Tuesday, 10 June 1947
Dáil Éireann Debate
(a) the statement of the name of such thing or of any brand, trade description or designation by reference to which such thing is sold, where such statement may reasonably be regarded as a recommendation of such thing to the public,
Somewhere or other the Bill excludes the power of administering surgical treatment to a patient except with his consent; but the definition of surgical treatment here would imply that it would be possible under the subsequent part of the Bill to administer a hypodermic injection, inoculation or some process of immunisation to a person or to take specimens of blood or other specimens for examination even though the person objected. I submit, therefore, that some further modification of the description “surgical treatment” is intended, because I take it that it is not intended by the Minister to take powers to take specimens of blood or other specimens from persons without their consent or to inoculate or immunise them. Under this definition of surgical treatment the Minister would have general power to treat persons against their will in the way implied.
Dr. Ryan: I expect that we will have a very full discussion on amendment No. 31 in which I am asking the Dáil to delete this reference to surgical operations altogether. I think it could be more usefully debated on that  amendment, because I should like to try to convince the Dáil that it would be better to leave out this matter of surgical operation altogether and to depend on the law as it stands.
In sub-section (1), line 3, page 7, to delete the word “accordingly” and substitute the words “as meaning infested to a degree which in the opinion of a registered practitioner is dangerous or injurious”.
The paragraph reads very widely at present. It says “the word ‘vermin’ means any insect, being bugs, fleas, lice or itch mites, and includes the eggs, larvae and pupae of such insects and the word ‘verminous’ shall be construed accordingly”. My amendment seeks to define more exactly the word “verminous”. There are certain powers given to the Minister in verminous cases later on in the Bill, and I suggest that these powers would be a bit too wide except “verminous” is defined in this way.
Dr. Ryan: I do not know what anxiety the Deputy can feel about this. First of all, we must remember that under this Bill an adult person  cannot be examined for vermin. He can only be examined for infectious disease. Therefore, the adult person does not come into it; he is not concerned as to what the definition of “verminous” may be. It only refers to people, let us say, who may be brought in with typhus fever, in regard to which vermin is a very important consideration. We must remember, if we try to get rid of vermin in school-children, that they may be comparatively clean to-day but they may be very bad in three or four days' time. These vermin are so prolific and multiply so quickly that if the medical inspector sees any sign of vermin at all he should be enabled to deal with the position so that they would not be permitted to develop and multiply, as they will if they get a free rein. I think it is better left as it is.
“the expression ‘institution’ means a hospital, sanatorium, maternity home, convalescent home, preventorium, laboratory, clinic, health centre, first-aid station, dispensary or any similar institution.”
I wonder whether the Minister intends. this to mean institutions that are State-aided and whether he would accept an amendment making that clear? I am not clear whether there are some parts of this Bill which, if this definition of institution is left as it is, would give the Minister power to have control over or interfere with institutions that are not in any way maintained with the assistance of State grants or grants from the rates. I would like to know whether institutions as covered in the definition are intended to mean institutions which are State-aided or rate-aided only.
Dr. Ryan: In this Bill we are dealing principally with the transfer of institutions from the public assistance authority to the health authority and from the sanitary authority to the  health authority and we are dealing with the provision of institutions by the health authority where they are not already provided, or the closing of institutions. The only instance where it could refer to an institution such as mentioned by the Deputy is where we say infectious diseases must not be treated along with certain cases. That is the only instance where we would interfere with, as it were, an independent institution.
Dr. O'Higgins: Where he takes those powers it is not clearly specified that it is limited to infectious diseases; in other words, there are powers in the body of this Bill under which the Minister can direct that certain types of cases will or will not be treated in certain institutions. I think it would be going beyond the Minister's intention if he were to exercise those powers with regard to a purely private hospital, and yet the definition as it stands would certainly leave those powers with the Minister in regard to any private hospital.
Dr. Ryan: I think the Deputy is somewhat mistaken in this matter. The original Public Health Bill did give full power to the Minister to specify any particular case going into any particular institution, but now we have brought it down to infectious diseases only.
Dr. Ryan: I think there are some provisions in this Bill that will take some time to implement. For instance,  it may take a long time before we can have the buildings, the equipment and the personnel to operate certain sections, whereas, on the other hand, we may be able to start straight away in some places. Take the mother-and-child welfare scheme. It may be possible to commence that scheme in the City of Dublin practically straight away, but it may not be possible to operate it in parts of the country for some time. The same will apply to other provisions.
Dr. O'Higgins: In the Schedule the Minister is repealing the Vaccination Acts. I think it is due to the Dáil that we should have a case made for that— if there is a case to be made for it. I believe very firmly in this Bill. I think there is an immense amount of good in it and, when it is fully implemented, when the funds are behind it and the machinery established, it will be, on the whole, very beneficial to the health of the people. Holding those views very firmly, nevertheless I feel that whatever good is in the Bill from a health point of view it is more than outweighed and undone by the repeal of the Vaccination Acts at the present moment. I could understand the Vaccination Acts being repealed by any Minister speaking on behalf of any Department who will come into the Dáil and say: “We do not believe in vaccination.”
Dr. O'Higgins: Of course, we are in committee and I do not think it would be in accordance with procedure and precedent to postpone a discussion on a matter which arises on a section of the Bill because certain Deputies, or a number of them, happen to be absent from the House. I am merely stating my view at this point; when we have got the views of other Deputies, then those views could be considered. As I was saying, I could understand the Minister, advised by the Department, coming in with a Health Bill and saying: “I do not approve of vaccination; it is not useful or beneficial” or “it is dangerous”, but in this Bill, or in the White Paper accompanying it, no such suggestion or no such assertion is made.
What is stated in the Bill is that we are repealing the Vaccination Acts, but the Minister's intention and the views of his Department are contained in the White Paper which says: “We are not giving up the power to insist compulsorily on vaccination; we will exercise such powers in the face of an outbreak, in the face of danger.” That is neither fish, flesh nor good red herring. That is faulty and dangerous to the extent of irresponsible recklessness. The Minister knows very well and does not dispute in his White Paper that vaccination is beneficial, is a safeguard against smallpox, but he repeals the Act and he says: “If there is danger, if smallpox reaches our shores, then we shall vaccinate in face of the danger.” That is tommy-rot. That cannot be done.
If you had an army of medical men you cannot do that. With the speed of modern transport, your vaccination is behind the enemy lines all the time and the spear-head of the outbreak is ahead of you. If you believe in vaccination  as you suggest in the White Paper, this repeal of the Acts is unsound and unsafe. One of the most important works ever written on smallpox for the benefit of the medical and the nursing profession was written about 1903 by a doctor named Wank. What prompted him to produce that particularly valuable book, which is still a standard work, was that in a club he heard in conversation that Great Britain, with the increased speed of steam vessels, had come within 12 days of Manchuria. He thought over this and he thought of the incubation period of smallpox which is roughly about 12 days. It struck him that it would be possible for a person to develop smallpox in Manchuria and to arrive in Great Britain by ship without ever showing a symptom of smallpox, without being ill, without being seedy. Two or three days after his arrival he might throw out symptoms which would permit of the disease being diagnosed but meanwhile he would have infected a number of other people. Because of that danger, due to Britain being within 12 days of the Far East, Wank sat down and wrote this most valuable book. It was circulated to the whole medical and nursing profession free so that every one of them would be on their toes, trained, in the methods of promptly diagnosing smallpox when they came up against it. That was because they were within 12 days of the Far East.
Last year or the year before we proceeded by way of heavy expenditure to make this island an air link between the eastern and the western world, to bring the Far East within 70 or 72 hours of our shores, to bring as far as we could, all the human traffic between the Far East and the western hemisphere through our territory here. So far, we appear to be highly successful in our efforts to do that, to bring travellers from the East here, allow them spend a day here, and then take off for the West. It is simply unthinkable that at the particular time we are doing that and when we hope to develop it further, any Minister for Health would come in and say: “This is the moment I select to remove from the people of this country the safeguard of vaccination.”
 I want to say to the Minister that as far as I could secure authoritative medical opinion on this—I do not put myself forward as anything in the nature of an authority—I have sought the opinions of as many people as possible who have had experience and who claim to be authorities on this question. The Minister has his own organisation. He and his predecessors have been at great expense to establish a public health service in Ireland whose whole function is to safeguard public health. He has an elaborate State organisation who specialise in public health matters, in preventive medicine, and unanimously they are against the repeal of the Vaccination Acts as being unfair to the people and dangerous to health. I want to know has the Minister any volume of medical opinion behind the course he proposes to take, either inside his Department or outside it. We know very well that smallpox is a disease that was very prevalent in these islands—both here and in Britain. We know that when most of us were children many of the old people we saw were pock-marked. We also know that whereas there is very little risk in vaccinating an infant, neither vaccination nor inoculation should be lightly taken when you are dealing with adults. If you had to choose between either inoculating or vaccinating a person, obviously, if you are thinking of health, you choose the period of greatest safety and you select the period of minimum danger. If you select the period of greatest safety, you will select the earliest possible age.
If you want to select the period of greatest danger you will select adult life for either one or the other. That is very well known, and yet we say that we will repeal the Vaccination Acts, but will vaccinate in the event of danger. In the event of a passenger who has been in contact with a case of smallpox either prior to departure or en route, landing at Rineanna and proceeding to Dublin, remember his fellow-passengers will be in Chicago before the disease can be diagnosed in their case. Some of the passengers may land in Rineanna, stay in an hotel in Limerick for a day or two and then come on to Dublin, perhaps stay in a Dublin hotel and later go on to the  Curragh races or Punchestown. Where are you going to vaccinate ahead of the infection in that case? Is it not common sense that it cannot be done? If the Minister believes in vaccination as a safeguard, then the time to safeguard our people is before the germ enters our midst and not after.
I could understand a Minister coming in and saying: “I am advised that vaccination is not safe, that it is not a protection and, therefore, I repeal the Vaccination Acts.” There would be an issue there, an issue that could be understood and thrashed out. I cannot understand the line taken in this Bill, in association with the White Paper, that vaccination is beneficial and, recognising the fact that vaccination has eradicated smallpox—I think I am quoting the White Paper— therefore, we repeal the Vaccination Acts but, in the event of danger, we still have powers to vaccinate people. That is absurd. There is no ground to stand on in such a contention. It is a sham from the very beginning. The conception of such a quibble is offensive to the mind of anybody taking public health as a serious question that must be seriously considered. It is neither one thing nor the other. If you want to run away from the Vaccination Acts, repeal the Vaccination Acts and do not have any of this sham about vaccination in the event of outbreak or danger.
These are my views. I would be interested to hear the Minister's. (1) Does he believe in vaccination as a safeguard? (2) If he believes in vaccination as a safeguard, does he think that it is possible to vaccinate when the disease has entered by air or by port or to do it successfully? (3) Does he think it is sound health policy that people should be vaccinated in adult life in preference to being vaccinated in early life? Does not he know the big dangers associated with such a course and is he going deliberately to lay the population open to those dangers any time word comes in the future of smallpox contacts or cases having entered this particular country by air or by sea?
Dr. Lynch: I have had considerable  experience of vaccination as practised for a great number of years under the dispensary system and I am sorry to say that I have to disagree with Deputy Dr. O'Higgins. I feel that vaccination in childhood, unless there is absolute necessity for such a procedure, does carry a certain amount of danger with it just the same as it would in adult life.
Dr. Lynch: Unfortunately, I have seen in dispensary practice quite a number of mortalities amongst babies and I have vaccinated quite a number of adults, and I think the Deputy will agree with me that cases of encephalitis are very, very rare. Is not that so?
