Last Wednesday evening, my predecessor in office, Deputy T. F. O'Higgins, reasonably and courteously told the Dáil how deplorable it was that the relations between the Irish Medical Association and the Minister for Health were so unsatisfactory. With similar courtesy Deputy Sir Anthony Esmonde endorsed what Deputy O'Higgins said; and finally the Leader of the Fine Gael Opposition expressed the same views, though not so happily or so succinctly. I hope Providence will forgive me that understatement.
I agree with all these Deputies. The existing situation is truly deplorable, deplorable, that is, from the point of view of the Irish medical profession— insofar as the Irish Medical Association, having regard to the course of action upon which it has embarked, has any true claim to represent the profession as a whole; or any power in present circumstances to further its interests or protect them, if protection should be necessary.
This deplorable situation on the other hand, as everyone knows who is familiar with the facts, has in no way reacted adversely upon the efficiency or effectiveness of the health services, or to the detriment of the patients who avail of them. All local authority hospitals are functioning with staffs as skilled and as complete as ever they had; and hundreds of dispensary doctors are devotedly doing their duty, secure now in the knowledge gained by experience that when their interests were discussed with the proper authorities, they received fair and sympathetic treatment from me.
That position will, of course, obtain also in the case of the district nursing service and nursing staffs generally. No person has suffered because of the break with the I.M.A., except those few practitioners who, obeying the ban, forewent their right to apply for appointments for which they were qualified and which, if they had been the best qualified candidates, they would have obtained, if it had not been for the Irish Medical Association.
It is not enough, however, to say that a position is deplorable and to leave it at that. If a deplorable situation is to be remedied, it is sometimes necessary to consider how, when, by whom, and for what purpose it was brought about. I propose to do that in winding up this debate, quoting chapter and verse for what I say, stating my case as briefly and simply as possible, so that the people may appreciate how this situation was brought about and recognise that it was not of my seeking.
I hope to convince the people also that no Minister for Health, who was truly concerned for their welfare, could surrender to the arrogant, unscrupulous and unjustifiable actions by which the present situation has been brought about. I shall begin by referring to the speech of my predecessor, as Minister for Health, Deputy Tom O'Higgins.
Deputy O'Higgins in opening this question referred to the fact that during his period of office he had been able to establish friendly relations with those who controlled the Irish Medical Association. He took some modest credit for that fact.
I do not wish to detract in any way from what may be due to him on that score; or to belittle the pride which he may feel in this achievement. Undoubtedly the attitude of the I.M.A. towards him was different, very different, from what it has been towards me. Just as it differed, in the same way, towards my colleague, the first Minister for Health, Dr. Ryan, not only in connection with the Health Act of 1953 but earlier in 1947; and to myself when, as Minister for Local Government and Public Health from 1941 to 1947, I had occasion to deal with that body.
But is there not something peculiar, something that calls for an explanation, in the very fact that relations between the Executive of the Irish Medical Association and a Fine Gael Minister for Health whoever he may happen to be have been invariably close and cordial; while with equal uniformity the relations between that body and a Fianna Fáil Minister have been invariably strained to breaking point, and, in the present instance, beyond it?
Why should this most peculiar position have obtained over all those years and indeed practically since 1932? Does it not suggest that there has been some malign and esoteric influence, some hidden hand, operating to shape and colour the relations between the Irish Medical Association and successive Ministers for Health? I think it does.
To my mind it suggests that for many years the Association has been controlled by an inner caucus and this caucus has been exploiting, for its own hidden purposes, whatever grievances members of the medical profession may feel they have in relation to the Health Services, the Health Acts and the Minister who is called upon to administer those Acts.
I submit indeed that the recorded facts do support the view that this dominating influence, whatever it may be, whoever may exercise it, has been a powerful factor in bringing the present deplorable situation about.
Deputy Tom O'Higgins recalled how pleasant his relations with the officers of the Association had been. I am glad that they were pleasant, very pleasant, I believe. The officers of the I.M.A. did not seek out an issue on which to quarrel with him. During the time he was Minister for Health the Association acquiesced in certain duties which he had prescribed for all consultant posts, medical, surgical and obstetrical, in the health service, and did not try to ban the posts to which these duties were attached. The duties to which I refer were:—
"(xii) To give any person (being a registered medical practitioner) authorised by the health authority or the Minister, when requested, the clinical details respecting any person who is or has been under his care in the hospital.
