Recent revelations show that the present imbalance of power between doctor and patient, medicine and society, may jeopardise public safety, writes Marie O'Connor.
Ours is a model of care that allows hospital consultants to run their medical practices as independent fiefdoms, unfettered by public controls. "A rigid, hierarchical culture derived from a semi-militaristic and religious service background" was how the Commission on Nursing described it in 1998.
Consultants are outside the loop of management in public hospitals: their contract guarantees "clinical autonomy". But in a model of care that gives total power to consultants, how can lesser mortals retain a sense of responsibility to patients?
Like Hydra-headed monsters, the number of revealed Caesarean hysterectomies and symphysiotomies continues to grow.
How Dr Neary was able to satisfy his proclivity for Caesarean hysterectomy for over a 25 years, unrestrained by colleague, board, institute or council, is a puzzle.
More perplexing still are the hundreds of symphysiotomies performed in Irish hospitals at a time when Caesarean section had become the procedure of choice for obstructed labour. Due to its perceived excess mortality and morbidity, symphysiotomy fell into disfavour during the last century in industrialised countries. The surgery facilitates vaginal delivery permanently, sawing through the junction of the pubic bones, and making repeat Caesareans redundant.
Irishwomen have publicly described how the operation, allegedly done for Catholic doctrinal reasons, left them unable to walk, incontinent, and in pain. How can a system apparently based on the personal belief systems of individual consultants ensure public safety?
To protect the patient, we must first understand how such events could have happened and the wider context of medical and obstetric culture, overlaid with patriarchal and religious values, and nurtured by State inertia.
The gaze of western medicine owes much to the way in which it constructed its knowledge, which derived from the dissection of dead bodies. Patients today are still required to sign forms "consenting" to unspecified medical procedures. Medical Council guidelines assume patient agreement, advocating the dubious notion of "tacit" consent.
"Active management", an obstetric regimen, also assumes patient consent, avoiding the build-up of bottlenecks in overcrowded wards by accelerating labour with, among other things, amnio-hooks. Its key ingredient, oxytocin, has been associated with brain damage and death in mothers and babies.
A product of the authoritarianism and chauvinism that characterised Catholic thinking in the '50s, active management was developed at the National Maternity Hospital. Half of all Holles Street's first-time mothers have their labours accelerated in this way.
Against this background of patriarchal control over women's bodies in childbirth, the removal or alteration of female body parts without consent becomes fractionally easier to comprehend.
We have been encouraged to view Dr Neary as one bad apple in an otherwise healthy barrel. But the barrel itself may be unsound, as initial exonerations, advices to undergo "further training" and secret four-year inquiries now suggest.
National or local systems of surveillance in health hardly exist. Only the most meagre hospital statistics are in the public domain. National inquiries into maternal deaths, stillbirths and deaths in infancy, routine in Britain, are unknown. Sweden has a national register logging all Caesarean, vacuum and forceps deliveries. Not Ireland. Dutch acute and general hospitals, including maternity units, are inspected. Not ours.
Had the Lourdes Hospital not ceased to publish its statistical bulletin in the late 1980s, Alison Gough and others might have been left with their bodies intact. There is no legal requirement to publish annual clinical reports: out of 22 maternity units, only three do so.
Hospitals, regulatory and other health bodies, such as the Medical Council, are generally closed systems, impervious to the public gaze. All is secrecy, and secrecy is all.
Compelling hospitals, and clinicians, to publish statistics on all procedures and their outcomes would transform hospital care, enabling comparisons to be made between hospitals and between doctors.
Public safety demands a role for service users in health: the "consumer panels" advocated by the medical profession are toothless. Following the Shipman and Bristol scandals, publicly selected service users in Britain were given parity with health professionals, opening up regulatory and other quangos. We should abandon the outmoded concept of "representatives of the public interest" and do likewise, emulating Sweden, where health has long been under public control.
Corporations such as the Royal College of Physicians in Ireland, a key player in hospital care, should be brought into the Freedom of Information net; the Act should be amended to include private hospitals; publicly funded voluntary hospitals should be accountable to the Ombudsman's Office.
That such a rigid, hierarchical culture could have led to such wholesale abuse is now evident.
Only a hermetically sealed, profoundly patriarchal and violently authoritarian system could permit such horrors. The era of laissez-faire medicine must now be ended. A public inquiry into Drogheda Hospital would be a beginning, and only that.
Marie O'Connor is a sociologist and health correspondent