Dr. Lynch: Again, is not it generally believed that the protection conferred by vaccination is only effective for a period of seven years after vaccination is carried out, as has been the practice up to this, in infancy? The immunity conferred is supposed to last only about seven years. Consequently, if an outbreak of smallpox occurred at the present moment the entire population would require to be vaccinated. I think that is the correct medical teaching. Why inflict on unfortunate babies this painful procedure and the danger of septic arms and other complications if after seven years you have to do the job again? In my experience, it would be far better to allow vaccination to go by the board and, when there is danger of an epidemic, if mass vaccination were carried out it would serve the purpose equally as well as general vaccination up to 12 months of age. That is what I think about the matter.
Dr. Ryan: I am trying to learn some medicine, but it is very hard to know. As regards the Bill, the intention was to put all these immunisation and vaccination processes under one clause. That is laid down, perhaps, better in Clause 20 than any other. I do not think that it is fair that Deputy Dr. O'Higgins should describe the whole thing as a sham. After all, we are doing what we think is right and to say that we are only shamming is, of course, to give the impression to the members of the House that we are simply putting down things that we think will deceive somebody or other —which is not our intention.
Under this clause we ask the Dáil to give us power to prescribe immunisation or vaccination against any infectious disease and we are putting into this clause that if the person, if he is an adult, or a guardian objects on conscientious grounds, we do not do it. I do not know whether Deputy Dr. O'Higgins will argue against that or not. If he does, it will be very much out of keeping with the speech he made here on the Second Reading of the Bill. The big objection, as far as I know, and I come from a county where vaccination was opposed more than in any other county, was that when the British Parliament passed the Vaccination Acts they gave a conscientious objection  clause to Great Britain and did not give it to Ireland.
Dr. Ryan: If we rescind the vaccination laws as they are and put it in under this clause we can re-enforce vaccination with a conscientious objection clause attached. I do not know what the medical opinion may be. I may say that the volume of medical opinion that I have got since this Bill was introduced would be in agreement with Deputy Dr. O'Higgins, that we ought not at this stage drop vaccination. If I am advised in that way by the Medical Consultative Council, say, well it would be my intention to enforce vaccination again but with this conscientious clause which is there for vaccination or immunisation in general. I do not like to enter into the controversy with regard to the effectiveness or to the danger of vaccination to adults or children.
When I was studying medicine I remember it was felt for a long time that some of the infectious diseases should be given to children when they were young. The theory in my time was that that was all wrong, that first of all if you keep children away they might not get it at all but that if they do, it is not likely to be as hard on them as adults as it would be as children. That may not be an exact parallel. It may be different with vaccination or immunisation. Take the example of the person mentioned by Deputy Dr. O'Higgins who comes to this country by plane, stays in an hotel in Dublin, then goes on to Limerick and from thence to Chicago and who had smallpox. I am afraid we would have to do the very same thing in existing circumstances if there were no vaccination, to try to look up every contact we could and have them vaccinated. Deputy Dr. O'Higgins says unless it is done within four days, it is not very much use. That has to be kept in mind. The clause with regard to infectious diseases lays down that the Minister can prescribe vaccination or immunisation against any infectious disease. The adult person or the guardian of the child may raise an objection and if so, his objection must  be respected but that is where we do the thing generally. If there is an outbreak then the Minister may overrule the objection and say that everybody in a particular area must be immunised or vaccinated as the case may be. That system appears to me to be fair all round. In conclusion, I would like to say that I have an open mind on this question and that if I find medical opinion is, as Deputy Dr. O'Higgins points out, in favour of vaccination, I shall certainly have vaccination restored.
Dr. O'Higgins: I do not want to press my views unduly on the Minister in this particular matter, but I do feel that we are not at the moment acting with a proper sense of responsibility. If I used the word “sham” I did not mean it in any offensive manner. It was just a word that came to my lips to describe the hollowness of the safeguard, or what we are putting up as a safeguard in substitution for the protection which we are removing from our people. The Minister may want to score debating points——
Dr. O'Higgins: I admit that my general outlook is against any form of compulsion in association with the practice of medicine. That is my general outlook. I am very much opposed to medicine being carried on under the threat of compulsion or under the threat of penalties. On the Second Reading of this Bill I made one exception when I said that there were exceptions to cases such as the ambulatory tribes and that I would allow compulsion, etc., and see a case in it in face of that particular difficulty. Now we are dealing with a process of law that has been highly successful in eliminating smallpox from these islands and we say that because it has been successful we will dispense with it and we say that we will dispense with it at the very time when we are aiming at bringing this country in point of time very many days nearer than it was before to the Far East which is, as we know, the danger point with regard to vaccination. What Deputy Dr. Lynch says, and which was repeated by the  Minister, is true up to a point, but only up to a point, that is, that the protection conferred by vaccination holds for a period of seven years. That is probably true. It holds only for seven years as an absolute protection but it has protective qualities for the whole of life.
For instance, if a person vaccinated in infancy gets smallpox at the age of 50 it will be extremely unlikely that that person will die of smallpox. It will be extremely likely that that person will get the very mildest attack of smallpox. All figures, all statistics, demonstrate that. Consequently, if we vaccinate in infancy, the necessity for vaccinating everybody ahead of the point of invasion has not the same degree of urgency as if we left them absolutely unprotected from infancy onwards. There may be fatalities in connection with vaccination. Deputy Dr. Lynch seems to have come across a great many cases. My opinion is that every fatality that ever occurred in connection with smallpox vaccination was very generally propaganded throughout this country and through-cut Great Britain and throughout Western Europe. I have come across most of that propaganda and I have not read of these fatalities that Deputy Dr. Lynch speaks about. Be that as it may, there are fatalities following any form of medical treatment. There are fatalities following every form of immunisation and inoculation. There are fatalities following every form of operation. Are we to give up operative surgery, inoculation, immunisation, every form of medical treatment, because there is an occasional fatality? The point is this. Vaccination in infancy confers a very high degree of protection for the whole of life and at least ensures that if the case gets smallpox it will not be a fatal attack. That is the immunity of protection our people have at the moment if the law as it stands at the moment is respected. We are going to remove that. We are going to adopt a policy where in the face of danger we will vaccinate.
Now every authority—I am not talking of most people in this country as being an authority—but every authority that has soldiered through an outbreak of smallpox lays this down: that, after  contact with smallpox, you will give them practically complete immunity if you vaccinate the first day. After contact you will give 90 per cent. immunity if you vaccinate the second day. If you vaccinate the third day you will only get 30 per cent. immunity. The other 70 per cent. of the cases will get the smallpox, so that to vaccinate after the fourth day is worthless.
If there is anything to be learned from the authorities and from the field workers, and assuming that what we have learned is correct, let us apply it to the case where a person disembarks at Rineanna after having travelled from the Far East. That person goes to the Gresham or to the Shelbourne and then to the Curragh races and then proceeds to the other side. The person arrives sick on the other side with a rash appearing generally on the third or fourth day. That case has been moving about this country. We get back word that it is a case of smallpox. How many adults, children or infants —of the contacts—does the Minister think can be vaccinated within four days of the original contact? It cannot be done and you might as well keep your vaccinators at home. You may protect them against a subsequent smallpox visitor landing here but not against that particular visitor.
I do not agree for a moment that it is equally dangerous to vaccinate or inoculate in infancy or early childhood as it is in adult life. I do not think that anybody will seriously put forward that contention, because even the layman can say this much, that the danger of any vaccination or immunisation is the danger of getting some cross-infection, of some other kind of disease supervening on the disease that you are giving the case by your vaccination or inoculation. Now, what is the infant range of travel? From the kitchen to the bedroom. What is the range of travel of any one of us? From here to Cork or to Donegal or wherever the whim directs us. The danger of the infant getting a cross-infection, encephalitis or any other infection is the odds of that infection being between the kitchen and the bedroom. How does that compare with the odds of meeting with infection between this  and Cork? It is common sense that you multiply the danger as the range of movement becomes greater.
With regard to immunisation, what is the literature that is emanating from the Minister's Department? To get it done at the very earliest point of life, not even to wait for school age but to get it done pre-school. That is correct, and it has learned opinion behind it. That is the outlook and policy of the Minister's Department and cannot be altered. We are dealing with something with which politics have been associated in the past. The Minister knows as well as I do how the conscientious objector clause came to be inserted in application to England and not to Ireland. It was never clearly understood here. There was a class— a religion—in England of conscientious objectors, of people who objected to blood-letting in any shape or form. They objected to military service. They objected religiously to blood-letting for any purpose whatsoever, even to save their King and country.
The term used —“conscientious objector”—was a very unfortunate one because over here we said that if a person had a conscientious objection to vaccination over there and was exempt, why should he not be exempt over here? Propaganda grew out of that. The birthplace of it was Wexford but the cradle was Portlaoighise. Both the Minister and myself were equally immersed in that atmosphere. Are we to say in 1947, with aeroplanes roaring overhead every hour of the day and night, that we are going to repeal Vaccination Acts in this country and insert the conscientious objector's clause? The people who would have a conscientious objection are probably wearing Easter Week medals on their chests. Have they a conscientious objection to blood-letting and can they be put on a par with the English conscientious objector?
I put it to the Minister, who is now the head of a very important Department of State, that there is a very great responsibility on his shoulders. That responsibility is peculiarly great by reason of the fact that he is himself a medical man. If he repeals the Vaccination Acts now, and does so lightly or because of unsound advice,  what will be the position if this country is ravaged by smallpox within the next ten, 15 or 20 years? There would be a certain degree of protection for a span of time, but that will be wearing off. There is even transmitted protection at the moment from the vaccinated parent to the unvaccinated child, but that will disappear little by little.
The Minister's contention is there has been a change in medical outlook, that when he was a student or a young doctor, people believed in early infection for children, but that now the policy is to keep the giving of the disease as far back as possible, or as late in life as possible. Of course, that is perfectly sound, and with the study of infectious diseases and epidemiology, it is perfectly rational. Why do we estimate that they will get milder attacks if they get it later in life? Why do we estimate that when people come in contact in picture houses, in buses and in crowds and get certain mild degrees of doses all through life, they are, in fact, as one year follows another, acquiring a degree of immunity, so that when they get the disease later in life, they have a high source of protection? That is the argument for early vaccination rather than, as the Minister applies it, an argument for later vaccination.
“An institution which is at the commencement of this section maintained by a health authority whether under any enactment repealed by this Act or otherwise shall be deemed to have been provided under this section by that authority.”
I wonder if the Minister's amendment includes the meaning that is included in the original sub-section. If the present amendment is inserted, it may exclude the interpretation of the original sub-section (4).
Dr. Ryan: I move amendment No. 7:—
In sub-section (1), page 10, line 2, to delete the word “a” where it first occurs and substitute therefor the words “an urban”.
This is a drafting amendment.
Amendment agreed to.
Section 14, as amended, agreed to.
Dr. Ryan: I move amendment No. 8:—
Before Section 15, to insert the following section:—
 (1) The Minister may by order transfer the control and management of the hospital to the corporation.
(2) An Order under this section shall contain such provisions as the Minister thinks necessary or expedient for enabling the hospital to be taken over and maintained by the corporation and may in particular make provision for any of the following things:—
(a) the dissolution of the board of governors of the hospital,
(b) the transfer of property whether real or personal (including choses-in-action),
(c) the transfer of debts and liabilities,
(d) the transfer of officers and servants.
(3) If the hospital is transferred by order under this section, it shall be deemed to have been provided under Section 10 of this Act by the corporation.
(4) In this section—
the expression “the corporation” means the Right Honourable the Lord Mayor, Aldermen and Burgesses of Dublin;
the expression “the hospital” means the Hospital of Saint Margaret of Cortona, formerly known as the West-moreland Lock Hospital.