(xiii) To give to the appropriate local authority all reasonable information respecting any person who is referred to him for examination and report by the local authority."
These duties have since been made by the I.M.A. the "casus belli" against me. In view of this is it not surprising that while Deputy O'Higgins held office from June, 1954, to 20th March, 1957, no more than the lightest and most fugitive objection was raised at any time by the Executive of the Irish Medical Association to the fact that he had prescribed these duties for posts of the status I have mentioned. On the 20th March the Dáil approved of my nomination to be a member of the Government and on the 21st March, 1957, I formally took office as Deputy Tom O'Higgins's successor in the office of Minister for Health. The House should note that date. It should note another date also, a date some four days later, the 25th March, 1957; for on that day the Irish Medical Association addressed this letter to my Department:—
"Dear Sir,
My Council has had under consideration the duties specified for the recently advertised post of Obstetrician/Gynaecologist, Galway County Council, and other Local Authority appointments. We refer in particular to duties stated as:
(xii) To give to any person (being a registered medical practitioner) authorised by the health authority or the Minister, when requested, the clinical details respecting any person who is or has been under his care in the hospital.
(xiii) To give to the appropriate local authority all reasonable information respecting any person who is referred to him for examination and report by the local authority."
I must break the quotation to point out again that these duties are expressed in the terms in which my predecessor formulated them. Despite them, however, and despite the fact that he insisted, rightly insisted, on their acceptance, his relations with the authors of this letter had been of the pleasantest. Is it not exceedingly strange, therefore, that under me they were seized upon by the Executive of the I.M.A. as an excuse for the rancorous campaign on which they subsequently embarked? To resume the quotation, the letter went on to say:—
"By long tradition, medical practitioners have been taught to consider themselves under both moral and legal obligation not to divulge, without the permission of the patient, any information which has been given to them by a patient under the seal of `professional confidence'. Strict application of the paragraphs cited above would, we are convinced, be in direct conflict with the accepted teaching of our Medical Schools.
A reply at your early convenience will be appreciated.
Yours faithfully,
Noel O'Reilly,
Medical Secretary."
Now let me again recall that Deputy Tom O'Higgins was Minister for Health for almost three years. During the whole of that period the conditions set out in the Association's letter which I have just quoted—or the equivalent of them in the case of D.M.O. appointments formed part of every appointment made under him. These included—
(1) A large number of posts as District Medical Officer—I may say that there are almost 1,000 D.M.O.s in the health service; and
(2) The following specialist posts:
Surgeon, Tipperary (N.R.) Co. Council.
Surgeon, Louth County Council.
Surgeon, Wexford County Council.
E.N.T. Specialist, Limerick County Council.
Opthalmic Surgeon, Limerick County Council.
Paediatrician, Galway County Council.
E.N.T. Specialist, Galway County Council.
Paediatrician, Limerick County Council.
Obstetrician-Gynaecologist, Galway County Council.
Surgeon, Galway County Council.
Surgeon, Kerry County Council.
Surgeon, Tipperary (S.R.) County Council.
Moreover, the post of obsterician-gynaecologist to Galway County Council had been advertised early in 1956, at which time Deputy O'Higgins was still Minister for Health, and the two duties, referred to in the I.M.A. letter that I have just read, were included amongst those to be discharged by the holder of the post. Yet no objection whatsoever was made to him in regard to them; which I think the Dáil must agree was more than passing strange, having regard to what followed later.
So much for the attitude of the Irish Medical Association to this question when my predecessor was Minister for Health. I think everyone will agree that it was one of the highest complaisance. The attitude of the Council of the Irish Medical Association changed, however, with all the slickness of a bedroom scene in a French farce, when Deputy O'Higgins went out and I came in. Within four days after I succeeded as Minister for Health, the duties which for years had been accepted under Deputy T.F. O'Higgins, became intolerable under Deputy MacEntee. The moribund conscience of the Council of the I.M.A.— or more properly a faction in the Council—was miraculously revived, and certain of its members suddenly discerned that the performance of the O'Higgins duties, as they may be conveniently referred to, violated certain moral and legal canons of great consequence. They must have been of great consequence, since to protect, as it has told us, the inexperienced and innocent consultants among its members, the Irish Medical Association has done its utmost to deter them from even applying for posts to which the duties attached, conditions which, it is necessary to repeat again, were found to be quite acceptable under my predecessor.
