Medicine and Labour Chapter 10 Medicine, Peace and Civil Liberties

The idea that the BMA was swinging to the left arose in 1983 as a result of two simultaneous events – the publication of the BMA report on nuclear war and the BMA’s opposition to the Police and Criminal Evidence Bill. These two issues are linked not only by that concurrence of time but also by certain common themes.

Both relate to the relationship of the profession with outside pressure groups that are seen as left-wing, and are dominated by the left but which in fact are capable of accommodating other political viewpoints as well (it is perfectly possible to make out a powerful right-wing case for civil liberties or against nuclear incineration).

In each case the profession is pulled into a debate which does not primarily affect health care, in one case because of important issues of medical ethics and in the other because of concern with health rather than health care.

In each case it is possible to analyse the relationship in terms of the concepts of patronage, legitimation and platform sharing which were set out in Chapter 8, and to observe the profession debating the transition point between health campaigning and politics, and the peace campaign will be described in detail as a case study of such a debate.

Civil Liberties

One of the issues which led many people to suspect a growing left-wing influence on the BMA was the uncompromising stance taken by the Association over the Police and Criminal Evidence Bill and over the Data Processing Bill. The full lobbying power of the BMA was deployed to protect the confidentiality of medical records where they were threatened by these two Bills. The Association was quite prepared to make common cause with the National Council for Civil Liberties and to establish working relationships with the Labour opponents of the two measures.

The issue of civil liberties is one that is difficult to place on the left/right spectrum. It is undoubtedly a left-wing issue in the sense that it is the left which campaigns for civil liberties as part of its struggle for social justice, and the National Council for Civil Liberties has its origins in, and is still primarily sustained by, the labour movement.

But civil liberties also strike a chord with the right-wing concept of the individual’s freedom against the state machine. Here the right divides. Its authoritarian strand instinctively supports the police. The battle for liberty will be seen as one that was won many years ago, and its defence as requiring the preservation of our existing society. The libertarian right, however, can be as assertive of civil liberties as the left.

There is, therefore, no neat correspondence between civil liberties and the left, and indeed the overt ideology of the medical profession is a libertarian one which sits happily in a civil-liberties seat.

The perception of a BMA/NCCL alliance as a surprising shift to the left is wrong for another reason, as the battle to keep medical records out of the hands of the police is a long-standing one. That the BMA should reiterate a long-standing policy should have caused no surprise to informed observers.

Medical Confidentiality

It is important for medical practice that no obstacle should be placed in the way of a patient seeking medical treatment. That is an important principle which commits the doctor to provide treatment to all who seek it without discrimination.

It would be a serious obstacle to a patient seeking medical treatment if that patient believed that information made available to the doctor could be used against the patient’s interests. Medical confidentiality therefore exists. It provides that doctors will not reveal anything told to them by their patients (or even the fact of a professional relationship or consultation) without the patient’s consent, except to other health professionals treating the same patient, or engaged in research, who themselves receive the information under the same seal of confidentiality.

There is one exception to the rule – the ‘public-safety’ exception, where the lives of other people could be endangered by confidentiality. An example would be a typhoid carrier who asked a doctor to conceal the diagnosis so as to be able to continue working as a food-handler, or bus-driver who asked the doctor to connive at the concealing of epilepsy.

There is debate as to how far the public-safety rule can be used to justify the apprehension of a criminal. There is no doubt that the rule would justify a doctor in breaking medical confidentiality in order to secure the apprehension of somebody who was likely to repeat a violent crime – the Yorkshire Ripper, for example – or whose criminal activities continued to harm the health of the community, such as a major drug pusher. There is equally no doubt “that very few doctors, if any, would be prepared to break medical confidentiality in order to secure the apprehension of a petty criminal.

Debate would centre entirely on the duties of doctors who receive, in the course of a professional relationship, information which suggests that a patient has committed a major crime. One view is that it is the seriousness of the crime which is the determining factor, for doctors must weigh the ethic of confidentiality against their duty as citizens. Another view is that it is the risk of recurrence of the crime which must be the determining factor, since the ethic of confidentiality must take precedence over the more general duties of a citizen, and therefore any breach must be justified in terms of the limits set by the ethic itself, ie in terms of the public-safety exception. Either view recognises some circumstances in which breach of confidentiality is justified to apprehend a criminal, but on either view they are very limited.