This institution, which is commonly known as the Lock Hospital, was renamed the Hospital of St. Margaret of Cortona. The history of this hospital is very vague and, as far as we can find out, it was never incorporated. The members of the board are, therefore, in a very dangerous position if anything should happen, as it would appear that they would be liable personally for anything that might happen in the hospital. In any case, it was intended for a long time that the hospital should be transferred to the Dublin Corporation, so that they could look after it and have it as an institution for their venereal diseases scheme, and this clause is put in to transfer it to the corporation.
Mr. M. O'Sullivan: The Dublin Corporation  is exceedingly anxious that Dublin City Deputies particularly should oppose the adoption of this particular amendment, on the ground that the building is an exceedingly old one and that its location makes it unsuitable for these particular requirements. The objection by the corporation is not simply because of any extra cost that may result in the change-over, but because of the well-defined decision taken by the corporation that it is utterly incapable of improvement in its present position. The alternative they suggest at present is that the hospital should remain as it is pending the establishment of a new hospital and that, in the meantime, greater facilities might be sought for the treatment of this particular disease in the general hospitals. Deputies from the corporation who inspected the hospital were unanimous in their decision that it is utterly incapable of improvement. I need hardly emphasise the implication of its unsuitability when I mention its particular location.
Dr. Ryan: I would like to point out to Deputy O'Sullivan that there will not be any additional cost on the corporation as a result of this clause being put in, as 75 per cent. of the cost of the venereal diseases scheme under the corporation is met by State grants. That will continue and the cost to the corporation, therefore, will be 25 per cent. and, other things being equal, should not be any higher as a result of this transfer. Neither will the State gain anything by the transfer, as the State will still have to pay 75 per cent. of the cost.
Mr. M. O'Sullivan: One of the viewpoints taken by the corporation is that, by the adoption of responsibility at this stage, they may delay the decision of the Minister on a new hospital. Maybe the Minister would indicate that it is his purpose to proceed with a new hospital.
Dr. Ryan: No, it certainly will not have that effect. I am very anxious that a new hospital will be provided and that will be done as soon as possible.
Mr. Cosgrave: Is it proposed to continue the grant of £2,000 a year?
Dr. Ryan: No. It is £2,600 now. The State will continue to contribute the 75 per cent.—whatever it may be.
Mr. Cosgrave: Is that 75 per cent. of the £2,000?
Dr. Ryan: No, 75 per cent. of the cost.
Amendment agreed to.
Question proposed: “That Section 15, as amended, stand part of the Bill.”
Dr. O'Higgins: Sub-section (1) lays down that the health authority may collect a reasonable charge for the maintenance of patients in any institution. I take it that that includes a fever hospital?
Dr. Ryan: Yes.
Dr. O'Higgins: Sub-section (7) of Section 37 lays it down that, where any case is sent to a fever hospital as a result of an order made by the health authority, no charge can be made. What does that mean? It means that if a farmer's child gets diphtheria and he accepts the medical man's advice and sends the child to a fever hospital, he will be charged two or three guineas per week for its maintenance. His neighbour whose child also had diphtheria reads this Bill, makes difficulties and says: “I will not let my child go to a fever hospital.” The health authority then makes an order and the neighbour who is a difficult citizen gets his child treated free, while the parent who is co-operative and accepts the advice of the medical authority has to pay. I think it is something which requires to be looked into between now and the subsequent stages of the Bill, because what will happen, in my opinion, is that everybody will get clever after a while and it will be necessary to make an order in every case of infectious disease and everybody will be treated free, be he prince or pauper. I am not pressing anything at the moment, but I think it requires looking into.
Dr. Ryan: Perhaps so. The policy we are aiming at is a policy of providing free institutional treatment for all infectious diseases, for children and for  those classes dealt with under the Public Assistance Act at the moment. The public health authority will have a discretionary right to make a charge on any person outside these classes. We come later on to certain amendments dealing with charges under the infectious disease regulations relating to ships and the intention is that these charges should remain when we get this Bill implemented.
Dr. O'Higgins: The Minister can see my difficulty. If they all force us to make orders, it means a lot of work and they will get free treatment—and people will get clever.
General Mulcahy: Is it the intention to charge for the treatment of fever cases in institutions?
Dr. Ryan: No. The policy is to have all infectious disease cases treated free in institutions, as well as children and the classes at present treated free under the Public Assistance Acts.
Dr. O'Higgins: That meets the point.
Question put and agreed to.
Sections 16 and 17 agreed to.
Dr. Ryan: I move amendment No. 9:—
Before Section 18, but in Part II, to insert the following section:—
(1) Whenever a health authority is satisfied that useful service is being or will be rendered to persons requiring institutional services by the provision of such services in an institution in the functional area of such health authority, such health authority may, on the request of the governing body of such institution and with the consent of the Minister, provide for such institution any land which is shown by such governing body, to the satisfaction of the said health authority, to be required for the efficient performance of the funetions of such institution or for the purpose of enlarging or extending it.
(2) Where a health authority determines to provide under this section any land for an institution, such  health authority may acquire such land either by agreement with the consent of the Minister or compulsorily under Part VIII of this Act and (in either case) may convey such land to or for the benefit of such institution.
(3) Where a health authority is requested by the governing body of an institution to provide under this section any land for such institution, such health authority shall, as a condition precedent to their so providing such land, require such governing body to undertake to defray the whole of the cost of so providing such land.
This is a new section which enables a health authority compulsorily to acquire land for an institution such as a voluntary hospital, an institution not run or owned by itself. There was a similar power in Section 22 of the Public Assistance Act, 1939, but it was limited to the acquisition of land for institutions providing accommodation for public assistance patients. There are certain hospitals which provide such services, but it would not be applicable to all voluntary hospitals and, in particular, to certain tuberculosis institutions, and these are the institutions we have particularly in mind in this connection.
Amendment agreed to.
Dr. Ryan: I move amendment No. 10:—
Before Section 18, but in Part III, to insert the following section:—
A health authority shall, in accordance with regulations made under Section 24 of this Act, make arrangements for safeguarding the health of women in respect of motherhood and for their education in that respect.
The section at the moment refers to expectant mothers and nursing mothers. It was thought that that might be a rather difficult phrase to interpret in certain circumstances and the phrase has been altered to refer to women in respect of motherhood. It is very hard to define the term “expectant”—how long or in what circumstances a woman  might be expectant—but we do know when she is a mother.
General Mulcahy: I think it would be safer for the Minister to speak with regard to the intentions of the original section. If this is put as an amendment, I take it that the discussion on the matter stops and the discussion on Section 18 has not begun yet, because the Minister ought to tell us what is contemplated under Section 18.
Dr. Ryan: This will necessitate the deletion of Section 18 in the Bill. We consider that this is a better definition. I take it the Deputy wants to have a discussion on the whole matter of mother and child welfare.
General Mulcahy: Yes. I submit that that is what the Minister is putting before the House when he asks us to accept Section 18, whether in the form in the Bill or in his amendment. This is the only occasion on which, I understand, the matter will be under discussion, and I suggest that the Minister ought to tell us on the amendment what he would tell us if we asked him to explain what his proposals were under Section 18 as a matter of general policy and what steps he proposes to take to implement the ideas in Section 18 or in his redraft of Section 18.
Dr. Ryan: I thought we dealt fairly fully with the whole question of mother and child welfare on Second Reading. We may take it that the Dáil is not concerned so much with the amended section as with the section itself.
General Mulcahy: The Minister's general proposals in the matter.
Dr. Ryan: The proposal is that, as soon as we have the opportunity—and the opportunity will depend more on personnel than anything else—as well as on improving our institutions, our dispensary buildings and making them more suitable for the reception of women who expect to become mothers, mothers and young children—they should be looked after by the district medical officer. As I pointed out on Second Reading, if we want to improve the health of the population generally, we should commence with the pregnant  woman, look after her during her pregnancy and see that she is in good health and capable of producing a healthy baby, and, the baby being born, we should, so far as lies in our power, see that the baby is kept in good health, is guarded against infectious disease and every other disease and is reared in a healthy way. That is the general principle we have in mind.
Coming down to the working of the scheme, it is likely that very many more dispensary doctors—district medical officers under the new scheme—will be required in some of the bigger dispensaries, because it may be impossible for the dispensary doctor to do this work as well as the work he is doing at the moment, though, in areas of smaller population, the dispensary doctor may very well be able to do this work as well. He will have the care of these mothers and of the children before they commence going to school. Afterwards, he will have the duty of school inspection and treatment of children generally until they reach the age of 16, as laid down in the Bill. I hope in time we may be able to provide for the specialists necessary, such as dentists and people who look after the eyes and ears, etc., to whom the district medical officer can refer these children if they want such treatment.
When I say that it is intended to have this work carried out by the dispensary doctor as district medical officer, there will be an exception in the case of the City of Dublin. In the City of Dublin, the three lying-in hospitals are prepared to undertake the mother-and-child service until the child is one year old and then it will pass over to the district medical service, the same as everywhere else. That is probably a novel idea which has not been tried elsewhere. But we are fortunate in this country to have such reputable people concerned with our maternity hospitals and I think it is well worth giving this system a trial in the City of Dublin at any rate.
Dr. O'Higgins: So far as I learned from the general body of the profession these three sections, 18, 19 and 20, are the operative sections of the Bill and  they are the portions of the Bill about which there are most doubts and fears. There are a great many points of view and I think every point of view has to be very carefully considered in a matter of such importance as this. I do not think anybody would disagree with the aims of these three sections, namely, to provide an efficient service for expectant mothers, infants, and children up to a certain age. But where opinions apparently clash is as to how it is to be done, the machinery that is to be used.
When the Minister talks about the district medical officer doing it, he is not talking of a dispensary doctor here and another there. He is talking of every dispensary doctor, and that is where doubts must arise. You have many types of dispensary doctors. You have them of all ages from 80 down to very young men. You will have octogenarians carrying out this particular work in these new clinics when they are built and down the whole age range. That is, as far as age goes. As far as time goes, you will have just as great a variation. The Minister knows well that no dispensary doctor can possibly hope to maintain himself and a family and educate that family on the salary, either past, present or future, of a dispensary doctor. All over rural Ireland doctors accept such positions in order to make the main end of their livelihood in practice, and the more successful a man is and the more efficient he is, the greater his practice, which grows with years up to a point.
There are dispensary doctors known to everyone of us who are working—not to exaggerate—15 hours a day between their present dispensary work and their practice. These are the most highly efficient and most successful practitioners. According to the Minister's statement, this service will be a responsibility placed on their backs just the same as in the case of a man in a dispensary district with a tiny population and with a very small practice who is merely there as a bird of passage until he is advanced into a somewhat better and busier district. So far as I have met dispensary doctors—and I do not claim to have met any more than others—they have very grave  doubts as to whether, when this Bill is fully functioning, the new duties under Sections 18, 19 and 20 can be carried out.
The Minister meets that objection to an extent by saying that there will be a great number more doctors required, which, of course, means that the size of the existing dispensary district in a great number of cases will have to be reduced, possibly halved. That is to be done by a law enacted by the votes of every one of us here, and not a single one of these, or anybody representing them, has been consulted as to what compensation will be given for the areas taken off them and for the new plantations. Surely that is not fair play. Every Deputy may not be as closely associated with medical men as some of us are. But surely there is not a single Deputy sitting anywhere in this House who would consider that that is fair or just treatment. If a cobbler had a practice by appointment or by contract through the machinery of the Local Appointments Commission in a small town or village and we were legislating without consulting that cobbler or anybody representing him to halve the number of his clients or his customers, would not every Deputy with a sense of justice be up in arms and say: “What compensation do you propose to give the cobbler? That is not fair play.” That is what we are doing with the dispensary men generally; that is what we propose to do in a happy-go-lucky style, without any consultation or discussion.