The Association indeed has gone even further than this. It has attempted to bring the whole machinery of the Local Appointments Commission to a standstill, by forbidding its members to act on selection boards established by that body. Now it cannot be pleaded that persons invited to act on such boards are inexperienced and innocent in the ways of the world. To safeguard them from its dangers they at least do not require the archangels of the I.M.A. to guide them. They are quite competent to look after themselves. The ban which the Council of the I.M.A. sought to impose on them had one object only, to procure a breakdown of the health services.
With these facts before it, must not the Dáil and the country wonder what brought about this radical change of attitude on the part of the I.M.A.? It cannot be denied that it was a radical change. Surely the members of the Executive responsible for it might reasonably be expected to give the reasons for it, might be expected to justify it. They have never deigned to do so. On the contrary, they have shown unmistakably that they have no regard whatsoever for public opinion. They have clearly demonstrated, in fact, that they have one attitude towards the Minister for Health and his Department, if he happens to be of a certain political Party, but quite a different one towards him and his Department if he should be a member of another Party.
In the light of these facts, can there be any doubt in the minds of reasonable people that the present dispute was deliberately engineered and developed for their own ends by a clique in the Council of the Irish Medical Association? Moreover, in view of the position in which the Association finds itself, can there be any doubt that when they did this, those responsible acted in complete disregard of the true interests of the medical profession? It cannot be denied that these interests demand that those who profess to act on behalf of the profession should work in cordial co-operation with the existing Minister for Health, whatsoever the Party he may happen to belong to, and that, like him, they must work within the law, whatever it may be. I shall show that at no time, so far as I was concerned, has the Council of the I.M.A. been prepared to do either.
But first it is necessary for me to point out that the duties which I have detailed, and to which the Association objected in March, 1957, were based on revised provisions regarding the keeping of medical records in relation to services provided under the Health Act, 1953. These revised provisions were introduced in Regulations made by Deputy Tom O'Higgins, then Minister for Health, in March, 1955, following consideration of objections by both the Association and the National Health Council to the provisions contained in regulations made in May of the previous year. Although the revised provisions did not meet with the formal approval of the Association, the National Health Council agreed to them; and the membership of the Council at that time was predominantly representative of the medical and ancillary professions and included nominees of the Irish Medical Association.
In these circumstances, had I been the quarrelsome fellow that Deputy Dillon has alleged, or the vain one that Deputy Dr. Browne suggested, I should have sent a brusque reply to the I.M.A. Instead, after full consideration of every aspect of the problem, having satisfied myself that the duties prescribed represented the minimum which would enable the Minister for Health, whoever he might be, to ensure that, if a patient under the Health Acts suffered through neglect or in consequence of a culpable act on the part of his medical attendant, the responsibility for this could be properly established and brought home to the culprit by investigation. This was the purpose which all my predecessors wanted to serve when they insisted on the duties, now objected to, being prescribed for all appointments. Being convinced that nothing less than the conditions which Deputy O'Higgins and his predecessors had insisted on would suffice, I directed that a reply should be sent in the following terms to the I.M.A. It issued on 18th April, 1957.
"...The Minister has asked me to say that he shares the anxiety of your Council to preserve medical secrecy. It is clear to him, however, from the voluminous correspondence with your Association and from the various discussions which have taken place, that the matter is one of considerable difficulty, to which successive Ministers for Health have given considerable thought, and it appears to him that the duty numbered (xii) of the duties of the post in question is the minimum necessary to enable him, and health authorities, to discharge effectively their obligations to the public. He is, however, prepared to examine the matter afresh in the light of any further considerations which your Association may wish to bring forward. He regrets that, because of his many commitments over the next few months, he will not find it possible to receive the proposed deputation in the immediately foreseeable future, but he would suggest that the question might profitably be explored further at an informal meeting between a small deputation from your Association and officers of his Department. If the Association agrees with that suggestion, a meeting can be arranged at any time.
In regard to the duty numbered (xiii), the Minister has asked me to point out that this applies only to a person sent by the local authority "for examination and report". The attendance of the person for this purpose must, in the Minister's view, clearly imply that person's consent to the furnishing of the report. Consequently, he cannot accept that, in reporting, the officer is being obliged to do anything contrary to the wishes of the patient or involving breach of medical secrecy. The principle of requiring medical examination and report is well established in everyday practice, e.g. in relation to applications for employment or for life insurance purposes, and the Minister is unable to appreciate that there is any difference in principle in the discharge of this duty by the officer concerned and the furnishing of a report by any other examining doctor in the circumstances mentioned. If, however, there are other considerations which the Minister may have overlooked, this matter also might be considered at the suggested meeting.