There is also scope for disagreement about whether the ethic requires the doctor to break the law. Doctors regularly comply with certain statutory notification requirements (in relation to infectious diseases, for example) but all of these could be justified on the basis of the public-safety exception, or on the basis of sharing information with a professional colleague for the good of the patient, under seal of confidentiality. Doctors are not therefore required by law regularly to betray confidences. The circumstances in which they might be required to do so is in respect of evidence given in court under subpoena. Where this occurs doctors must tell the court that they would prefer not to answer on grounds of medical confidentiality. If, despite this demurral, the court orders doctors to answer, they may do so. The profession does not require them to try to refuse, and merely gives permission to submit to force majeure. The profession would undoubtedly support and honour a doctor who declined to do so and accepted committal for contempt in defence of the professional ethic. The profession draws short of demanding such courage, but it does not prohibit it.

The profession has also been careful to distinguish between court orders (which the doctor may comply with) and requests from the police for information (which the doctor is, with the very limited exceptions described above, obliged to decline).

The police perceive the profession’s attitudes as anti-social. They see doctors as letting an excessively rigid attitude to a professional ethic stand in the way of their duty as citizens. The public probably share this view to some extent. They are probably surprised that drug addicts pass through the Casu­alty Departments of our hospitals without the police being informed, and are certainly amazed to discover that if the police are investigating a crime and visit doctors’ surgeries asking questions like ‘Have you treated a patient with a wound on the upper arm since we believe a burglar sustained that wound in the course of a crime?’ they are likely to be told’ I cannot tell you for reasons of medical confidentiality.’

To the medical profession, however, the situation is quite simply that no obstacle must be put in the way of patients, not even drug addicts or burglars, who would be unlikely to come for treatment if they thought the doctor was a potential informer.

This principle of unimpeded access is one that doctors have been prepared to defend to the extent of suffering torture or death.

The doctor who treated the fleeing assassin of Abraham Lincoln was punished for treason. Dr Sheila Cassidy suffered imprisonment and torture at the hands of the Chilean junta for providing medical treatment to freedom fighters.

There are no recorded cases of doctors suffering torture or death in the United Kingdom in defence of the ethic of unimpeded access, nor even of such a defence leading to imprisonment (although journalists have been imprisoned for refusing to reveal their sources).

There was in 1974 a court case which touched on these issues.

On 3 January 1973 a Dr Hunter treated a man at his surgery and later visited and treated the man’s girl friend. They had been involved in a road accident and Dr Hunter advised them to inform the police. Three weeks later a police officer visited Dr Hunter and told him that the car involved in the accident had been stolen and that the driver and passenger had run off after the accident. He asked Dr Hunter to identify the driver under Section 168 of the Road Traffic Act, which requires any person to supply, upon request by a police officer, information which it is in his power to supply to permit identification of the driver of a motor vehicle involved in a motoring offence. The police officer stated that the driver of the vehicle was suspected of dangerous driving. Dr Hunter declined to provide the information on the grounds of medical confidentiality and later refused a written request. He was fined £5, but never gave the information.

Confidentiality is a centrepiece of medical ethics and hence is central to the profession’s perception of itself as ethical and service-oriented. As such it is part of the process by which the profession shaped itself. The victories of doctors in preserving confidentiality are part of the battle to create the profession, and carry the emotional commitment that flows from that.

Onward from Confidentiality

There is no reason, in principle, why the conflicts over medical confidentiality should be anything but an encapsulated blemish on the good relations between the medical profession and the establishment, or why their relationships with bodies like NCCL should be anything but temporary alliances over specific issues.

However, the medical profession has an ideology of struggle, for it was out of struggle that it was forged. It has a libertarian philosophy which places it in that sector of establishment politics which is most open to civil-liberties arguments. It has had its own experiences of oppressive behaviour by the police, and resistance to that oppression. It is therefore fertile ground for civil-liberties organisation.

Thus it should not surprise us that the medical profession sustains an active Amnesty group, which is not seen by the profession as particularly anti-establishment. Indeed the launch of Medical Amnesty was welcomed by the BMA and a series of articles on medical prisoners of conscience was run in BMA News Review.

The 1984 ARM passed a resolution calling on the BMA to campaign against torture. The BMA withdrew from the World Medical Association following the admission of South Africa (interestingly, the two reasons given for ostracising South Africa were the abuse of medical ethics by doctors supporting the apartheid police, and the fact that apartheid impeded access by patients to health care facilities), and in 1986 passed a resolution calling for a medical boycott of South Africa, and another expressing support for doctors oppressed in Chile.