The Minister will say that that matter will arise in connection with the regulations and that we will deal with it afterwards when the regulations become effective. You will deal with the doctors when the regulations are being implemented and you will have the law to compel them to toe the line. Can you imagine any two bodies going before the Labour Court and the Dáil passing a law beforehand making it mandatory that one side has to accept what the other gives irrespective of the court? The precedent being established here in relation to the medical profession is one that is going to be disastrous.
On the other side of the water they  had a Bill which is a kind of forebear of this Bill; this Bill is rather a mild copy of theirs. How did they work it? A negotiating committee of the medical profession sitting daily with the Minister's representatives went into every clause, section or sub-section of the Bill that might in any way affect injuriously the members of the profession or overload them with work. All that was gone into fully between representatives of the profession to be affected and the Minister's representatives before the Bill came before Parliament. That is the precedent over there and that was carried out in full by two British Governments very dissimilar in make-up, by the Government under Mr. Churchill and by the Government under Premier Attlee. But that did not mean that the medical people got everything they wanted, or even half of what they wanted. At all events, their case was listened to and their objections were made and the Minister went before Parliament and said: “There is a negotiating committee there; we have been carrying on negotiations with them around every clause and section of this Bill; we know their views and we have studied them and considered them.”
Over there, remember, the practice is very dissimilar from here, but here we have a Bill which proposes to bisect the income of more than 50 per cent. of the dispensary men without any consultation with any of them. We will do it by law and we will negotiate with them afterwards when the law of the land lays it down what duty they must do, if they do not wish to become lawbreakers. That is as far as area goes.
As far as patients go, I ask every Deputy to consider what we are doing in these three sections without any discussion with the representatives of the profession. Even assuming what the Minister has already told us will not be so, that we are leaving them all their present areas, without curtailing their areas or the size of their districts— assuming we leave all that, what are we doing with their practice? Every woman, every infant, every child up to the age of 16 years will become a free patient.
Mr. Dillon: If they wish to.
Dr. O'Higgins: If they wish to.
An Ceann Comhairle resumed the Chair.
Dr. O'Higgins: There are very few philanthropists in the country who are going to press money on a doctor for his services when they are entitled to have those services free. However, he will be bound to give his services free. If he gets a present, that is another matter, but by law we will ensure that every woman, infant and child up to 16 years, for every ailment and every disability, gets free treatment. The Minister knows as well as I do how a doctor in rural Ireland makes his livelihood. It is not by the hardy men who will stagger along through an illness and only send for a doctor when on the point of death. That is not where he makes his livelihood, and he does not make it out of young, healthy adults either. It is out of the income gained by attending women and children. That is where 60 or 70 per cent. of the ordinary dispensary man's income comes from.
In the next five or ten minutes, if I sit down quickly enough, we will make that the law of the land and we will do it without discussing it with them, without hearing their views, without hearing what they think about it. Is that fair? Is it reasonable or rational? Was the like of it ever done on any body of men before? Was it ever done by any Parliament? The Minister and his officers sit in secret; they produce a design that is very attractive. In the main, they formulate a policy that is very sound, but before its application to the individuals vitally affected in the material sense, they do not discuss it with them. Doubtless, the Minister's answer is “We will”. We will, as soon as the dice is loaded; we will, as soon as the law is made; we will, as soon as the Minister is in a position to say: “There is the law of the land, approved by Parliament; those are the duties you must carry out, no matter if I do not give you a halfpenny.”
On those terms he will negotiate and I am appealing to the Minister's sense of fair play. I say that that is not reasonable; it  is not fair to a body of men who have contributed towards making the name of this country what it is, a body of men who, in face of periodic dangers, have worked on in the danger zone unselfishly, a body of men who rarely raised financial questions, a body of men who, in the main, do 50 per cent. of their work gratuitously. I do not think we are treating them fairly.
I am rising, without a mandate, to point out to every Deputy here exactly what we are proceeding to do, and I would like every Deputy, from the Minister downwards, to ask himself is that fair treatment to mete out to those men—to pass a law to have their area of practice curtailed, to reduce by two-thirds their number of patients and not even to discuss with them how they will be treated financially, what compensation they will get, or, in fact, whether they are willing or able to undertake the new duties that will be imposed on them by law.
An Ceann Comhairle: It seems to me the discussion now ranges over amendment No. 10 and Sections 19 and 20. Am I right in saying that these three sections dealing with attendance on women and children are being discussed?
Dr. O'Higgins: Yes, I mentioned the three of them.
General Mulcahy: Does that suggest that there will be a restricted discussion when we come to Sections 19 and 20?
An Ceann Comhairle: There might not be, but the discussion might not be too wide on the points already covered. I do not want to say that they are finished with.
General Mulcahy: There will be, I am sure, some detailed discussion on Sections 19 and 20.
An Ceann Comhairle: I am merely anxious to know what portions of the Bill the discussion covers.
Dr. Ryan: I may have misled the House by giving what I visualise to be the position of dispensary doctors doing this job. So far as the Bill is concerned, all we are doing here is  putting an obligation on the health authorities to give a free service in relation to mother and child welfare. We do not tell them how it is to be provided. I did assume that we would get agreement with the dispensary medical officers to do it. Agreement means negotiation of course. That is what I had in mind. I thought that to proceed properly, we should first put this obligation on the health authority to provide this service and then, when we come to make our regulation, we could negotiate with the dispensary doctors or whoever else may be brought into the scheme. In my own forecast of how the thing would work, I thought that we might get the dispensary medical officers to carry out the work, sometimes perhaps by taking away part of their present dispensary districts from them and sometimes, in a fair-sized town, by giving the dispensary doctor an assistant. All that, however, is subject to negotiation.
Dr. O'Higgins: That is a nice time to negotiate. When these sections are passed they become the law.
Dr. Ryan: They are.
Dr. O'Higgins: And all that remains then is to make the regulations.
Dr. Ryan: The health authority must provide the service.
Dr. O'Higgins: The health authority must and the machinery for implementing the Act is to be laid down in regulations. The White Paper makes the thing clear. The Minister's Second Reading speeches, opening and closing, make it clear that the machinery will be the dispensary doctor. The Minister did say that there may be extra doctors required. He said that there was a survey being carried out of dispensary areas and that we may require a lot more dispensary districts. If we accept the Minister's previous speech, it means that the area of practice of each doctor is going to be reduced—a very serious loss of income to the doctor. Be that as it may the Minister says the time for negotiation and the time for discussion is when the Bill is law. That is Departmental prompting. Of course, that is the ideal time from the point of  view of the Department but surely it is not the prompting of a human sense of fair play? Surely it is not the prompting of a Minister anxious to try to do the right thing by a very deserving profession? It is the ideal time for Departmental chiefs to meet unfortunate dispensary doctors and talk turkey to them. It is the ideal time, when they can get a few moves in the game in advance and have the law on their side.
The dispensary men are simple meat then, when they have no right to refuse to carry out the new duties. Will they call them in to negotiate now and say to any one of them: “I am going to halve your practice, I am going to take 60 per cent. of your patients away from you”? Will they meet them before the case is prejudiced, by the votes of the whole lot of us? If they met them that way, ahead of the Bill, then they would be negotiating on equal terms because the Dáil may accept it from me that there is no group, no members of the community who are so anxious for good health, for healthy mothers and healthy children, as the members of the medical profession. If the negotiations took place before the Bill were passed, then there would be equal negotiations, held in an atmosphere where it would be possible to have fair play, but there is no good in negotiations with the other fellow when he is looking along the sights of the rifle and you are looking down the muzzle. That is the kind of negotiation we are going to have after the Bill becomes law.
Dr. Ryan: What does this Bill make law?
Dr. O'Higgins: The Bill makes certain laws——
Dr. Ryan: What law?
Dr. O'Higgins: The Bill gives the Department power by regulation to impose certain duties on doctors.
Dr. Ryan: It does not.
General Mulcahy: We have to read Section 18 as redrafted in connection with Section 24. The Minister implies that this section simply gives him authority to do certain things when he  makes up his mind to do them. He has indicated earlier that the regulations or the machinery cannot be enforced in every part of the country at the same time but the Bill gives him power to order a health authority to put certain machinery into operation. Section 24 indicates that the Minister may make regulations “applicable to every health authority, every health authority of a particular class or to a particular health authority” and that the regulations may prescribe the manner in which the powers can be exercised and the extent to which the powers may be exercised. So that the Minister has power to discriminate as between the various authorities as to the extent to which the scheme will be put into operation at any particular moment or in any particular manner.
It would help us all if the Minister gave us some idea as to some geographical area in which he is going to approach the matter in the early days with a view to putting a scheme into operation. The Minister indicated that it might be possible to put it into operation in the City of Dublin at an early stage. The City of Dublin is a very special case and I think we would all be very interested to get from the Minister some idea as to the kind of machinery he was going to operate in the City of Dublin which would give full medical treatment to women and children in the way he has indicated here.
I think that from the point of view of the problem of which Deputy Dr. O'Higgins spoke, it would be desirable that we should have some idea as to the part of rural Ireland in which the Minister intended in the early days to put the scheme into operation. He said that he could order a health authority to put a scheme into operation. When a particular authority, say the authority in Westmeath, is ordered by the Minister to put a scheme into operation, is it the health authority that starts negotiations with the medical officers or is it the Minister who will start negotiations with the doctors in the locality? What exactly is the process going to be? I think it is very important that we should  have the Minister's views on that particular matter.
Deputy Dr. O'Higgins speaks of the effect of this Bill on dispensary doctors but there are also other medical practitioners who will be affected by it. Take any large urban centre where there are doctors in private practice who have no official appointments as dispensary doctors. As soon as this scheme is put into operation in their area, there is taken away from them the greater part of their ordinary private practice. In any contemplation for loss of livelihood such as Deputy Dr. O'Higgins spoke about, that particular class of medical practitioner should be taken into consideration. What is going to happen a doctor living out of private practice in, say, a substantial urban centre when this scheme is put into operation? He is going to have the greater part of his livelihood taken away from him.
Mr. Dillon: I should be very interested to hear a neighbour of my own, Deputy Dr. Brennan, give his views on this proposal because I think a queer situation arises. Deputy Dr. O'Higgins is of course well versed in medical matters and experience but I suppose he has had most of that experience in the eastern part of the country, for which I am not competent to speak.
I do not know the usual practice there but I would be amazed to hear from dispensary doctors coming from the part of Connacht in which I live that the volume of red tickets they receive is in any sense substantial. There are all sorts of medical services provided free at the present time but no considerable body of the population avails of them. I think it is the exception rather than the rule for a dispensary doctor in the west to be summoned on a red ticket to anyone but those who are virtually destitute. The fee may be small; the fee very often is nominal; the fee very often is not paid but the doctor goes on the understanding that he is going to a fee-paying patient and not in answer to a summons on a red ticket. I think it is right that I should emphasise that it not infrequently happens that the fee never gets paid and those of us who know dispensary doctors appreciate  very warmly the extent to which they attend the poor amongst their neighbours, sparing them what would be for them the humiliation of presenting a red ticket and yet foregoing a fee because they feel they are not in financial circumstances which would justify the doctor pressing them for payment.
But I cannot see the institution of ante-natal clinics and provision for maternity welfare of that kind substantially reducing the fee-paying practice of the dispensary doctor in the part of Ireland from which I come because I do not anticipate that 10 per cent. of the total panel of patients with whom he deals will avail of those free services. Consider any small town in the West of Ireland and the houses from which the dispensary doctor draws the bulk of his fees. How many residents who own their home are going to send their wives to the dispensary for ante-natal care, to sit in the dispensary waiting to move in in due course to the dispensary nurse and the dispensary doctor in the public dispensary? I think very few.