Mise, le meas."
In view of the senseless suggestions which were made by Deputy Dillon in his speech last Wednesday, I should like to call particular attention again to the following passages from that letter:
"He," that is to say the Minister, "is, however, prepared to examine the matter afresh in the light of any further considerations which your Association may wish to bring forward. He regrets that, because of his many commitments over the next few months, he will not find it possible to receive the proposed deputation in the immediately foreseeable future, but he would suggest that the question might profitably be explored further at an informal meeting between a small deputation from your Association and officers of his Department. If the Association agrees with that suggestion, a meeting can be arranged at any time."
and
"If, however, there are other considerations which the Minister may have overlooked, this matter also might be considered at the suggested meeting."
It has been charged against me that I have treated the Executive of the I.M.A. with discourtesy, that I have been cavalier in dealing with their representations. Quite the contrary has been, in fact, the case as these passages prove. Until the I.M.A. deliberately and without any justification whatsoever, broke off all relations, every communication from that body received my personal attention and was courteously replied to.
Moreover, at all times, as the letter shows, my most experienced officers, from the Secretary of the Department downwards, were at the disposal of the representatives of the Irish Medical Association for the discussion of any matter of sufficient moment as in my opinion as Minister would justify a demand on the limited time of these exceedingly busy men.
In this particular case not only was a reasoned reply sent to the I.M.A.'s letter, but the Association was invited to send representatives to discuss what modifications, if any, could be made in the duties in order to reconcile the views of the Association with the minimum requirements of the Minister. The suggested meeting took place on 31st May, 1957. At it the representatives of the I.M.A. admitted that the problem was a difficult one. Certain possibilities of amending the duties to make them more acceptable were examined and discussed; and, as a result, a revised statement of the duty to which the major objection had been expressed was drafted and put in a letter to the Association on the 9th August, 1957. The Association replied, under date 8th November, 1957, some three months later, to the effect that the duty even in its amended form was unacceptable. The reply, moreover, went on to say that if the duty were not cancelled, publication of the correspondence in the Irish Medical Journal would be a regretted necessity.
Notwithstanding this first flourish of the Association's cudgel, I had the temerity to address myself again to the question, and, in the hope that I might persuade its objectors to revert to the attitude of reason and goodwill which they had adopted towards my predecessor, I sent a further letter on 9th December, 1957. In it were set out in detail the reasons why as Minister for Health I must prescribe the duty, or something very close to it for all medical, surgical and similar appointments of consultant status in the health service. In an endeavour to meet the views of the Association, however, I proposed to amend the already amended version of the duty, as it had been prescribed by my predecessor, by whittling it down still further to the irreducible minimum that would serve the public requirements.
That letter was virtually the last of the correspondence which I had with the Association on this matter. It set out fully the reasons which make the duty, as I have said, an indispensable condition and is an essential portion of the record. I must ask the indulgence of the House while I quote it in full.
"A Chara,
I am directed by the Minister for Health to refer to previous correspondence and discussions regarding No. 12 of the Duties prescribed for the office of Obstetrician/Gynaecologist at the Galway Regional Hospital. The duty as drafted was as follows:—
"To give to any person (being a registered medical practitioner) authorised by the health authority or the Minister, when requested, the clinical details respecting any person who is or has been under his care in the hospital."
The Minister has asked me to assure your Association that he agrees with the view that, normally, the relations between a doctor and his patient should remain confidential and that there should be no breach of this confidential relationship, without the consent of the patient, save for the most compelling reasons related to the public good. This, of course, is already accepted in the case of infectious diseases where failure on the part of the patient's doctor to notify the disease might have far-reaching consequences from the public health point of view.
When a deputation from the Association discussed the duty in question with officers of this Department on 31st May last, it was explained that the circumstances in which compliance with the terms of the duty might normally be invoked were:—
(i) in the investigation of a complaint by a patient, made either to the health authority or to the Minister;
(ii) in the investigation of a complaint made by a seemingly responsible person in relation to the treatment of a particular patient or patients; and
(iii) in a general investigation of the work of the officer where, from observation in the course of an inspection, the Medical Inspector had reason to believe that the officer was neglecting or otherwise failing in his obligations to his patients generally.
