To trust professions or not to trust them? That is the question. First let’s learn from history. In later posts, I’ll set out the principles that we can apply to institutions that are around us now.
In the Marx Brothers film, A Day at the Races, Mrs Upjohn (Margaret Dumont) has infatuated faith in Dr Hackenbush (Groucho Marx). Everyone else can see he’s a quack. His qualifications and prescriptions aren’t worth the paper they’re written on.
Outside vaudeville, losing trust is no joke. Breaking professional trust is a personal trauma. It affects our bodies, our minds, our relationships, and our lives at home and work. Quacks only think about your money. They abuse our trust as they confidence trick their way to our wallets.
When you’re desperate for help, how do you tell a trusted doctor from the dodgy quack, effective treatment from snake oil?
Spotting the quack
We can check credentials and treatments in advance. But even with an instant check online, can a lay-person understand and trust what we find? You can complain afterwards to a professional body. But a quack doesn’t have one.
And what if the professional body is more concerned with their own status and status quo? What if the profession’s standards and normal practice are themselves self-serving, out of date, or faulty? What if it’s a new field that hasn’t got its standards sorted out yet? After things have gone wrong, how likely will a complaint get through? How many years does it take for complaints to improve a profession’s practise?
In my own life time and career as a doctor, there have been new disorders and big changes everywhere including my specialism, child psychiatry. In 1995 the government introduced a welcome new framework that changed the way we worked in the UK’s NHS to a more joined-up multi-disciplinary multi-tier system: CAMHS (child and adolescent mental health services). In my time, I have criticised my profession’s over-use of a medical model in child psychiatry, and the hyperactive way we dealt with ADHD. In an era when all CAMHS drifted away from the needs of children in separated families going through family courts, I have held my hands up about my own part in our collective ignorance and incompetence.
Trusting our professions
The question of trust in professionals and institutions is both ancient and modern. Each generation thinks it’s better than before. Across the world, we have way more democratic influence and access than ever to expanding mountains of information, trading and professional standards, legislation, campaigns, feedback, complaints systems, checks and balances and so on. Yet – or as a result – our present institutions are crumbling as Niall Ferguson showed in his 2012 Reith Lectures.
Meanwhile, in our everyday experience of professions and institutions, how do we know the quack from the competent? What blind complacency now might future generations be shocked to see? Let’s look back on historical precedents to build the wisdom of hindsight. With COVID-19, history shows us that pandemics are not unprecedented. You can read how people coped with pandemics 700 years ago, 100 years ago and in the last 20 years too. You’ll find history repeats itself. One new thing the Covid pandemic does show is how quickly and massively the whole world can rise and change to tackle a serious challenge – if and when it sees it’s there.
So, for this short course in seeing what’s around us now and taking steps to change what’s wrong, we start with what people put up with in previous times.
Bad institutions 500 years ago
This is just one of a great many reformations of the established churches. It’s an example from historical fiction in the better-than-factual accounts of Hilary Mantel. In Wolf Hall she gives the usually enigmatic Thomas Cromwell a long heart-felt speech to Henry VIII. It’s 1530. Henry has marital reasons to pull down the Catholic church in England. But Cromwell’s damning portrayal goes further than strategic advice to his boss. He is passionately principled about how rotten the typical monastery then was, how far the monks had strayed from their highest God-given professional standards.
“… May I suggest to Your Majesty that, if you wish to see a parade of the seven deadly sins, you do not organise a masque at court but call without notice at a monastery? …”
In modern times, we have modern versions of how a good religious institution can harbour evil abusers. Mantel’s Cromwell sees the problem then as institutional rather than the personal failing or evil nature of individual monks. He says that priests “train themselves out of natural feeling” to become “cold people … who mean it for the best, of course”.
So, 500 years ago, a well-established institution, professing the worthiest aims and with wide public support, had still become corrupt and harmful. Read the whole of Cromwell’s speech to learn what to look for now. The blindest spot is in how, like the monks, individual professionals add their own best personal intentions – they ‘mean it for the best, of course’.
In my own career, as I said, I dismissed new diagnoses because they didn’t fit with my well-intended multi-professionally-sanctioned views. I most sincerely ‘meant it for the best’. In fact, like mine, individual professionals’ best intentions add a twist to the knife of institutional harm. The knife carries the triple whammy power of aligned but unwittingly malignant best intentions of individual, profession and institution. As CS Lewis wrote:
“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. … those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.”