Now, if the addition of some of the services outlined in Sections 18, 19 and 20, which I believe we are considering more or less together, should involve a reduction in the actual area of a dispensary doctor's dispensary, in many parts of the country that may be a great blessing, because some of these areas are much too big, but I am not altogether sure that that must inevitably reduce the dispensary doctor's income. What I think it is going to do is this—to make it virtually impossible for the young doctor to set up, as some of them do at the present time, and earn a livelihood side by side with the dispensary doctor. I think you will find in most dispensary districts that when a young doctor hangs out his shingle a good many people say: “Ah, that will vex the dispensary doctor,” and then discover, to their amazement, that the most relieved man in the parish is the dispensary doctor because he knows that, being the senior man, being the established man, he will retain the bulk of the fees and it is not altogether unwelcome, very frequently, to have a second doctor in the area who carries part of the burden and who  will do locum for him if he wants to go away for a day to the races.
If, however, you reduce the size of the dispensaries and increase the number of public health doctors throughout rural Ireland the principal effect, I think, will be that no young man may attempt to set up a practice in rural Ireland unless he has a dispensary. Apart from that, I do not think it will have very much effect on the existing income of the doctors who are practising in that part of the country which I know. I want to emphasise that I am making that reservation because I fully appreciate that in eastern Ireland, where you have a large number of agricultural labourers, you may have a very much larger section of the population using the red-ticket system and a completely different set-up. So far as the part I know is concerned, I doubt if this arrangement will make very much difference to the doctors' emoluments or earning capacity. When I read of all these magnificent schemes about ante-natal care, etc., etc., I am a little amused because all of us know perfectly well that the vast bulk of the population will never avail of them. If they want ante-natal care the husbands will send for the doctor but the wives are not going to sit in a dispensary and advertise to all and sundry that they are going to have a child in eight months' time because my experience about the neighbours at home is that that is a matter about which they have a quite extraordinary delicacy. There is a kind of universal conspiracy to avoid letting the neighbours know too soon. God only knows why. But if you think the average young girl or seasoned matron is going to notify the whole parish eight months before her child is born that she thinks that she is going to have one, you never made a greater mistake.
When we come to the child welfare department and get down to Section 21, I think we are in a different sphere of country altogether because, if I read that section, as amended, correctly, it is quite daft and if left in the Bill in its present form, will certainly result in the Bill being declared unconstitutional. I had to warn you about that once before and I was told I was a bad  dog and was just trying to vex de Valera.
An Ceann Comhairle: The Taoiseach.
Mr. Dillon: But the Taoiseach got a shock this afternoon. Now I hope the Minister for Finance will polish his spectacles as I have polished mine and take the precaution of consulting Bunreacht na hEireann before we go very much further with the next section we have to discuss. Pending the discussion of that section, I want to raise a specific question, distinct from the general matter of principle touched upon by Deputy Dr. O'Higgins. I observe in the sections under discussion that the Minister has power to direct the health authority to provide for the treatment of children's illnesses and defects and to ascertain cases of mental deficiency. I want to ask him this specific question, and I would greatly appreciate a categorical reply.
When the last Public Health Bill was before the Dáil I received what I understood to be an assurance that in the event of its passing one of the first things to be done under a similar section would be to direct the Dublin Corporation to establish a psychiatric clinic for children in the City of Dublin to which delinquent children brought before the Children's Court and remanded in custody might be sent so that during the period of their remand their psychological condition could be investigated, their physical health examined and an adequate report made to the district justice on these matters before he finally made up his mind how to deal with them. I read of proposals for the examination of all the children in the national schools, sick and well, and with that proposition everybody seems to agree without any doubt at all. There is, every Friday, gathered in the Children's Court in Dublin Castle a group of children, drawn almost exclusively from the houses of the poor, whose conduct manifests the existence of some defect in their physique or psychology, whose conduct cannot be explained on any other basis than that they are in some sense abnormal. Do Deputies  of this House realise that there is no machinery available to anybody for determining the quality of that defect and that the district justice is obliged to dispose of those children in absolute ignorance of the most essential information that he should have before making up his mind how best to deal with them and that they must be dispatched to an institution which, of its nature, is obliged to receive them on the assumption that they are normal and free from defect and to treat them accordingly? It is from such as these that the inmates of Borstal come and the recidivist persons who serve in penal servitude prisons.
I am asking the Minister will he say this: that when this Bill is passed he intends, under the powers conferred upon him, to require of the Dublin Corporation, in collaboration with the Department of Justice, to institute such a clinic as I have in mind so as to ensure that here after every child brought before the Children's Court who cannot in the circumstances be returned at once to the custody of its parents and who must be retained in custody on remand will be sent not to a bleak remand home, with no amenities whatever in it, but to a properly equipped psychiatric clinic where whatever difficulties the child labours under may be diagnosed and where the authorities of it will have power to prescribe that the proper treatment for the correction of those defects will be made available and where the parents of the child will be facilitated in getting for their child that without which the child must grow up a problem and, possibly, an enemy of society—that for which they themselves cannot afford to pay and that for which we all know we would be able to afford to pay and would procure for our own children were they similarly affected. May I mention this? I have been pressing in this House for 12 weary years the necessity of the institution of such a clinic as I here prescribe. I know of no Deputy in any part of the House who has argued against me on this subject. How long, oh Lord, how long! Are we ever going to reach the stage when somebody will take sufficient interest in this particular small group of children to provide the means of their  redemption? The cost would be trivial. The means and personnel to equip it effectively are available. Nothing now is required but the initiative to put the matter in train. Will the Minister now say that it is his intention to do so without delay, for if he will I will charge myself with the responsibility of reminding him of his undertaking at that proper time and I feel certain that nothing more than that would be necessary once such an undertaking had been given by him?
Dr. Brennan: I must say I am in substantial agreement with what Deputy Dr. O'Higgins said in connection with the position in which dispensary doctors will find themselves when this Bill is put into operation. I am satisfied, however, that the Minister will be perfectly reasonable and that he will meet dispensary doctors and discuss the situation with them. I would be glad if it would be possible for him to meet representatives of the dispensary doctors before the Report Stage of this Bill and that he would then be in a position to tell us what he proposes to do or introduce some clause whereby he would provide that the remuneration would be in proportion to the additional duties assigned to dispensary doctors and also that due consideration of the private practice taken from them as a result of the new duties imposed would be considered.
Another question will also arise: that is the question of the training of doctors for those duties that will be assigned to dispensary doctors. As a dispensary doctor, I would not be conversant with the duties which are at present carried out by the county medical officers of health. It would be necessary to have some short courses for dispensary doctors in which they would be given a general idea of the type of work, which would be new to all dispensary doctors. There would also be the question as to whether we could supply the necessary number of qualified nurses for that type of duty.
There is also the question that what applies of course to dispensary doctors as regards taking away private practice would also apply to the dispensary  midwife. The case of the dispensary midwife should also be taken into consideration when the assignment of the extra duties to doctors and nurses under this new scheme comes into operation.
I am very pleased that the Minister has seen fit to take note of this question of mental deficiency. It is a big problem, especially in the rural districts, where people are still inclined to hide the fact that they have anyone mentally deficient in their home. I think that, under this mother and child welfare service and with the inspections contemplated, it would be possible to find out the extent of that problem. I am aware that the Minister is getting some of the county medical officers of health to agree with him to investigate that problem. The question will then arise—where are these people to be treated? I have sent cases of that type to local institutions. They had to be kept there for months and months before a place could be found for them in an institution where they could be properly looked after. I hope that, under this scheme of hospitalisation, due consideration will be given to that problem, and that there will be proper institutions provided by the Government to cater for a substantially greater number of such cases than can be catered for at the moment.
I agree with some of the things Deputy Dillon has said about tickets. I do not think that the fact that people have been discouraged to get red tickets means that there is not as much free medical treatment given to-day as in former times. The fact is that, at present, dispensary doctors do not insist rigidly on the presentation of a ticket. They realise that if they were to do so patients might feel that they were not getting the sympathy and the consideration which they expect from the doctor. In the West of Ireland at any rate it is true to say that doctors are not insisting rigidly on the presentation of tickets. I think that is all to the good. I think that the presentation of the ticket was a relic of the old slavery that existed in the country. I should like to see that system abolished altogether. I am satisfied that if a person is not able to pay, or does not  present a ticket, that the doctor will act as conscientiously and as faithfully as if he were getting a fee.
I agree with Deputy O'Higgins that there will be a substantial reduction in the income of dispensary doctors as a result of the operation of this proposal. I cannot agree with Deputy Dillon that if you divide a dispensary district and put two men there, that the dispensary doctor will be as well off as he was before. Is it not obvious that, if you divide a district, the private practice will be divided, and that there will, therefore, be a substantial reduction in the income which a doctor gets from his private practice? I think there cannot be any justification for the theory put forward by Deputy Dillon. I think that the Minister should see the dispensary doctors and also the representatives of the midwives. In that connection, due consideration should also be given to the private practitioner. I should like, if it were possible, that the Minister would see the members of the profession before the Report Stage of the Bill is taken. In that event he might be in a position to give the House a better outline of his policy in this respect.
Mr. M. O'Sullivan: I am sure Deputies would like to join in the well-deserved tribute which the Minister paid to the three maternity hospitals in this city. The most interesting portion of his statement as it applies to Dublin was that in future the care of the child, up to the age of 12 months, would be the responsibility of the three maternity hospitals in the city. I should like if the Minister would amplify his statement and indicate what the machinery will be when that new change comes to be operated. I can understand that the three hospitals will be able to provide the medical and nursing attendance, but I venture to think that the treatment will have to go much deeper than that. There will be the question of suitable accommodation and, so far as the mother and child are concerned, the question of clothing.
As to proper housing conditions, to what extent will the hospital authorities be empowered to implement the  full machinery of this section? Will there be any conflict as between the hospital authorities and the local health authorities, and to what extent does the Minister propose that there should be liaison arrangements between the two? In asking that, I have in mind the position that is likely to arise in so far as the child welfare department of the City of Dublin is concerned. We have a very excellent department there as the present time, inadequate only in so far as personnel is concerned. It is doing remarkably good work. To what extent will it be affected under the new machinery suggested by the Minister? I think it is important that we should have some details of that kind before we pass from the section.
I am not able to adjudge what the position with regard to the dispensary doctors will be. It would appear that we shall have a different type of machinery so far as the City of Dublin is concerned. As an ordinary layman, I should like to add my voice to the appeal made by Deputy O'Higgins and supported by Deputy Dr. Brennan that there should be consultation with the people concerned. I think that very good results might result from such consultation. Apparently, there is going to be a radical change so far as the dispensary doctors are concerned. In so far as they may have serious apprehensions with regard to their position, I think that a conference between them and the Minister might be a very good thing indeed.
I support wholeheartedly the plea made by Deputy Dillon. He has made this subject of the mentally defective child his special care here for years past. I think that he may rightly claim the support of every Deputy in the House for the suggestion that he has made, and that he should seek for more than an assurance from the Minister that when this Bill becomes law the Dublin Corporation will be required to set up the type of clinic that he has suggested. May I say that even now the Dublin Corporation would be only too pleased to set up the type of clinic he speaks of if it were empowered under the present law to do so? My information is that it is not. Therefore, I suggest to Deputy Dillon that  he should try to get more than an assurance from the Minister requiring the Dublin Corporation to set up this clinic. That assurance will be valueless in my opinion unless the Minister takes steps to see that there is some section in the Bill authorising the corporation to provide the service that Deputy Dillon and other members of the House would like to see in operation.
Mr. Dillon: I think Section 19 does that.