In the circumstances at (i) above it seemed to be accepted that there could be no objection to the duty as drafted, since in complaining, the patient, prima facie, gave his consent to full investigation and disclosure of information.
In the circumstances at (ii) or (iii) above, the patient or patients might be unaware that the doctor was regarded by anybody as being remiss in his treatment. If, in the course of the necessary investigation, it was necessary to approach one or more patients for their consent to the disclosure of information, a presumption would immediately be created in their minds, however carefully the approach was made, that there was some neglect or dereliction on the part of the doctor and, even if they could be assured later, following investigation, that there was no such neglect or dereliction, a suspicion would remain in many cases, with consequent injury to the reputation of the doctor and of the hospital. The deputation appeared to appreciate that point.
It was conceded by the official side in the course of the discussion that local circumstances might make it undesirable that a medical officer of the health authority should pursue an investigation in the absence of the consent of the patient to the disclosure of information and that the duty should be amended appropriately. The amended draft of the duty already forwarded to the Association made such amendment.
The net point at issue, therefore, appears to be the right of the Minister's Medical Inspector to pursue his investigation in relation to particular patients in the absence of the consent of the patients to the disclosure of information.
The Minister has given the most careful and sympathetic consideration to this point. As the Association appreciates, the Minister's responsibility to the Oireachtas requires him to ensure the highest level of service is given by all officers of health authorities, including medical officers, in respect of whom he is the appropriate Minister and his concern is to ensure that he will be in a position to discharge that responsibility in a manner which is fair to the officer concerned, to the service to which the officer belongs, to the patients concerned and to the public generally.
In a further effort to meet the genuine difficulty which the deputation agreed exists, the Minister suggests that, in the case of an investigation by one of his Medical Inspectors, the hospital doctor concerned will be entitled to refuse to supply clinical details of any patient in the absence of the consent of the patient unless there is produced to him a certificate from the Minister that the public interest requires the supply of the information without the consent of the patient. The duty as revised would read as follows:
‘To furnish the clinical details regarding any person who is or has been under his care in the hospital, to a registered medical practitioner authorised by the health authority or the Minister on request, on production of the written consent of the person (or the written consent of the person's representative or next-of-kin) or, in the case of a registered medical practitioner authorised by the Minister, the Minister's certificate that it would not be in the public interest to seek such consent.'
The Minister trusts that your Association will find it possible to accept the foregoing revision, which is the outcome of the most anxious consideration by him of the problem in an effort to meet the point of view of the Association.
Mise, le meas,"
The Dáil will note and appreciate how clearly this letter established that, in order to avoid doing unjustifiable harm to the reputation of the medical, surgical or other specialist concerned and the hospital to which he happened to be attached, it might be essential, in certain special circumstances, for the clinical details of a patient's case to be furnished to a duly authorised medical practitioner, without such patient's consent. It will be noted too that this was an aspect of the matter which the representatives of the I.M.A. with whom it had been discussed, before the letter issued, also appeared to appreciate. It remained, therefore, to define what these special circumstances might be. The letter set out how I proposed to define them. Clearly I was restricting them to the narrowest possible field, to wit, the service of the public interest as certified by the Minister for Health; but strictly within the limitation that the information was necessary to enable him to discharge his responsibility to the Oireachtas and to the people for the care and treatment of all those who avail themselves of the health services.
There was nothing new in imposing a duty to furnish clinical details when the public interest required it. My immediate predecessor and all those before him had prescribed this duty for certain posts. Apart from this, however, there is not an inquest held at which clinical details are not given in open court, often by the medical attendant of the deceased, whether the next-of-kin agrees or not. Nor was there anything new in requiring doctors in the health service to recognise that the service of the public interest must be an over-riding consideration in this matter. Dispensary doctors have been required for very many years to keep a register in which are entered not only the names of their individual dispensary patients, but clinical details relating to them, and they are bound to make this register available to the authorised Medical Inspector when called upon to do so. Furthermore, as the letter pointed out in relation to infectious diseases, the over-riding weight of the public interest is accepted by all medical practitioners, whether in the public service or in private practice, as justifying the notification of the clinical details of all cases of such diseases to the appropriate authority. And if this disclosure can be made in the case of an infectious disease, or in the case of dispensary patients, why may it not be done in the case of a hospital patient, if it is necessary to do so, in order that the Minister for Health may be able to satisfy himself in the first instance, and the Oireachtas, if called upon, as to whether there was wilful or culpable negligence in the treatment of such a patient.