Closer to home, it is interesting to consider the position taken by the BMA over the provision in the Police and Criminal Evidence Bill that dealt with intimate body searches. The BMA position was that nobody except doctors ought to carry out such searches, because it would be medically dangerous, and it would not be ethical for doctors to do it since free consent would not have been given and it therefore followed that the provision ought to be removed.

The principle of doctors carrying out intimate body searches is not really an issue of consent, because the search is not a medical treatment. The doctor is in the position of an ‘examining doctor’ who is asked to examine a person to obtain information for a third party. The person being examined is not a patient receiving treatment, but simply the subject of an examination, and so there is no doctor-patient relationship to give rise to issues of confidentiality or consent, except insofar as it is necessary to ensure that the examinee knows the nature of the consultation and does not confide freely in the mistaken belief that a doctor-patient relationship exists, or insofar as the examinee has in the past been a patient and consent is therefore needed for the doctor to break the confidences of that previous relationship. Such issues are well sorted out in relation to doctors taking blood samples for analysis of alcohol concentrations in cases of drunken driving or in examinations for life-assurance purposes.

Although the ethical principle of consent to treatment does not apply, the legal principle of consent to an examination being necessary to avoid it constituting an assault does. But statutory authority would be a substitute for such a legal consent.

The BMA’s position on intimate body searches cannot therefore be justified from the standpoint of consent and confidentiality. If that were the only consideration involved the BMA could be accused of being the unacceptable face of trade-union power obstructing the investigation of crime.

International declarations of the ethics of medical involvement with prisoners prohibit doctors from participat­ing in torture or degrading punishment, or from certifying people fit for such punishment. The use of a doctor’s medical skills for the purposes of punishment is expressly prohibited.

If therefore it were thought that an intimate body search was being carried out not to search but to degrade the prisoner, it would be unethical for a doctor to participate. It would then be necessary for a doctor asked to carry out such a search to be satisfied that the reasons for the proposed search were substantial and bonafide and accorded with the objectives of the law. Such an ethical obligation, emphasised by professional organisations as an unavoidable duty, would have put the doctor into the role of a protector of the suspect.

But the BMA’s reaction went further than that. I support the BMA’s stance because I believe that, just as most strip searches are carried out to degrade rather than to search, so would intimate body searches. Many in the establishment would argue that, whilst some police or prison officers might abuse their position, on the whole the systematic use of searches to degrade prisoners does not occur and every search is justified by the demands of security or investigation.

It is interesting that the BMA took a position which implied (even if it was not explicitly stated) that it shared the civil liberties view of the matter rather than the establishment view.

Medicine and the Peace Movement

During the Korean War there was a feeling in Europe that another world war was imminent. A group of doctors who felt that they might have a special function either in helping to stave off the emergency or to mitigate its consequences formed the nucleus of the Medical Association for the Prevention of War (MAPW). The inaugural meeting took place on 16 March 1951, and a statement of policy was adopted at a meeting held at the Royal College of Surgeons in May 1951.

The objects were to unite doctors in efforts to prevent war and in particular: to consider and formulate the ethical responsibilities of doctors in relation to war; to study the causes and results of war; to examine the psychological mechanisms by which people are conditioned to accept war as a necessity; to oppose the use of medical science for any purpose other than the prevention and relief of suffering; to urge that the energies and money spent in preparation for war against man be directed into the fight against disease and malnutrition; to seek the co-operation of all doctors, in all countries, having the same aims.

In an article about the history of MAPW Margaret Penrose, editor of the MAPW Journal, comments, ‘The new group enlarged rapidly and other organisations like Science for Peace (definitely more political in their aims) sprang up at the same time.(General Practitioner, 13 March 1981.)

The distinction of MAPW’s professional approach from the political approach of other organisations is important. The Association’s constitution provides that it will not be associated with any political party, and, as can be seen from the policy statement, its approach has always been that of the educational and scientific learned society rather than that of the campaigning pressure group. It has regularly published a journal full of articles which analyse the effects of war and the psychology of its prevention.

During its first year the membership of MAPW rose to 378 with branches in Birmingham, London, and Oxford. Over the first five years of its existence MAPW was extremely active, protesting at the ban on medical exports to China, at the use of napalm and collective punishment in Malaya and at the chemical destruction of Malayan forests. The scientific effects of nuclear war were studied, and the Association also concerned itself with bacteriological war and with medical ethics in relation to war.

