due to well-considered mea- 44 sures, will not pass them into law. I trust that my hon. Friends will be content to consider their Bills as indications to the Government of the paths which they may pursue in medical reform. The Government alone can deal with a subject so important to public interests. They are perfectly aware from the 40 years' war on this subject, that much reform is needed, but that in making it great evil as well as great good may ensue. The interests of the public and the interests of the medical profession can be best brought into co-relation by the aid of a Government having no prejudices or passions created by professional contentions, and whose only object can be to give the public security for its health and life, and to the licentiates and graduates in medicine that status which will be assured by the possession of high scientific and skilled practical knowledge of their profession.
§ MR. W. E. FORSTER
said, there were two points for discussion—one, as to the mode of examining and certifying medical practitioners, and the other as to the constitution of the Medical Council. With regard to the first point the Government entirely appreciated its great importance. They were aware of the very great practical evils that resulted from there being 19 accredited bodies for certifying medical practitioners, but they had been unable to deal with the question this year. That had led two private Members to bring in Bills on the subject, but neither could hope to pass his Bill during the present Session. From the number of questions pressing on the Government for legislation, he could not pledge them to bring in a Bill next year; but he could assure hon. Members that it was their wish and anxiety to do so. If they were unable to deal with the subject next year, and if any private Member, such as his hon. Friend the Member for Salisbury (Dr. Lush) or any other, took up the subject, no obstacle would be thrown in the way of the fullest consideration of it by the House; and if it was desirable the Bill might be referred to a Committee upstairs. Legislation had failed last year because, although the Bill which had been, introduced into the House of Lords had been most carefully considered, it had been thought desirable, when the Bill came down to that House, to add to the questions they were then attempting 45 to settle the other question of the constitution of the Medical Council, and it was then too late in the Session to deal with that subject.
§ MR. BRADY
said, there were at present 19 different medical examining bodies, 19 modes of medical licensing, and 19 different systems of medical education. The Bill proposed to reduce these to one for Ireland, one for Scotland, and one for England. It would not be easy to decide the question in the present Session; but he trusted that the Government would early next year introduce a satisfactory measure on the subject.
§ SIR JOHN GRAY
said, he must express his gratification at the announcement that the Government would consider the subject during the Recess, with a view to grappling with it in the next Session.
§ Motion, by leave, withdrawn.
§ Bill withdrawn.