More pointers for reform
To help underline how the institutionalised or righteous mind can be doing wrong, here’s a few more quotes. They can all be found here:
“I think the people involved really genuinely thought they were doing the right thing.” Dr Helen Martini, GP on the Orkney child sex abuse scandal
“Overconfident professionals sincerely believe they have expertise, act as experts and look like experts. You will have to struggle to remind yourself that they may be in the grip of an illusion.” Daniel Kahneman, Thinking Fast and Slow
“They were making critical decisions .. based on little or no knowledge, and doing so with an air of complete assurance.” James Surowiecki, The Wisdom of Crowds
“Unskilled and unaware of it.” The Dunning-Kruger Effect
“The rules … appear to them self-evident and self-justifying. … I do not mean that they choose what is customary … It does not occur to them to have any inclination except for what is customary … the deep slumber of a decided opinion.” John Stuart Mill, On Liberty, 1859
So now we turn to what the more recent history of blood-letting tells us about well-meaning professions and institutions, competent practice and quackery. Medicine – and blood-letting – grew in Asia and the Middle East 1000s of years before Western medicine got going. This is about the more recent evidence-based profession of medicine, and one of it’s most long-standing treatments.
Until the early 20th century, blood-letting was a standard and much valued general treatment for pretty much everything you could suffer from. Apart from modern scientific uses – blood tests, blood transfusion, rare diseases – it finally died out a century ago. For 2000 years before that, it was based on the best humoral theory physicians had. The four humors were black bile, yellow bile, phlegm and blood. Each corresponded to four personality types: melancholic, choleric, phlegmatic and sanguine.
We can be amused by this. But think how many equally imaginary ‘sciences’ – spiritual belief systems, alternative medicine, astrological personality categories – some of us are still strongly attached to without much objective evidence. When push comes to shove, though – as with the Covid pandemic – sensible people head for the more evidence-based approach,
Hippocrates then Galen applied the theory of the four humors to medicine. Physicians delegated the job of removing blood to the blades of barbers who were on their way to becoming today’s surgeons. Cutting contraptions made the procedure more impressive. Then leeches became popular. Some doctors were explicitly extreme, removing most of the blood until their patient fainted.
Patients would expect and request blood-letting. In 1799 George Washington asked for blood-letting (among other things) for a severe sore throat and it probably helped end his life. As enlightened science grew in the 19th century, it still took about 100 years of sometimes heated debate in the medical profession before the evidence of objective research showed that patients did worse with leeches than without.
100 years and counting
In the 1830s, Pierre Charles Alexandre Louis used the new scientific counting method to demonstrate that blood-letting was ineffective in the treatment of pneumonia and other fevers. But many doctors were not prepared to discard therapies ‘validated by both tradition and their own experience, on account of somebody else’s numbers‘. An anonymous 1871 British Medical Journal editorial (pp 283–284) enthusiastically argued that, before giving up on blood-letting, tests would show the long-established facts and benefits of blood-letting to make “the detraction of blood a thoroughly scientific proceeding“. The acceptance of science and humanitarian care in medicine was no doubt accelerated by the single-minded campaigning work of the paramedic and statistician, Florence Nightingale, born 200 years ago this year. Therapeutic blood-letting was not on her to-do list in the Crimean War, but the last recommendation of blood-letting was only 100 years ago in 1923 in a medical textbook.
We would now think of generalised blood-letting as quackery. The Bible uses the leech as a symbol for greed; capitalists have often been portrayed as leeches. But leech-craft was an old word for healing – doctors weren’t denigrated for it. At the same time as defending blood-letting in the 1800s, physicians and barber surgeons were growing into an authoritative profession, both protecting best practice like blood-letting (for patients) and fighting against quacks and their snake-oil (to protect the profession and standards as well).
On Dec 1st 1814 Mr George Stevens wrote to the London Medical and Physical Journal (Jan 1815, pp 20-22, ‘remarks on the various Forms of Quackery’) with a very balanced critique of unproven treatments in ‘your profession’ and those used by quacks.