Over two-thirds of Margaret Penrose’s historical article about MAPW’s first 30 years related to its first five years. After its initial burst of activity the organisation seems to have settled down as a scientifically respectable, scientifically rigorous, educational body serving as a source of facts and as an educationally-oriented conscience for medicine. This is an extremely valuable, albeit unglamorous, contribution.

In 1980 the first Congress of International Physicians for the Prevention of Nuclear War was held in Washington. 80 doctors from eleven countries participated. By the time IPPNW held its fourth Congress in 1984 it had grown to attract 400 delegates from 50 countries, and was addressed by two heads of state. The fourth Congress considered the effects of arms expenditure on public health (pointing out the contribution to health which could be made with the money currently spent on arms), the ecological effects of nuclear war and the effects of fear of nuclear war on the psychological well-being of children. A working party produced an outline curriculum for medical education and nuclear war, another working group considered non-violent conflict resolution and another looked at the need for research. The Congress received a report on the interim results of gathering signatures for a petition – the International Physicians’ Call for an End to the Nuclear Arms Race. No less than a quarter of the world’s doctors had already signed the petition.

This growth of IPPNW reflected an upsurge of interest in the issue of nuclear war amongst doctors throughout the world. The upsurge of interest from 1980 to 1984 was reflected in the United Kingdom.

The Medical Association for the Prevention of War organised a conference at the Royal Society of Medicine, addressed by several prominent doctors.

There was recognised to be a demand for an organisation which would take a more campaign-oriented approach to the problem than MAPW and so the Medical Campaign Against Nuclear Weapons (MCANW) was formed. MCANW and MAPW were not intended to be rivals, but rather to reflect different styles of activity.

MAPW’s membership increased as a result of the new interest, but MCANW grew phenomenally. Branches opened in most major cities and membership increased into the thousands. So rapid was this growth that there was no real opposition to it, and it began to become the medical orthodoxy.

MCANW was not led by the left. The MPU was taken by surprise by the growth of the movement. It responded to it by producing a four-page leaflet ‘What Chance for Health Care After the Bomb?’ which described the medical effects of nuclear Avar and was well received in the labour movement and the peace movement. But MCANW was a broad-based campaign of ordinary doctors concerned at the drift into nuclear war. That was its strength, the factor that gave it respectability and wide support.

It was also its weakness. MCANW is not practised in medical politics. This can be illustrated by an event which occurred at a meeting of MCANW Council which was discussing lobbying the BMA. Sheila Adam (then secretary of MCANW and a member of MPU Council, since elected to the General Medical Council on an MPU platform) pointed out that non-members could still influence the BMA through their craft committees. So unaccustomed to medical politics was the organisation that it refused to believe that this was the case.

(In 1983, 1984 and 1985 MCANW issued lobbying material before the ARM which was, as in previous years, addressed to BMA members attending their Divisions and ignored the half of the ARM which comes from craft committees and in which non-members can influence events. However in 1985 it subsequently issued material reminding people about craft committees, so it may be that MCANW has learned this lesson.)

The success of MCANW, however, was such that the BMA had to respond.

The Board of Science Report

The BMA’s response to the growing professional interest in peace was to set up an investigation by its Board of Science.

The Board of Science was reluctant to get involved in the affair, but once instructed to look at it set out to examine it with scientific detachment. There is no doubt that the members of the investigation were at first unsympathetic to the radical ideas of MCANW and SANA (Scientists Against Nuclear Arms). As they proceeded with their tasks, however, they became increasingly convinced.

The report began by reviewing the physical principles and construction of nuclear weapons and then by examining the likely form that a nuclear attack on the United Kingdom might take. It then proceeded to estimate the mortality and morbidity that would result from a nuclear attack, and the long-term medical effects, psychiatric effects and radiation effects. There was then a short chapter reviewing the assumptions that underlie civil defence. The effects on the health service were then considered.

It then proceeded to its conclusions.

It pointed out that the United Kingdom contains a large number of targets likely to be attacked in war, and has densely populated conurbations. Because of the proximity of potential targets and population centres throughout the UK, the Board could see no areas, ‘apart from remote tracts in Scotland, and perhaps in North Wales, that do not place potential targets adjacent to communities of people’. It pointed out that this combination of density of people and density of targets was unique to the United Kingdom. It emphasised that the world nuclear arsenals far exceeded that necessary for a policy of deterrence, and that it was impossible to predict the nature of a nuclear attack on the UK. However ‘with one exception, all the experts who contributed to the Working Party said that a nuclear war could not be contained, but would escalate to an unlimited, total exchange of nuclear weapons.’