But whatever view we may take of this argument, surely the fact remains that if the argument were not accepted, if it could be refuted, the letter in which it was stated with such care and clarity required an answer. Beyond a formal acknowledgment that the communication had been duly received no answer to it has been forthcoming, even to this day. The letter has remained unanswered, because it is unanswerable. It had clearly established the necessity for the duty to which exception had been taken. But the fact that the need for the duty had been established did not suit the book of the dominant element within the I.M.A.
Their plans demanded that a local dispute with the Minister for Health should be fomented, forced and kept alive until the moment set by them for a complete rupture arrived. It was necessary, therefore, to render my letter of the 9th December, 1957, ineffective in so far as it might affect the views of members of the Association, to kill it in short. This was done with exquisite craftiness and most resourceful chicanery which did not baulk even at a stupendous lie to accomplish its purpose. Having made that charge against the Chairman, the holder of the combined offices of Honorary Treasurer and Honorary Secretary and certain members of the Council of the Association for the year 1957/58, I shall now set out to prove it.
I shall begin by detailing how, as recorded in the official Journal of the Association, my letter was dealt with, and I would ask the Dáil to follow the record carefully.
According to the I.M.A. Journal for February, 1958, the letter of 9th December, 1957, was considered at a meeting of the Central Council of the I.M.A. held on 9th January, 1958, at which, in the words of the official report "divided opinions were expressed" and consideration of it was postponed to the next Council meeting and in the meantime it was decided to obtain the views of branches.
In its April issue the Journal recorded that the letter, dated 9th December, 1957, was again considered "with"—I quote—"the replies of those Branches who had responded to a request that they should give their views on the letter. After a long discussion, in which divided opinions were expressed, it was decided that the Executive Committee should arrange to set up a Committee consisting of trained experts in theology and members of the I.M.A. to investigate the ethical questions involved." Perhaps such a Committee as is here referred to was set up. I do not know. I have been unable to trace any subsequent reference to it. But the mention of it at least gave the impression that the Minister's letter was receiving the serious consideration, I quote, "of trained experts in theology", who without doubt it was hoped would be able to demolish his arguments in due course. Doubtless the members, the majority of whom, the Secretary of the I.M.A. has told us so frequently, are simple and guileless, were content with this; and so the plotters were able to keep the pot simmering, without boiling over until the chosen moment arrived.
We then move on to the month of June, when the Annual Report of the Council of the I.M.A. for 1957/8 was published in the Journal. Under the heading "Professional Secrecy", this Report stated that "negotiations are still proceeding with the Department of Health on the question of professional secrecy". Will Deputies please note that statement? It is the lie to which I have referred, an utter and shameful and cynical falsehood. No negotiations were then in progress; nor had any negotiations taken place subsequent to my letter of 9th December, 1957. In fact, as the House now knows, beyond a formal acknowledgment of its receipt, at that date no reply whatever had been received to the letter of the 9th December, 1957. And no reply has been received since except what I shall now detail.
On the 22nd November, 1958, that is almost a full year after I had sent to the Irish Medical Association a reasoned and courteous statement of my case, the following notice—the "Important Notice", as the Association has designated it—appeared in all the daily papers:—
"IRISH MEDICAL ASSOCIATION"
"Medical Practitioners are requested not to apply for, or accept, the following positions:
Surgeon, County Hospital, Bantry;
Surgeon, Laois County Council;
Surgeon, Monaghan County Council;
Surgeon, Sligo County Council;
without first communicating with the above Association at 10, Fitzwilliam Place, Dublin."
On the same day the following letter, dated 21st November, 1958, was received in the Department of Health from the Irish Medical Association:
"Dear Sir,
My Association have studied the conditions, terms of appointment and salary for the positions of—
Surgeon, County Hospital, Bantry;
Surgeon, Laois County Council;
Surgeon, Monaghan County Council;
Surgeon, Sligo County Council;
and have decided that they cannot recommend these appointments to their members.
Yours faithfully,
(Sgd.) Noel O'Reilly,
Medical Secretary."