Dr. Ryan: There are two things that we ought to keep separate when talking about this section. One is the obligation that we put on the local authorities and the health authorities to provide this mother and child welfare service. We are going a bit further than that. There was an Act passed in 1915 which is referred to as the Notification of Births (Extension) Act. It is laid down there that sanitary authorities may make such arrangements as they think fit, with the sanction of the Local Government Board for Ireland, for attending to the health of expectant and nursing mothers and of children under five years of age. We had, therefore, from that period the duty—while not so specifically enforced, perhaps—laid on the local authorities to consider this question or provide these services as far as they thought it advisable.
The next thing raised was the school inspection. We are going a bit further than that in these clauses here, by making it obligatory on the health authority to provide these services for the mother and for the child up to 16 years of age. The health authority will have to provide these services. The question has been put whether it is the health authority or the Minister would carry on the negotiations with the medical men. There will be two sets of negotiations, as far as I can visualise the position. I should say that the Minister will meet the Medical Association and the Association of Dispensary Officers and discuss generally with them the new powers that they will be asked to take over by the health authorities. I am quite sure that they will be able to argue their case fairly effectively, as far  as the extra work is concerned and as far as the loss of private practice is concerned. I did meet the Medical Association already and they had thought of those points before they were raised here at all.
Then we may take it that there will be a second set of negotiations in each particular area. When the health authority is changing the size of the dispensary, all relative factors will have to be taken into account. I have no doubt whatever, if a dispensary doctor has a certain area at the present time and if he claims on the one hand that he would have too much work in the new area and on the other hand claims that, if part of it is taken from him, he will lose a certain amount of private practice, these things will have to be kept in mind and an agreement reached with these men.
I was asked if I could meet the dispensary doctors at this stage. I had a preliminary talk with the Medical Association on this Bill and pointed out that nothing very much could be done until the Bill would pass, if it was going to pass, and at that stage we could discuss their position in view of the regulations to be made. As far as my recollection goes, I do not think they thought that unreasonable. They did ask to see me again recently and I said I thought there was no great use in meeting them until the Bill had gone through the Oireachtas. If they press I do not mind meeting them. I would be very loath to refuse to meet representatives of a body of men who are very seriously concerned in a measure of this kind, but if I do meet them at this stage all I can say is that, as soon as the Bill goes through, we will be able to get down to talk business.
I do not agree with what Deputy O'Higgins says, that the Minister should have met these men before the Bill was brought in. What could he say to them? Is it not obvious that the negotiations go down practically to each individual county where the changes are being made? They go down to individual classes, at any rate. As I said already, if an agreement is reached with these dispensary men, some of them will probably have to surrender part of the territory, because they would have too much to do otherwise.  In some cases, it may be possible to appoint an assistant to a dispensary medical officer and leave him as he is. That would be so in a fair-sized town. There would be various ways of dealing with each man's difficulties as the case may be.
The case was mentioned of men who are in private practice. That case was also raised when I met the Medical Association and I said we would have to consider that and see what could be done. In the first place, of course, if there are young men, a number of them may be appointed to new dispensaries or as assistants to existing dispensary men. If you take a man in private practice in a town and if the clauses are passed as they are here, if the parents must send their children to school to be inspected or, alternatively, get the private practitioner to inspect them and send in a certificate, it will give more practice to those private practitioners than they get at the moment and not less, as I have no doubt whatever that, under the Act, a number of parents will send in the certificate to show that the child has been inspected rather than send the child to stand amongst other children for inspection.
With regard to mental deficiency, I do not know if it arises in particular here, but I am very interested in that subject. First of all, we will probably need legislation, as the Mental Treatment Act dealt only with a certain class of people, and I think we will have to bring along proposals to the Dáil for legislation on this question of mental deficiency. In the meantime, I think we can do practically anything we are asked to do here. One of the difficulties we have in regard to mental defectives is that we have not got nearly enough accommodation for institutional treatment. We are making moves in that direction. Since I became Minister for Health, I have sanctioned a scheme for the enlargement of one institution and at least one scheme for a new institution for mental defectives; but we want many more than that before we will have sufficient.
Deputies know that these people have to be graded. Some of them can  be turned into quite ordinary citizens capable of earning a livelihood, some of them may be improved at least to the point of looking after their person, and some of them are practically hopeless, at least as far as medical science goes at the moment. Therefore, we have to provide a number of institutions to deal with these various classes and we are getting on with that as quickly as we can.
As regards the specific request for a clinic here in Dublin for the examination of those children who come before the Children's Court, I have no doubt that it will come in time, but I would not like to say just here and now what it may be possible to do. I shall certainly make inquiries into the matter and see whether it may be possible to do something on those lines.
Mr. Dillon: Would the Minister undertake to consult the Minister for Justice in regard to that?
Dr. Ryan: Yes, that will be necessary. I would like to point out to Deputy Dillon and others that, until we get these institutions going, we will be limited in what we can do with regard to those children who may be mentally defective. The last question raised was concerning the lying-in hospitals. These have agreed to carry out this scheme in the City of Dublin for the welfare of the mother and for the child until the child is one year old. They will do that, first, by ante-natal clinics in the hospitals and also by domiciliary visits by nurses employed by these lying-in hospitals. Then they will carry on as at the moment by providing, so far as they can, for confinements in the hospitals, and, as well as that, sending out nurses, students, and, if necessary, doctors, to women confined in their own homes.
There will be post-natal clinics for these mothers and for the children up to one year old, and again, where they are not in a position to visit the clinics, there will be domiciliary visits by nurses and, if necessary, by doctors from the lying-in hospitals. When the child reaches the age of one year, all records will go to the health authority. The health authority has been in these negotiations and has  approved of the scheme, so that there is a perfect understanding between the health authority in the City of Dublin and the lying-in hospitals on this matter.
Mr. Heskin: It strikes me very forcibly that, in order to make these sections effective, it would be better to get local authorities to have maternity wards available in every hospital. It is very doubtful if you will be able to get the ordinary people in rural areas, or even in towns, to attend the dispensaries for the purpose of getting instructions from the doctor. Take, for instance, mothers and expectant mothers. It will be very hard to get them there, whereas, if they were encouraged to go into a maternity ward for, say, a fortnight or three weeks before confinement and for a month after, it would be much more effective from the point of view of the welfare of the child. I cannot see for the life of me how it will be possible for the dispensary doctor to instruct all mothers and expectant mothers in his area, and the general feeling is that it would be much more practical to have maternity wards attached to all the existing county and rural hospitals. That would overcome much of the difficulty which arises in these areas and, in my opinion, would be 100 per cent. effective in safeguarding the future of the mother and the welfare of the child.
Dr. O'Higgins: I am sure the Minister has no intention of misleading the Dáil, even to a minor extent, and I freely admit that my recollection may be at fault, but the Minister, in the course of his remarks, stated that he had met representatives of the Irish Medical Association, and, taken in conjunction with the subject he was discussing, this Bill, one would assume that that meeting was in relation to this Bill.
Dr. Ryan: No, I should like to correct that impression. I do not want to mislead the Dáil and it would be very bad if I tried to do so. The Medical Association came to me with regard to the present cost of living and we discussed that matter. They made a few remarks about private practice and I  said that we would discuss that later on.
Dr. O'Higgins: That is what I was about to say. The meeting the Minister had with the Medical Association was with regard to a national increase vis-à-vis the cost of living. This Bill was not even in their hands at that time.
Dr. Ryan: I do not think it was.
Dr. O'Higgins: The Minister informed them that, when the Bill came, he would have to discuss the matter of their remuneration under the Bill. They have requested and urged upon the Minister to see them and discuss these things before the Bill becomes law, because they are not asleep to the delicacy and the dangers of the position, namely, that their bargaining power is very considerably reduced once this Bill becomes law. The Bill lays down that the health authorities shall make provision for a certain number of things. It does not make it mandatory, I admit, on the dispensary doctor to give his services, but it does make it mandatory on the health authority to have a scheme in accordance with the Minister's regulations. The Minister may decide: “We will allow any dispensary doctor who wishes to keep out of the Bill to keep out of it, but we are going to see that the services under the Bill are given.” How will they be given? They will be given by having another doctor, or two other doctors, salaried by the Department, in the district to carry out the services outlined in the Bill, plus anything and everything else they can get from the recalcitrant doctor who does not toe the line and do as he is bid. Surely the Minister will not argue that the doctor's bargaining position will not be considerably worsened when this Bill becomes law. I think it is obvious.
With regard to the extent to which a doctor may be very seriously hit in his private practice by these clauses, I do not pretend to know nearly as much as Deputy Dillon with regard to the customs or inclinations of the coy ladies of Connaught—whether they would go to a maternity clinic or not.
Mr. Dillon: Deputy Dr. Brennan will confirm what I said.
Dr. O'Higgins: It may be that they would be reluctant to do so, but the very smallest extent to which they will be injured under these clauses would be in the matter of maternity clinics. I do not think Deputy Dillon adverted to the fact that any and every illness or defect—not just maternity work but any and every illness or defect from which the classes referred to may suffer — is to be treated free — the infant, the child and the youth— whether it is pneumonia, appendicitis or a broken leg. If I can read English, that is what this phrase “provide for treatment of their illnesses and defects” means. We have already been told that the treatment referred to here is to be free and freely available, so that for every and any illness or defect that any child, male or female of any class, up to 16 years of age may suffer from, there is free treatment available. We are also told— and this was hammered in and it is important, if this Bill is to be a success —the work, duties and services established under this Bill will be in no way associated with the poor law services which still have the taint of destitution and pauperism. That was made very clear on the introduction of the other Bill and of this Bill.
Mr. Dillon: Surely the Deputy is not arguing that if I send for the dispensary doctor in Ballaghaderreen to visit my child, he must attend the child and refuse a fee, and that he cannot sue me for a reasonable fee for having attended my child?
Dr. O'Higgins: I am certainly arguing this much, and I think the Minister and I will find ourselves in the rather unusual position of standing shoulder to shoulder with regard to this, that if a doctor comes under this scheme and is called to attend a child under 16 years for any illness or defect, he cannot sue for a fee. Is that not so?
Dr. Ryan: That is right.
Mr. Dillon: That is fantastic. Why should it be so?
An Leas-Cheann Comhairle took the Chair.
Dr. O'Higgins: We are providing free treatment for every illness and  every defect of every child up to the age of 16 in the whole of the country.
Mr. Dillon: Why?
Dr. O'Higgins: Because there are 77 Deputies over there; that is why it will go through, anyway. I am not objecting to that in theory. If we could give bread, meat, tea, sugar, butter and houses free to all the people of the country without injury to the bakers, the grocers, the butchers, or anybody else, it would be a grand country. We are proposing to give free medical treatment, but we are to give it free by injuring the doctors, or, at all events, we are not prepared to say how we propose to compensate the doctors. What we do say is that as soon as we have the law behind us then we will talk to the doctors.
Deputy Brennan, who is sitting two seats behind the Minister, asked to have the negotiations with the doctors carried out before the Report Stage. Deputy Brennan is no fool. He knows very well the difference between negotiating with and meeting the doctors before this Bill is law and afterwards; so do the Minister's advisers know. When this Bill becomes law, it will not be a case of “How much will you take”; it will be a case of “How much I am prepared to give you”, and whatever is given, be it little or much, there will be no alternative but to accept. All I say is that the profession deserve better of the Department, of the Dáil and of the country than to be treated in that way. If it were any other organised section of the community who were freer, if you like, to use weapons that doctors cannot use, no Minister would dare to treat them that way; no Minister, no matter how many votes he had behind him, would come into the Dáil with proposals to treat them that way—that he would put them on the wrong side of the law and after that negotiate with them. It is not fair play and it is not justice.