There is then an extremely significant paragraph:

There are discrepancies between the projections for blast, heat and radiation produced by the Home Office and SANA. The latter rely on methods and figures derived for the most part from the United States Department of Defense and the Office of Technology Assessment. We have examined the methods for calculating the projections used by SANA and the Working Party believes, on the evidence it has received, that the projections from SANA give a more realistic estimate of the blast, heat and radiation effects of nuclear weapons.

The next two sections of the conclusions reject the idea that evacuation or shelters would be effective civil-defence strategies. The section on shelters is particularly closely argued.

The next section dealt with long-term effects.

Water would be the first requirement of survivors of a nuclear attack … The present water tanker capacity of the UK is wholly inadequate to supply survivors with water for even basic needs.

Government plans for the distribution of emergency supplies of food do not aim to provide a balanced diet. This would have serious consequences for people requiring special diets, diabetic patients, for example. There may not be a sufficient quantity of food in store to tide survivors over until alternative sources could be found … It is likely that agricultural production in the northern hemisphere would be severely disrupted, so that food production for the survivors of the initial effects of the war would be very difficult.

Survival becomes even more difficult if stratospheric ozone depletions also take place. It is difficult to see how much more than a small fraction of the initial survivors of a nucleus war in the middle and high altitude regions of the northern hemisphere could escape famine and disease during the following years.

Other problems with implications for public health would be extensive radioactive contamination of the environment, failure of water and sewerage systems and lack of basic drugs and medical supplies.

It is inaccurate and misleading to suggest that after a nuclear attack on the United Kingdom there would be a return to a rural civilisation of two centuries ago. The Working Party believes that there would be an increase in infant mortality, communicable diseases due to infections, and deficiency diseases caused by inadequate nutrition. The UK no longer possesses the skills or primitive technologies which allowed our predecessors an existence with some measure of comfort. The skills of the twentieth century do not permit a return to that style of life after a nuclear attack.

The final section of the conclusions, dealing with effects on medical services, points out that even the entire medical resources of the NHS, even if entirely undamaged in the attack, would be incapable of dealing with the casualties of even a single bomb.

We believe that such a weight of nuclear attack would cause the medical service in the country to collapse. The provision of individual medical or nursing attention for victims of a nuclear attack would become remote. At some point it would disappear completely and only the most primitive first aid services might be available from a fellow survivor.

The report was dynamite. Its conclusions were very similar to those of the MPU report two years earlier, but much more influential, partly because it was supported by more detailed analysis, partly because the BMA is a larger and more influential organisation, but most of all because the MPU is a politically aligned organisation whose report was politically motivated whereas the BMA report manifestly was not. We see again the paradox that the depoliticisation of the medical profession enhanced the political power of its report. The report’s prestige grew even more when it became known that the members of the panel had been won to a point of view which they had been reluctant to reach, but to which scientific integrity had compelled them as they reviewed the evidence.

The BMA report was the definitive judgment between the rival scientific views of the left and the right. And the left won.

The Debate in Dundee

It was inevitable that the 1983 ARM would be dominated by the report. The report was published in February, too late to be an issue in the election of delegates, but well before the closing date for submission of motions.

The report had been widely acclaimed by the peace movement and the Labour Party at a time when nuclear disarmament was emerging as a central issue of the coming General Election campaign. This acclaim itself frightened the profession which saw itself being drawn into political debate, on the side of the left, on a central issue of party politics. There was therefore a strong body of opinion that wished to play down the report, whilst at the same time recognising that to suppress it would demonstrate a lack of professional integrity that could not be justified.

To the Medical Campaign Against Nuclear Weapons, however, the report was a point from which to commit the medical profession to the peace movement. Its objective was to secure a disarmament resolution from the ARM in Dundee.

Seventeen disarmament resolutions were submitted to the ARM, of which ten were multilateralist, one unilateralist and six called for a freeze. Against these resolutions were five resolutions which said that the BMA should take no political stance. There were 72 other resolutions on nuclear-war issues, including 26 opposed to and ten in favour of civil defence. There were eighteen resolutions calling for public education about the BMA Report and ten resolutions simply welcoming or endorsing the Report.