“… When I hear the learned part of your profession exclaim against quackery, I often wish to know which of them is guiltless, to cast the first stone. Was this private in the guards the only practitioner whose patients were taking an equally innocent tisane, and how many of those whose remedies were more powerful were really succeeding better, and, after all, are we certain that there is no efficacy in a decoction of hay? Ought there not, therefore, to be certain lines fixed between the quackery of regulars and the quackery of professed quacks? … ” (page 21)
Note that this unusually acute scientific thinking on quackery – half a century before the biased doctor in the 1871 BMJ wrote on blood-letting – comes, as for Florence Nightingale later on, from the intelligence of an outsider to the profession. Credit that the journal published his letter – would they publish it now?!
Unquestioning public support
There don’t seem to have been any campaigns against blood-letting itself. Nor was anyone arguing that doctors weren’t the right people and generally competent for the job of treating illness. The use of leeches may have seemed like civilised progress from the barber’s crude blades. Meanwhile blood-letting was plainly a very impressive concrete treatment – they wouldn’t be using it if it didn’t work. In anyone else’s hands, cutting into someone’s blood vessels would be criminal assault! No one criticised it as – in 1815 – they criticised using a tisane of hay as a treatment. Blood-letting wasn’t finally given up until well over 100 years later.
So the wider public valued the doctors’ use of what we now see as harmful methods. The public and governing rulers left the medical profession for many centuries to find out for themselves what the best treatments were. With the thinking and values of that time, the profession did its best to validate their own theories and treatments while challenging those of the quacks. Even after enlightened scientific thinking, everyone gave both the treatment and the profession their fullest support for over a century while they worked out if blood-letting was good or bad for patients.
Looking back, we might criticise how it took over 100 years for some simple counting to persuade the profession to stop a useless treatment. But we can see that before that they used the best theories and methods available – and that they ‘meant it for the best’. The medical profession took a fairly ethical approach. The blood-letting cure was no better than a quack’s, but the motives, theory and technology were honourable at the time. The poor have always had to turn to folk cures, but no one would have campaigned to take the job of curing illness from the institutions of medicine.
Some take away points
Next time I’ll set out the general principles of how to judge our trust in the individuals who become our professionals, our professions and their institutions. After that we will take the general principles and apply them to what we see around us now.
We’ve taken two history lessons – religious monasteries and medicine’s blood-letting. Keep in mind what you would think if you found some of these same things going on now in any of our modern-day professions and institutions. It may not be easy. As Daniel Kahneman says, you may “struggle to remind yourself that they may be in the grip of an illusion.”.
But why? If absolutely everyone is happily deluded about monasteries or blood-letting (even if we suffer or die as a result), if we were all like Mrs Upjohn and her misplaced faith in Dr Hackenbush’s methods – what’s the problem, where’s any painful broken trust? Isn’t illusion better than truth? No it is not. The world would be a nightmare if it was just a social construction, full of Mrs Upjohns and quacks like Dr Hackenbush. In the service of the best for ourselves and each other, we are bound to keep searching for a better truth, to challenge illusion, to take the red pill not the blue pill.
Once a better truth has been found, the way it’s told and when and to whom may be a complex judgement – as it is for what parents tell and don’t tell their immature children about the world. At times professionals may also need to tell things slant. But professionals, professions and institutions must be trusted to know and be guided by the very best truth there is or face being stripped of their office.
So, learning from past examples, we should criticise any profession or institution now that we find is deluded, that does not actually carry out the jobs they profess to be good at. We should robustly challenge any profession or institution that is under a self-justified illusion that they have the expertise yet don’t even ‘count’ their cases to measure the outcome. Professions or institutions like that are failing and unfit for their purpose, they may need to be stripped of their office … even though they may look for all the world like they are experts, may have been doing their completely-assured customary thing for decades, may all ‘mean it for the best’, may make a comfortable living in their profession, and may be actively approved and employed by everyone else. Now we’ve seen what that looks like in the past, we should have eyes to see it in the present.
We have made allowances for 2000 years for the medical profession and its now disproven practice of blood-letting. But we wouldn’t now sit back for 100 years waiting for a modern profession to start applying higher ethical standards, using some science, some ‘counting’, to evidence the value of that profession’s or institution’s work. We would not be by-standers now, would we?!