Authority can all too easily pressure good people into doing nothing

WE'VE got into a mad sequence, have you noticed? Something goes wrong. Let's say it's a surgeon who whips out women's wombs. Hundreds of them. He gets nailed. Eventually. But a single nailing is never enough.

We go hunting for the less-guilty, but still-guilty. Frequently underpinning the hunt is an expectation that the still-guilty will include nuns. Nothing animates the latent love of coursing in Ireland at this time like the possibility of a bunch of old nuns getting ripped apart.

We've developed blame and belief-blame into a mad dual reflex that kicks in at the drop of a tragedy. The need to blame comes first. The need to punish a set of beliefs we no longer share is right behind it.

It's very satisfying. And it delivers no gain to anyone - and distracts from more useful processes.

Take the Neary case. We've been so eager to blame the surgeon, those who stole records on his behalf and the nuns running the hospital where he worked that we've missed two points: 1) Some people did things right. 2) The ones who did things wrong fitted a pattern we know about and have the power to prevent.

The ones who did things right were the two nurses, one a midwife who talked to a solicitor who was at the hospital to address a separate issue.

The solicitor, in turn, did the right thing, by raising the alarm. The then North-Eastern Health Board did the right thing by taking action.

Taking action against a consultant who's been around forever and is adored by female patients who believe he saved their lives was not easy, but the NEHB did it. The next group who did the right thing (shock, horror) were media, notably The Irish Times and Prime Time, which - at some risk to themselves - blasted the story into the public mind and helped ensure action was taken. (The sad irony is that many of the women mutilated by Neary initially joined marches to protest the coverage.)

Finally, the Minister for Health and the Government did the right thing when they had the full information.

But, OK, you still want to go the blame route. Why were the two nurses the first people to do the right thing? They weren't.

Others had done it earlier. And the ranks had closed against them in a twisted, dangerous and coercive collegiality: we're a team, here, and if you're part of the team, you can't be saying bad things about one of us. Park that for a minute and consider the power of the white coat.

White-coat hypertension is now a recognised syndrome. When you're surrounded by scary machinery and scarier doctors, your blood pressure shoots up.

White-coat hypertension isn't induced just by doctors.

Vets do it to THEIR patients: recent research shows that the minute a perfectly calm cat finds itself in the veterinary clinic, that perfectly calm cat says to itself "Oh, bloody 'ell, this is the place where they stick things in me, fore and aft" and its blood pressure does vertical take-off.

White-coat hypertension is not confined to patients and cats. It would be interesting to slap a blood pressure cuff around the arms of young doctors and others on rounds with consultants who may, at any point, ask them difficult questions. Chances are they'll have elevated blood pressure.

Now, park THAT for a minute and consider Stanley Milgram, who conducted arguably the most significant experiments in the power of perceived authority.

He brought a bunch of ordinary decent folk into a room equipped with scary technology. The room had a glass window. The room was operated by an authoritative man, who explained that the guy the ordinary decent folk could see through the glass window was strapped to a chair and wired up to electrodes they, the ordinary decent folk, controlled by a lever in front of them. The guy behind the glass window was to be given mild electric shocks by the ordinary decent folks every time he gave the wrong answer to a question. Clear? Clear.

So the ordinary decent folk, one by one, started giving the guy behind the window mild electric shocks. And, when those didn't work, they were instructed to up the level of the shocks. The guy behind the window began to protest a bit. The authority figure instructed the ordinary decent folk to heighten the level of the shocks. They did it. The guy behind the window began to scream. They kept going until he slumped.

NOW, what the ordinary decent folk didn't know was that the guy they were 'shocking' was only letting on. He wasn't connected to anything. He was fine and dandy and unshocked. But they didn't know that. They thought they were rattling his fillings and scrambling his brain with electricity. And you know what? They kept doing it.

These weren't anti-Semites getting their big break from Nazis, using the opportunity offered by the Holocaust to express their latent hatred of Jews. They had no latent hatred of anybody, least of all the guy behind the glass. They were simply persuaded by the reassuring and coercive figure of authority in the room with them that they had to do their duty.

Only a tiny minority took their hands off the lever and said: "To hell with this, I'm not doing it."

When you add the Milgram factor to the white-coat hypertension factor to the collegiality factor, you get one hell of a pressure on potential whistle-blowers. But that's not the end of it. In the Neary case, when whistles started blowing, another factor came into play. A not unusual factor.

Neary called in a group of eminent medical figures who produced a positive report about his work. (Blame, anyone?) Put that report from eminent medical figures up against the worries of an individual nurse or matron and an individual nurse or matron can look very small and whiny.

We have a rake of anti-bullying and harassment legislation in this country. If you look crooked at someone, you can be sued. In fact, if you FAIL to look crooked at someone, you can still be sued - that counts as exclusion.

But that legislation fails totally when it comes to breaking the poisonous cycles of collegiality and authority at the front lines of life-and-death professions. Of which acute hospital care is just one.

Another is piloting passenger planes. One of the worst airplane accidents - the 1977 crash in Tenerife - was contributed to by an impatient pressured pilot who didn't listen to information coming from a crew member and whose authority and attitude prevented his colleague from persisting. Tenerife was not exceptional.

A bullied pilot is a pilot who will freeze at the controls or make a grievous error. It doesn't matter whether the bullying is by another individual or is pervasive throughout the airline: it endangers passengers.

The Medical Council, IMO, IALPA and all concerned with professions where individual decisions can mean life, death or mutilation to others, must ensure that training, selection and management do not perpetuate or permit the combination of coercive pressures which we know persuade ordinary decent folk into silent collusion with evil.