A curtain raiser for the debate occurred at the Junior Members’ Forum (JMF) in April. This is a conference of representatives of BMA members under the age of 40 and within twelve years of qualification. It is traditionally more radical than other sections of the profession, and indeed the 1983 JMF elected as its chair Mike Donnelly, a leader of the left in the BMA.

The JMF’s only constitutional significance is that it sends two delegates to the ARM (of which I was one in 1983) and that it submits motions. It has a rather greater emotional significance as a clearing-house for the views of the younger members of the profession, and is a traditional training ground for its future leaders. The 1983 conference passed a motion calling for a nuclear freeze, but rejected a motion of support for the Medical Campaign Against Nuclear Weapons.

More constitutional significance attaches however to the craft conferences, where the various sections of the profession decide their policy. The Annual Conference of Local Medical Committees, representing GPs, passed a ‘no political stance’ motion by a large majority, and the Conference of Senior Hospital Medical Staffs, representing consultants, did likewise. The writing was on the wall for the ARM motion in the light of these two decisions. ‘No political stance’ was a concept deeply embedded in the medical psyche and was obviously coming to the fore.

The Hospital Junior Staffs Conference called over­whelmingly for a freeze and defeated a unilateralist motion (drafted by the MPU) by only 28 votes to 22. The Annual Conference of Community Medicine concerned itself mainly with the absurdity of civil-defence plans.

Throughout the run-up to Dundee considerable interest had centred on the personality of Stuart Horner, chair of the CCCM and a member of the enquiry. Dr Horner had denounced the civil-defence planning currently being undertaken by the NHS, a courageous act in view of his role as District Medical Officer for Croydon.

As a result of the considerable press publicity accorded to Dr Horner, government ministers came to visit the CCCM. At the outset of the meeting a decision was made to make no statement to the press, a decision which reflected the wish of the BMA to damp down the controversy surrounding the issue, especially since the General Election campaign had now opened. The meeting was stormy, and somebody leaked a full report of it to the press. And so to Dundee.

The Medical Campaign Against Nuclear Weapons held a caucus meeting but decided to play down its role as an organisation, and not to make any reference to MCANW within the conference hall. The Dundee peace groups lobbied the hall, but Dundee MCANW did not take part in the lobby. Dundee CND organised a fringe meeting, which I addressed, but no other conference delegate attended, nor, for that matter, did any local doctors.

The debate on the motion that the BMA takes ‘no political stance’ was long and of high quality, and ended with the motion being commended to the meeting by the Chairman of Council. It was carried by 248 votes to 70. This was seen by the left at the time as a defeat, but in fact this was far from the case. The ARM endorsed the Board of Science report by a large majority, called on the BMA to publicise it widely, and called for teaching on the medical effects of nuclear war to be included in medical undergraduate courses. All of these were important decisions and it is arguable that they were more important because of rejection of the political stance, so that the report continues to stand as a powerful independent non-political report by an organisation which has refused to take a political stance on the issue. The left can make its own political rhetoric – what the BMA has given us is scientific legitimation, and that is amply provided both by the quality of the report and by the ARM’s overwhelming endorsement of it. It should be noted that a year later the BMA, with little fuss, passed a resolution calling for worldwide disarmament and for transfer of the resources saved to health, both at home and in the developing countries. There were a number of reasons why this resolution passed so easily, which I have already discussed in the chapter on public health and politics. To reiterate, the differences were that the resolution was surrounded by less external political fuss, that it made allusions to health care, and that it was an ‘apple-pie-and-motherhood’ resolution since nobody objects to worldwide disarmament.

Community Physicians and War-Planning

Community physicians played a central role in the medical debate about nuclear war. In their role as health planners they were directly involved in the controversy about health-service planning for nuclear war.

Within the BMA the CCCM was seen to be prominent in the peace faction, but that was very largely because of the personal energies of Stuart Horner. The committee itself took a relatively low-key approach, confining itself to a refusal to plan within the unrealistic assumptions set out by government.

Although many community physicians were active in MCANW many others (probably a majority) were troubled by the politicisation of their role as health authority officers, and in most districts the war-planning circulars were implemented.

The Faculty of Community Medicine set out to produce a statement on civil defence, only to be faced with threats of resignation by Regional Medical Officers in response to the first draft. It was later possible to produce an acceptable draft, which emphasised both the importance of planning for all emergencies and the importance of not misleading the public into believing that plans were more effective than they really were.