The Minister made reference to school inspection by every dispensary doctor and I can see a lot to be said for it. But, remember, the health statistics of the country are based on the returns from the various administrative areas. We have never reached the point of having uniform standards  and the health statistics at the moment are based on 30 different standards. The standard of classification for, say, malnutrition in one county differs very much from the standard in the next. The standard as to what would be classified as an enlarged tonsil in one county differs very much from the standard in the next. Doctors, of course, have different standards, except they go through some machinery for arriving at something like a common standard. In army medical services all over the world that is the very first of many difficulties that have to be faced—different standards coming up from the different regimental and medical officers and, so far as possible, you get them to a common depôt where an agreed standard will be reached. Then you have something like a uniform standard.
Even with regard to the county medical officers of health at the moment you have 30 different standards. Our health statistics are faulty to the extent that the standards differ. People often ask: “Why is it you have so much more goitre in one area than in another?” The answer may well be that the standard of what would be classified as a goitre worth mentioning differs between one administrative area and another. We are all conscious of that and we know it; but, as I say, we have 30 different standards at present.
Now we are going to put 1,000 men on the job, some of them trained in medicine in the last century, some of them having completed their training in the last month; all the dispensary men that are there at the moment and the extra 300 or 500 that the Minister indicated on the Second Stage of the Bill. Where will that land us? In Bedlam.
You might just as well liquidate your statistical department so far as health is concerned, because you cannot base national health statistics on 1,000 different standards. It may be that you will have some system for making something like a rough-and-ready national standard. But the more I read this Bill and the more I see the implications of different sections, the more I am convinced that we are legislating in haste and that we will do the consideration, the deliberation and the  consultation after we are committed to a certain course.
The Minister knew when he was over here and knows since he went over there that when a Minister introduces a Bill the Ministerial colours are hoisted and nailed to the mast. It is too late then to have a Bill altered or modified to any extent. The points that might arise on an important question like health should all have arisen and been discussed before the Ministerial colours were swung up. After a Bill becomes law the position is very much worsened. It is not only a Ministerial retreat and a hauling down of the colours; it is a case of coming into the Dáil with an amending Bill to make not only the Minister and his Department, but all the Deputies of Dáil Éireann, look foolish in the public estimation. If portions of this Bill which we are putting through turn out to be unwise or unworkable, we will have travelled somewhat further along a road that we should only have trod with caution. All these conversations, negotiations, and discussions which the Minister says will be carried out in the dim and distant future, but only when the Bill becomes law, should have been carried out before the Bill was introduced.
The Minister for a great many years was Minister for Agriculture. During these years when he was Minister for Agriculture I do not believe that he ever introduced any legislation affecting the cattle of this country or the health or welfare of the cattle without discussing it with some organised section representing the agricultural mind. He was only dealing with cattle then; now he is dealing with humans, and his attitude in his dealing with humans is “I will get my Bill through first and then I will discuss it with the people entitled to have views and expected to know most about health problems”. It is very different from the way things were done on the other side of the water. There they had years of negotiation and then legislation, years of negotiation in advance, negotiation going on all the time the Bill was under discussion, and the chits going in and coming out from Parliament, negotiation following the passage of the Bill and even during the different stages of the Bill, the Bill being altered,  amended and remoulded because of the advice given.
In the past, one of the curses of this country was the number of secret societies and now every Government Department is to become a kind of secret society, framing and considering legislation in secret without any of the affected parties, any of the experienced personnel that knows something about the subject, being consulted, every one of them locked out. Then the Bill is brought into Parliament, where the bells ring and it becomes law, assurances and promises being given that, after the Bill became law, “We will then talk to you about what should or should not have been in the Bill or how it should operate”. I can only raise my voice against the wisdom of proceeding along such a course; the rest is for the Minister.
Mr. Dillon: I should like to hear somebody defend or justify the proposition that my neighbour should pay for medical attendance on my child. In the name of God, why should that be? I can quite see that it is a good thing to provide, throughout the country, the best medical attention available for anybody who is not able to afford a doctor, so that nobody's child will go unattended simply because that child's parents are poor. But how do you proceed logically from that principle to the proposition that in this country the State will provide medical attention for the children of everybody? Why should you not clothe my child? Why should you not provide him with everything else? I consider that is a daft principle.
I think I know the clues to this foolish proposal. One is the extremely bad example of the Socialist Government in Great Britain and the other is the basis of family allowances in this country. The reason family allowances were made applicable universally here is a purely administrative reason, because we do not want to apply a means test in the case of every applicant. What we provided was that any person who is liable to income-tax would have his income-tax allowance abated by an amount to correspond with what he actually receives  under the Children's Allowances Acts so that, in fact, he would not benefit at all. But for purely administrative reasons and to avoid the means test we gave it to everybody. Surely to God we are not going to take that as a precedent for declaring that every citizen, without regard to his income or circumstances, is entitled to bespeak the services of the dispensary doctor and then tell him that is part of his duties for which he is paid by the county council.
I do not choose that the county council should pay for the medical treatment of myself and my family. If I fall on hard times, I prefer to depend on charity; I elect to go to a charitable institution rather than to the State or authorities acting under the State. If I were a resident in Dublin I would go to the Sisters of Charity or the Sisters of Mercy or some charitable institution and there seek assistance rather than go around to a public health dispensary and take State aid. It is no shame for someone who is poor to turn to the source of charity which is provided there for the purpose of consoling and helping those who need medical treatment, but I think any Christian man may feel a very profound reluctance in passing over his family responsibilities to the State.
That we in this House should announce that every man's child hereafter, whether his parents desire it or not, must become the responsibility of the State in so far as the maintenance of its health is concerned, is to me an astonishing and most undesirable proceeding. I think the initiative in bringing the individual child or the individual expectant mother within the scope of this scheme should be most strictly reserved to the family to which that mother or child belongs. There should be every facility for any family requiring such assistance to get it, but the initiative in be speaking it should be a matter for the family, and any attempt to short-circuit that is, in my opinion, a most undesirable development of a trend which is becoming all too strong the world over of abrogating to the State the duties which God Almighty laid upon a man and woman when they chose within the bonds of matrimony to bring children into the world.
 There is no use writing Article 41 into the Constitution if, when legislation comes to be passed by this House, Article 41 is treated as if it were clap-trap. Either the State recognises the family “as the natural, primary and fundamental unit group of society and as a moral institution possessing inalienable and imprescriptible rights, antecedent and superior to all positive law”, as set out in Article 41, or it does not. If we continue to permit the State to take over one duty after another of the parents of the family, it must be perfectly clear that when Article 41 was enacted by this State, somebody had his tongue in his cheek. I cannot too strongly emphasise a distinction between automatically bringing everybody's children, whether they like it or not, within schemes like this and making this scheme available to any family in the country who desires to avail of it. I am in favour of the latter proposal, but I am radically opposed to the first.
I want to inquire of the Minister, in connection with the powers taken under this section, whether he intends to do anything with a view to remedying the extraordinary situation in the Dublin dispensaries where, in fact, the numbers attending the dispensaries make it utterly impossible for the dispensary doctor adequately to deal with patients who require his aid. Has the Minister looked into that matter and has he any intention, under the powers conferred on him, to require the health authority in the City of Dublin to provide one doctor per so many patients as evidenced by attendances at dispensaries and the calls on dispensary doctors during the last four or five years? If my information is correct, the conditions in the dispensaries in the city are becoming almost farcical in that the doctors are asked or expected to treat numbers of people far in excess of the ability of the most industrious and hard-working man carefully and adequately to diagnose and treat their complaints.
Secondly, I want to express amazement at Deputy Heskin's proposal. If the National Agricultural Party is going to hospitalise every expectant mother in this country a month before  confinement and keep her in hospital for a month afterwards, the whole country will be filled with lying-in hospitals and a system will obtain in this country unlike anything which obtains in any other civilised community in the world. I think Deputies generally in the House will agree that it would be deplorable if a suggestion such as Deputy Heskin has put forward were adopted. It may be sometimes necessary in special circumstances that a woman should have her baby in hospital but I think the weight of competent medical opinion would be that any woman who can have her baby in her own home would be very well advised to do so and that the general hospitalisation of expectant mothers is something greatly to be deprecated.
I want lastly to press upon the Minister for Health, of whose goodwill I feel convinced, that the class of juveniles for whom I want clinical treatment falls between the class which is described as mentally deficient and the class which is described as normal. A continually recurrent problem is how to provide for sub-normal children. The urgency of the matter of the clinic which I here propose to the Minister is that, in my submission, the function of this clinic is to prevent the psychotic child from becoming mentally deficient or, more correctly, from becoming mentally deranged. My hope is that we would establish by collaboration between the Minister for Health and the Minister for Justice a clinic of this character primarily designed to take the place of the remand home, and that round it would rapidly grow a child guidance clinic to which the problem child might be referred by the dispensary doctor or the medical practitioner in the City of Dublin. At the present time if any general practitioner or dispensary doctor finds himself charged with the responsibility of advising parents what to do with a child whose conduct has reached such a degree of abnormality as to cause parents to bring it to a doctor, he is constrained to say: “There is nothing we can do because there is no place to which you can bring such a child for treatment.”
An essential pre-requisite adequately to treat that child is to get him into  some clinic where he can be observed, without his knowing that he is being observed, so as to arrive at a correct diagnosis. That is an essential pre-requisite and that can be done only by a staff highly trained for that purpose. If that is done, the vast majority of psychotic children—in this they are unlike psychotic adults— can be pulled back from the brink of insanity and made perfectly normal children. Undoubtedly, it is only too true that in the case of the psychotic adult the prospects as to what the psychiatrist can do for him, on the evidence of results, are not encouraging, but the very reverse is true in the case of psychotic children. There is abundant evidence of that in the child guidance clinics in London and in the innumerable child clinics that operate at present in the United States and in New Zealand. It is a source of constant amazement to me that public health authorities in this country have evinced so very little interest in this problem and indeed sometimes react to petitions with impatience as if one were an eccentric in being interested in such matters when the problem is recognised and is being effectively dealt with in Great Britain, the United States of America and indeed in most of the Dominions.
I dare to say that with every month that passes without a clinic of the kind at least one child who might have been saved is going over the border of mental derangement which may be diagnosed and bring it within the ambit of a mental hospital or which may be concealed and will wind up by its being shovelled into a recidivist prison as an incurable criminal.
The problem is one which few people outside doctors know much about. I feel certain it is one which has come under the personal attention of the Minister for Health in the course of his professional career and I bespeak his sympathetic and urgent support for the proposal to establish this clinic now, not only to provide for the children referred to it by the courts but in its development to enable every general practitioner and dispensary doctor in this city to take some steps  to meet that recurrent and, to my mind, most desperate problem.
Dr. Ryan: There were just a few points raised that I would like to refer to. Deputy Dr. O'Higgins was talking about the consultations that were carried on in Great Britain when the Bill was going through. I must say that I got a very different impression from reading the British medical journals. They did not seem to be very satisfied with the negotiations that were going on there.
Dr. O'Higgins: They were not satisfied with the result.
Dr. Ryan: They were not satisfied even when the Bill was passed.
Dr. O'Higgins: No.
Dr. Ryan: And after the Bill was passed the agreement was made.
Dr. O'Higgins: And they raised the ante 50 per cent. since.
Dr. Ryan: There is no use in saying the doctors were satisfied in England before the Bill was brought in.
Dr. O'Higgins: I did not say anything of the kind.
Dr. Ryan: That is all right, so. We agree. I met the consultative council that was set up and I discussed this Bill with them. They are not satisfied either. They raised some points which I promised to attend to. As a matter of fact, I have dealt with a few of the points by amendment already, and as regards the position of the dispensary medical officers, as I have said, I pointed out that we would have to discuss all these various problems that might arise when the time would come. I do not think that they could expect that anything else could be said at this particular time. What they want, of course, I must say, is this—not that their position should be settled now but that we should not bring in too much free treatment because that is going to interfere with private practice.