Now, it will be observed that the authors of this letter did not deign to indicate the conditions and terms of appointment to which objection was taken. Even to this day I have not been informed officially of them, though I have ascertained them through another channel. I am sure that the House will note that the persons responsible for this gross discourtesy are those who squeal and complain because in my capacity as Minister I will not suffer such an affront. I was left to learn the grounds on which the I.M.A. sought to justify its arbitrary, unjustified and unjustifiable action from a letter kindly sent to me by a correspondent who had communicated with the Association as requested. In view of the repeated assertions by the Association that this notice to communicate with it, is not the equivalent of a ban, the opening paragraph of that letter is revealing. It reads:—
"Dear Sir,
In answer to your enquiry concerning the recent County Surgeon posts for Bantry, Laois, Monaghan and Sligo, the Executive Council of the I.M.A. at the request of the County Surgeons' Group, examined the conditions of employment and salary scales offered. As a result of this examination the Executive Committee decided that the conditions and salary scales were unacceptable to the Association and, accordingly, advised members not to apply or if they had applied to withdraw."
It may be said that this is only an advice and not a direction. But those who recall the treatment which was meted out by certain members of the I.M.A. at the instance of their Council, to the distinguished surgeon who filled the breach in Mallow after the removal of the County Surgeon there, will know that when that letter was written in December, 1958, the advice could only be ignored at one's peril. That, of course, is no longer the case. Public opinion, outraged by the attitude of the Council in the Mallow case, has seen to that.
The grounds for objection by the Association to the posts in question, as stated in that letter, may be summarised as follows:
(a) Two of the duties, alleged to infringe "medical secrecy" were unacceptable on ethical grounds; and
(b) The salary was inadequate because the middle income group had become entitled to hospital and specialist services (that group was being extended to include persons with incomes up to £800) and the limitations on private practice and fees were contrary to Section 25 of the Health Act, 1953.
The House, when it recalls the reports which I have cited as appearing in the issues of the Irish Medical Journal for February, April and June of 1958, of the discussions on this matter of “professional secrecy” will be surprised that the I.M.A. executive had the hardihood to provoke a quarrel with the Minister for Health on such an issue. Thus when the Central Council discussed the matter in January, 1958, we know from the I.M.A. journal “divided opinions were expressed” and consideration of it was postponed to the next Council meeting. In March, 1958, when the views of the branches were discussed at length, it was again reported that “divided opinions were expressed and it was decided to set up a Committee of trained experts in theology and members of the I.M.A. to investigate the ethical questions involved”. That has been a lengthy investigation. It would appear, indeed, not to have reached finality, for so far no results of the investigation have been published. It must be that once again “divided opinions” have been expressed; or it even may be that the duties as framed by my predecessor and as revised by myself were held not to be objectionable on ethical grounds.
Good grounds for this surmise are afforded in the notice which the I.M.A. sent to me on the 21st November, 1958, and which I have already read to the Dáil. In that letter for the first time the question of salary attaching to the banned posts was raised. I suggest that the reason for raising it then was that it was found that after my letter of a year earlier, "professional secrecy" was a cock that would not fight. So the break with the Fianna Fáil Minister for Health, which was now due and timely, had to be forced on another issue, that of salary.
But whether it be on the issue of "professional secrecy" or on the issue of salary what does a faction within the Irish Medical Association, a faction within this "house divided", as I may properly describe the I.M.A. to have been, take upon itself to procure in November, 1958, and what has it been endeavouring to procure ever since, even in this month of June, 1961? Nothing less than a complete breakdown in the health services of the State.
Deputy Dillon has tried to persuade the House that the poor and the sick are suffering because of disorganisation of the health services. There is no foundation whatever for that suggestion. The plan of this clique within the Association to bring about such disorganisation has failed. The services have not broken down, nor have they been disorganised except for one very brief period following the removal of the County Surgeon in Mallow. Except for that short time and in relation to that hospital, not one patient can be said to have suffered because of the action of the I.M.A. Every skill that was available at any time for the treatment of the sick in our local authority hospitals and our dispensaries is there in undiminished measure to-day and just as devotedly at the service of the patients.
But if those responsible for this "Important Notice", those responsible for this ban, had their way, were able to enforce their boycott, that would not be the case. Patients might die, people might perish, but the men who have chosen to embark the Association on this wrong-headed course might be as perverse as ever.