A point of view which began to find considerable favour amongst younger community physicians from about mid-1983 onwards was that the correct course of action was to combine the CCCM’s demand for realistic planning assumptions, the Faculty’s comments on honesty with the public, and the BMA Report’s assessment of the effects of nuclear war. It was argued that if these three official stances of the profession were combined the only course of action possible was to produce and publish plans which dealt with such questions as rationing food so that it only went to those who could work, euthanasia services, storage of those dying from radiation sickness and epidemics and so on. Such plans would bring home the stark reality. Rod Griffiths, District Medical Officer for Central Birmingham, commented, ‘My plan will include a map of the sites of medieval villages around Birmingham, so as to indicate to people where they might find a site with water and soil capable of supporting a few hundred people.’

The government was faced with a refusal by the BMA, supported by the Royal College of Nursing, to carry out unrealistic planning, and clear indications that realistic plans might actually be more embarrassing than refusal.

In some ways the BMA response was that of a paper tiger. There was little evidence that the majority of community physicians, especially those in the more senior grades who were involved in war-planning, had any intention of doing anything but obey the DHSS circulars. No more than a handful of districts would have produced radical plans of a politically-educative type, and it is unlikely that the BMA leadership would have carried out any widespread publicity of such actions.

The main threat for the DHSS was the continuation of a debate that it was losing. In mid-1984 they responded to the BMA request for new guidelines for health-service war-planning. These guidelines related almost entirely to conventional war, with nuclear war confined to parentheses, footnotes and passing references.

On the face of it the BMA had won a major victory. In reality things are not that simple. The acceptance of the new guidelines by the BMA will open the way for the passing references to nuclear war to be opened up by those community physicians who are prepared to plan accordingly, whilst the government will be saved the embarrassment of confrontation with those who are not. Moreover the subsequent introduction of general management into the NHS opened up scope for responsibility for war planning to pass from unwilling community physicians to willing managers.

Nor can the profession or the peace movement even claim a victory. The references to nuclear war, whilst insignificant enough to allow the guidelines to be accepted and to allow conscientious objectors to ignore nuclear-war planning, are sufficiently significant that they can be picked out to show that the government had not climbed down.

The State of the Medical Peace Movement by the mid- 1980s

The achievements of the peace movement in medicine in the early 1980s were immense. A large section of the profession was mobilised behind an anti-establishment campaign. The BMA provided scientific legitimation for the views of peace-movement scientists and in doing so changed the nature of public debate about civil defence. The battle over health-service planning was fought to a draw, and whilst war-planning will take place it will be much less than the government had wished – in most districts it will be no more than a token.

It would be expected that a movement which had fought such a hard campaign and achieved so much would be tired. MCANW by 1985 showed signs of running out of steam. MAPW, in contrast, continued its low-key educational and scientific work tirelessly.

MCANW faces internal tensions that arise from the breadth of its membership and the fact that it therefore embodies many of the myths and assumptions of the profession.

There are those within MCANW who think that it should adopt a primarily educational role, although this would merely duplicate the work of MAPW. There are others who believe that it should direct its efforts towards the institutions of the medical profession. It has set up a working party on its role as a lobby of the BMA, but there are serious difficulties in a single-issue group seeking to become a medico-political faction when the breadth of its membership precludes it from allying with other factions or taking positions on other issues. It fielded candidates for the 1984 General Medical Council elections, but they were not successful, suggesting that its large membership does not see MCANW as the prime focus of its medico-political loyalty. However MCANW votes prob­ably contributed to Sheila Adam’s extremely good result on an MPU platform, which shows the value of uniting progressive forces behind an umbrella organisation.

The most important question facing MCANW, however, is its relation to an increasingly militant peace movement in the country at large.

MCANW embodies the depoliticised assumptions of the medical profession. It is therefore reluctant to identify itself with militant activity or even with CND. Despite this it has won the respect of the peace movement, but there is undoubtedly a place for a medical organisation which will go further. With this in mind the MPU has established a Peace and International Affairs Campaign Group, which will be prepared to take up the kind of overt political activity that MCANW shrinks from.

Will the peace movement in medicine prove capable of sustaining three organisations – the scientific and educational MAPW, the broad campaigning MCANW and the overtly political MPU Peace Campaign? Or will support polarise away from MCANW to the safe MAPW, on the one hand, and the excitingly militant MPU Peace Campaign on the other? Or will MCANW, with its balance between safety and campaigning, continue to overshadow its rivals to left and right alike?