As regards this free service, Deputy Dillon asked how could it arise, or how could it be defended. The mother and child welfare scheme in operation at  the moment is free to everyone who wants to avail of it.
Mr. Dillon: Hear, hear—who wants to avail of it.
Dr. Ryan: Yes, to anyone who wants to avail of it.
Mr. Dillon: Yes.
Dr. Ryan: In the original Public Health Bill, brought in last year, it was free also and when I was bringing in my Bill I had all points brought to my notice where Deputies were in disagreement with the Bill. As far as I remember, nobody disagreed with the provision that they should be free. Therefore, we did not make any change. The reason advanced for this free treatment is: It is essential that mothers and children should be looked after and it is argued that if you make certain people pay, those on the border-line may not adopt the best treatment for their wives and children because they may not be able to afford it. If you do not give free treatment to everyone you must draw the line somewhere, at some level of income, or in some way of that kind, and the argument is that you might in that way make it difficult for certain people to adopt the best treatment for their wives and children or that they may not, at any rate, be too anxious to pay for the treatment that would be advisable. It was thought better, therefore, to offer this free treatment to everybody. Of course, the Department, before I went into it—and I agree with the view of the Department—were of opinion, and are still, that we should not, if possible, have any taint of charity in this——
Mr. Dillon: “Taint”?
Dr. Ryan: ——so that everybody would adopt the best possible treatment for his wife and children. I am just giving the arguments. There may be arguments against it. I am quite prepared to admit that Deputy Dillon may give very good arguments against it and if Deputy Dillon will put down an amendment we could have an interesting discussion as to whether it should be free or not.
Mr. Dillon: Perhaps the Minister would say, is it practicable to differentiate between the procedure of making it free to everybody and the procedure of making it free to those who ask for it? I think there is an important principle there involved. I would like to make it free to anyone who asks for it.
Dr. Ryan: I would like to point out to the Deputy, of course, that it is not illegal for anybody to pay the doctor, if he wants to.
Mr. Dillon: But the initiative at present is from the State to the family. I think the principle is safe if the initiative is passed over to the family. Let the family ask for free treatment and they will get it.
Dr. Ryan: I see the point, yes. That is not the position. The family will be entitled under this Bill to demand free treatment from the medical officer, whoever he may be, but I am inclined to think—and I think Deputy Dillon thinks the same—that many people will not ask for this free treatment; they will pay. There is, I think, a historical error in one of Deputy Dillon's statements. He said we are following the Socialist Government in England. It was the Coalition Government that brought in this principle.
Mr. Dillon: That does not make it any the less socialistic.
Dr. Ryan: Perhaps not; or any more palatable, either.
Mr. Dillon: No.
Dr. Ryan: As to the number of doctors in Dublin, I could not say what the position is at the moment but I have no doubt that when these schemes come in, such as mother and child welfare, we will require a very much bigger staff of medical men in the City of Dublin. It means adding to the staff in each dispensary or making more dispensaries. As far as I have given any thought to that subject, I think it would be better to add to the staffs in the dispensary districts as they are.
Mr. Dillon: And the equipment.
Dr. Ryan: Certainly. Deputy O'Higgins raised the point referred to by Deputy Dillon. I think there is a tendency that way, that women, even in the country, are inclined to go into hospital for their confinement and if there is a big tendency in that direction as years go on I suppose we will have to provide for it.
Mr. Dillon: I hope we will do everything we can to discourage it.
Dr. Ryan: But I do not think it would be practicable to have the whole scheme for expectant mothers, antenatal clinics and all, carried out in hospitals. That would take far too long and it would be impossible to provide the number of beds which would be required.
Dr. O'Higgins: I take it that free treatment includes whatever hospital treatment is required?
Dr. Ryan: Yes.
Dr. O'Higgins: Would the Minister relate that to Section 15, because either one or the other would want some looking into? I mean, there would have to be exceptions made in Section 15 of children up to the age of 16.
Dr. Ryan: Yes, that is probably right.
Mr. Dillon: And will you think of my psychotic children who want treatment before you embark on the Mental Deficiency Bill?
Dr. Ryan: Yes, I certainly will do anything that is possible. We have a fair amount of power.
Mr. Dillon: I think you have power.
Dr. Ryan: We will do everything we possibly can.
General Mulcahy: The Minister indicated in dealing with the Financial Resolution that the cost to the State of the mother and child scheme would be £250,000 per annum when it was in full development. I understand that there are 500 or 600 dispensary districts at the present moment. No doubt by the time this scheme is in full operation that number of dispensary districts will be doubled.
Dr. Ryan: Hardly doubled.
General Mulcahy: Well, substantially increased at any rate.
Dr. Ryan: Fifty per cent., perhaps.
General Mulcahy: I find it very hard to think that the service the Minister speaks about, over the whole of the country and including institutional treatment, is going to be established at a cost to the State of——
Dr. Ryan: The State will contribute £250,000 but the local authorities will contribute an additional £250,000.
General Mulcahy: The Minister still thinks the service can be provided at the cost to the State of £250,000?
Dr. O'Higgins: Taking the 500 dispensaries which are in existence at the moment, without increasing the number at all although there seems to be general agreement that we need a lot more, £250,000 would allow an expenditure of about £800 per dispensary district. Take the Minister's own figure—600—put 600 into £250,000— £400 roughly. My reason for subtracting is that there will be an extra nurse in each dispensary district.
Dr. Ryan: Yes?
Dr. O'Higgins: There will be the existing men, say 200 existing men. There will be a nurse in each district— we will say there are 800 districts. How much are we going to pay the nurse?
Dr. Ryan: I do not know.
Dr. O'Higgins: Say we pay her £100.
Dr. Ryan: Much more, I am sure.
Dr. O'Higgins: Say we have 300 extra doctors at a salary of £500——
Dr. Ryan: £150,000.
Dr. O'Higgins: ——and so much extra for the 600 dispensary men we have at the moment. I think the Minister is an optimist.
Dr. Ryan: £250,000 from the State, £250,000 from the local authorities as well—that is £500,000. We may be wrong.
Dr. O'Higgins: That is not dealing with the Minister's exception under infectious diseases and other things.
Dr. Ryan: We may be wrong.
 Amendment put and agreed to.
An Leas-Cheann Comhairle: The acceptance of that amendment wipes out Section 18.
An Leas-Cheann Comhairle: Amendments Nos. 11 and 12 could be discussed together.
General Mulcahy: I move Amendment No. 11:—
In sub-section (1), line 24, after the word “Act” to insert the words “and subject to the consent of the child's parents”—
The section, as it stands at present, reads:—
“A health authority shall, in accordance with regulations made under Section 24 of this Act, do, in respect of children in their functional area who are not pupils of any school, the following things—
(a) safeguard and improve their health and physical condition;
(b) arrange for their medical inspection at schools or other places;
(c) provide for their education in matters relating to health;
(d) provide for treatment of their illnesses and defects;
(e) ascertain cases of mental deficiency.”
The effect of my amendment would be that the opening of the section would read, “A health authority shall, in accordance with the regulations made under Section 24 of this Act, and subject to the consent of the child's parents, do, in respect of children in their functional area who are not pupils of any school, the following things...” I submit to the Minister that it is imperative to insert that amendment there. By the natural law it is the family and not the State which is charged with the duty of promoting the physical welfare of the members. The State may be required in case of necessity to offer assistance to the family but, in giving that assistance, it must be careful to respect the autonomy of the family. If the State intrudes in this matter and overbears  the authority of the family we will reach the position in which there will be a deterioration in family morale which will prove detrimental to the whole social strength of people here and I believe, as a result of that, detrimental to public health. Article 41 of the Constitution has been quoted by Deputy Dillon in relation to our previous discussion. I would ask the Minister to refer to Article 41 of the Constitution, sub-paragraphs 1 and 2, in which is laid down under the heading “The Family”:—
“1. The State recognises the family as the natural primary and fundamental unit group of society, and as a moral institution possessing inalienable and imprescriptible rights, antecedent and superior to all positive law.
2. The State, therefore, guarantees to protect the family in its constitution and authority, as the necessary basis of social order and as indispensable to the welfare of the nation and the State.”
“Guarantees to protect the family in its constitution and authority.” Article 42 of the Constitution, subparagraph 1 says:—
“1. The State acknowledges that the primary and natural educator of the child is the family and guarantees to respect the inalienable right and duty of parents to provide, according to their means, for the religious and moral, intellectual, physical and social education of their children.”
I submit to the Minister that the provisions of Section 19 here, and, as you say, Sir, also in a similar amendment of mine to Section 20, are such as to suggest that the Minister would propose to override the authority of the family, if necessary, in these matters. I submit that, in the first place, that would be wrong from a moral and from a natural law point of view. I submit, in addition, that it would be contrary to our Constitution. Therefore I move amendment No. 11, that these words be inserted, “and subject to the consent of the child's parents.”
Dr. Ryan: I do not think the Deputy's two amendments are necessary.  These are, if you like, directors to the health authorities to provide all these things but no child is obliged to accept treatment through its parents or otherwise. The only compulsion that it is sought to insert in this part of the Bill is the compulsory examination of children in certain circumstances. That question can be discussed on amendment No. 14. It is unnecessary to insert this amendment, and I suggest to the Deputy that he might withdraw his two amendments.
General Mulcahy: Am I to understand that the Minister's approach to this is that, under the regulations which he contemplates making under Section 24, there will be nothing in the way of taking power to override the authority of the parents in connection with the safeguarding of the health, medical inspection, the provision of education or the treatment of the illnesses of their children?
Dr. Ryan: The point I am making is that the only compulsion it is sought to insert here is with regard to the inspection or examination of children. If the Deputy has any strong views about that they can be discussed on amendment No. 14.
Amendment, by leave, withdrawn.
Question proposed: That Section 19 stand part of the Bill.
General Mulcahy: On the section, will the Minister say whether, under the regulations made under Section 24 and intended to deal with the matters contained in Sections 19 and 20, it is his intention that these will be subject to review and approval by the advisory health council?
Dr. Ryan: If the Deputy moved an amendment on that, I am afraid I would have to oppose it.
General Mulcahy: The Minister's line, therefore, I take it is that the regulations which will be made in relation to children as regards the safeguarding of their health, medical inspection, treatment of illnesses, the ascertainment as to whether they are mentally deficient or not, will not be subject to approval by the advisory health council.
Dr. Ryan: Not its approval. I have every intention of setting up the health council. I have not yet decided how exactly it will be constituted, but it will be constituted of doctors, nurses, dentists, and so on. My intention would be to submit regulations of all kinds to that health council, but I could not accept the principle of getting its approval in all cases.
Question put and agreed to.
Amendment No. 12 not moved.
Section 20 agreed to.
Dr. Ryan: I move amendment No. 13:—
Before Section 21, to insert a new section as follows:—
Before holding under Section 19 or Section 20 of this Act a medical inspection of the children of a particular class in an area or of the pupils of a school, a health authority shall give in the prescribed manner the prescribed notice of the time and place of such inspection.
There was a certain amount of discussion on this section on Second Reading. I expressed the opinion as regards certain things that it might not be necessary to enforce the section, as it stood, in every county. I thought that we might provide, at any rate, that it need not be enforced all over at any particular time. Consequently, I am proposing to divide the section so that it may be possible to do what is proposed in the way set out. The proposed new section will replace sub-section (1) of Section 21, and will extend its provisions to require notice to be given other than to non-residential schools. If this new section is agreed to, we can take the remaining part of the section as a new section and discuss the principle of compulsory inspection on that.
Amendment agreed to.
Dr. Ryan: I move to report progress.
Progress reported; the Committee to sit again.
The Dáil adjourned at 10.30 p.m. until 3 p.m. on Wednesday, 11th June, 1947.
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