I have already told the Dáil that the first of the posts in the local health services which the I.M.A. endeavoured to proscribe were those of County Surgeon. The ban on these posts was imposed on 22nd November, 1958. It was followed by other bans in rapid succession. The post of County Physician was banned on 6th December, 1958, and that of Obstetrician-Gynaecologist in Waterford Regional Hospital on 22nd January, 1959. Previously on 8th January, 1959, the Central Council of the Association had passed a resolution refusing to cooperate in giving effect to the Health and Mental Treatment Act, 1958, but this resolution was subsequently rescinded. The "march of the bans" reached its climax when, on 23rd May, 1959, all resident and non-resident medical posts in local authority hospitals were banned.
I would ask the Dáil to note the dates on which the several bans were imposed. They bear a remarkable relation—too remarkable to be merely coincidental—to the development of certain political events. The first ban, that on county surgeon posts, was imposed on 22nd November, 1958, and came very closely after 12th of that month, when the Third Amendment of the Constitution Bill was introduced in Dáil Éireann. The Second Stage of the Amendment of the Constitution Bill was taken over the period from 25th November to 16th December, 1958. The second I.M.A. ban, that on county physician posts, was announced on the 6th December and fitted in very nicely with these Dáil proceedings. The Committee Stage of the Constitution Bill opened in Dáil Éireann on the 8th January and ended on the 21st January, 1959, and on the 22nd January, 1959, the third ban fell on the post of obstetrician-gynaecologist.
On 19th May, 1959, nominations for the office of President closed; and on 17th June the polls in the Presidential Election and on the Referendum to amend the Constitution were taken. The esoteric circle which, I think, runs the I.M.A. apparently thought it expedient to intervene again and so, using the removal of the Mallow county surgeon as an excuse, they imposed, as I have mentioned, a comprehensive ban on all resident and non-resident medical posts in local authority hospitals. In doing that, however, they went too far. They outraged an overwhelming majority of the profession, and as a result of the widespread indignation expressed this ban was quietly abandoned once the Referendum had been taken and the Presidential Election was over.
Looking back over these events, as I have faithfully and accurately detailed them, who can doubt that from the very day on which a member of the Fianna Fáil Party took office as Minister for Health on March 20th, 1957, a group within the I.M.A. were determined to provoke a dispute between him and the Association. They laid their plans carefully and astutely. First, they opened this issue of "medical secrecy", an issue on which they found no ground for quarrel with my predecessor. Then they carried on negotiations with me, through my officers, ostensibly in an endeavour to reach agreement on the matter. When I had gone as far as I could to meet them, by amending the duty in the way set out in my official letter of the 9th December, 1957, they pretended to give serious consideration to the acceptance of the duty in its new form.
The letter in which the amended duty was set out was discussed at the meeting of the Council on 9th January, 1958. It was then circulated to the branches and discussed again by the Council on 13th March, when it was decided to set up a committee with the help of theological experts to consider it. It was a wonder they did not refer it to the Holy See. It was again referred to in the annual report of the Council for 1957/58, when the members of the Association were informed falsely that negotiations were proceeding.
It was then put into cold storage. I heard nothing more about the matter. No one else heard anything more about it, until the opening of the debate on the most critical and important political issue to be put before the people since the Constitution of 1937. The issue was then taken out of cold storage, warmed up, and used as an excuse to ban one important medical post after another. The purpose for which these bans were imposed in this dispute was quite clear. They were imposed in order that the doctors of Ireland might be led to believe that their profession would not get justice from a Fianna Fáil Minister. The end in view, of course, was that in their resentment doctors would use their votes and influence against the Fianna Fáil Party. No doubt many of them were influenced by the political chicanery of their leaders to do this.
On the other issue, that which was raised at the eleventh hour, and without any prior notice whatever, that of salary, events as they transpired manifested clearly that this was being used merely as further excuse for the row which certain persons in the Association wished to provoke. In the Dáil, in reply to Questions and in statements in the course of debates, in the Press and elsewhere, I pointed out, time and time again, that I had no authority of any kind to negotiate with the officers of local authority health services behind the backs of their employers. I stressed that under the County Management Act, 1955, it was essential that all such negotiations must be with the representatives of the appropriate health authorities, in the first instance. It could not, in fact, be otherwise, since every officer of a health authority who is aggrieved by the action of his authority in relation to his salary and conditions of employment has the right to appeal to the Minister for Health.
