“A nation of rich peasants" was widely considered a reasonable description of New Zealand as recently as 20 years ago. The economy, heavily dependent on the export of agricultural products to Britain (which guaranteed to purchase whatever was produced, at a guaranteed price) was very regulated and protected. Competition was discouraged -externally by import restrictions, quotas, and tariffs, internally by centralized fixing of most wages and many prices. An extreme example: to protect the dairy industry, the sale of margarine was forbidden by law, except to persons who could produce medical evidence that they were unable to eat butter. A cradle to grave welfare state, and minuscule unemployment, ensured that New Zealanders enjoyed one of the highest standards of living in the world with far less economic inequality than in Britain or the United States. They were a relatively homogeneous lot, and rather complacently ignored the unequal status of women and the native Maori people.

The attitude and behavior of professionals reflected the larger society. There were no private universities, so the government was effectively able to control both the content of professional education and the number of recipients. Since most immigrant professionals were British or Australian, and since the universities were largely modeled on the British system, professionals too were not a very diverse bunch. They tended to prosper about equally because of the regulation of numbers, restrictions on competition, and (in many cases) legally fixed fees. Many argue that they were (and in some cases still are) paternalistic, authoritarian, aloof, sexist, and racist.

In recent years there have been massive social and economic changes in New Zealand. Britain's joining the European Community led to a progressively reduced quota on New Zealand agricultural products, forcing the primary sector to become efficient and to diversify both products and markets. Since 1984 the economy has been largely deregulated. Women and Maori demanded, and to a considerable extent secured, a recognition of their inferior and unjust position and action to remedy it. Immigration from Britain decreased and the entry of thousands of Asians and Pacific Islanders affected Auckland, in particular, which for some years has had the largest Polynesian population of any city in the world. With deregulation came competition, more scope for enterprise, more consumer choice. On the downside, many businesses failed and unemployment greatly increased; economic divisions are now much greater, though the welfare system means that no one lacks the basic necessities.

Naturally, the professions have changed too, As in the United States, though not to the same extent, most restrictions on competition and marketing of services have been eased or removed. Not everyone approves of these changes. The President of the New Zealand Law Society (equivalent to the American Bar Association) vehemently opposed his own organization's alteration of its rules to allow advertising. Many doctors strongly disapproved of articles about the work of a famous heart surgeon which appeared in a top selling glossy magazine and in Air New Zealand's inflight magazine (complete with details of the services he offers, and prices) which they viewed as excessively self promoting. The public, however, has generally benefited from an improvement in the range of services available and in some areas through price competition.

One problem that health care professionals don't have to worry about in New Zealand is malpractice suits. Since 1973 virtually everyone has been covered by a no-fault accident insurance which is run by a government-owned corporation and funded by a payroll tax. In exchange for this cover-which provides health care, income replacement, and in appropriate cases a payment for pain and suffering or loss of quality of life-New Zealanders gave up the right to sue for negligence in almost all cases. This is one government institution which is unlikely to be turned over to the free market.

But while professionals in New Zealand don't face trial by judge and jury, they are increasingly being made to face trial by the popular media and hence "the lynch mob of public opinion" (this and subsequent quotations are taken from Metro magazine, July 1990). Television current affairs programs and magazines regularly carry stories of dubious professional and business practice. Such media attention is usually sparked by allegedly mistreated clients and interested parties who are dissatisfied with the response or lack thereof by professional disciplinary bodies. These bodies, it is argued, serve first and foremost the interests of the professionals they are supposed to regulate and only secondly those of their clients.

Such accusations are made in other countries too, of course, but they have special force in New Zealand whose small (3.3 million) population makes it very likely that top professionals will have worked or studied together at some time. For instance, in a recent case concerning the conduct of a physician, it was revealed that the head of the medical disciplinary body had gone through medical school with the physician who was under investigation. No doubt this is not uncommon. New Zealand has only two medical schools, one dental school, two engineering schools, and five law schools.

Professionals are accused of covering up their transgressions and protecting errant members. Many people agree that the professions "must be prepared to have their work scrutinized by the popular media because what they do concerns us all.” The media are often effective in bringing injustices and dubious practices to light and getting something done about them, as well as alerting others to the risk that they too may fall victim to incompetence or misconduct. In a recent case, a proprietor of a gas-station regularly sold glue to young people whom he knew were glue sniffers. It is not illegal to do this, nor is sniffing glue itself illegal, and there is no professional society of gas station owners to regulate members. But the day after the story was reported on national television, people picketed the gas stations and asked drivers to boycott it. The oil company also threatened to stop supplying the station. The owner quickly decided that selling glue to kids was no longer profitable. More generally, the media attention devoted to the medical profession has helped to bring about some positive changes: "Doctors have been more willing to listen to their patients. The emphasis has gone on to the health consumer:'

Unfortunately, the New Zealand media, like everyone else's, are prone to sensationalizing stories, thus (maybe unintentionally) leading viewers and readers to become unduly concerned about the extent and seriousness of an issue. Professionals have suddenly found themselves "working in a climate of suspicion;" as one doctor put it. This suspicion-sometimes amounting to hostility-may have a detrimental effect on professional-client relations generally. Professionals increasingly see snap judgments about the "guilt" or "innocence" of a practitioner being made by reporters and members of the public who do not have access to the relevant information or the expertise needed to make such judgments.

Given the lack of access to the court system and the limitations of "trial by media," the interests of all might be better served by adjusting the systems that are already in place to deal with complaints of professional misconduct. The outcomes of such hearings are likely to be fairer to all (and to be perceived as fairer) if their membership includes lay people from the community as well as practitioners. One reason why this has begun to happen is the change in the status of women in New Zealand.

The improved status of women is reflected in new entrants to the professions- over half the students in the Schools of Law and Medicine at the country's largest university, Auckland, are female, and Maori are catching up. It is also the main reason for the intense pressure on the medical profession to be more responsive to client needs. An article by two women's health activists in 1986 claiming that hundreds of women in an Auckland hospital had been the unwitting subjects of experimental treatment for cancer caused a furore, leading to a government-funded Commission of Enquiry and successful charges of disgraceful conduct against the Chair of the Hospital Research Committee which had approved the treatment. In the wake of these findings, all the Area Health Boards which run publicly funded health services, including the main hospitals, are required to set up Ethics Committees, which must have a predominantly lay membership and include adequate numbers of women and Maori.

One of this article's authors, Gunn, is Chair of the Waikato Area Health Board Ethics Committee. Originally it was expected that the Committee would deal mainly with research applications but, in the year since its establishment, the Committee has found itself making Board policy on such issues as patient information, commercial sponsorship, informed consent, resuscitation, and perhaps the most controversial issue of all, resource allocation.

New Zealand was the first country in the world to introduce a comprehensive and effective public health system, though there have always been private hospitals and most family doctors, many specialists, and practically all dentists are self-employed. Traditionally, medical treatment well beyond what was necessary to life and health was available at no charge in public hospitals. Their standards of care and expertise have generally been higher than those of for-profit hospitals but the latter do not have waiting lists. In line with the move to a market economy, Health Boards are questioning whether they should continue to provide services such as elective abortions, sterilizations, and tattoo removals. If patient autonomy ought to be respected as health activists claim, presumably patients ought to take more responsibility for their own health care. Does this mean, for instance, that a doctor is entitled to refuse to treat a patient who refuses to quit smoking, as some family physicians have done? What about home supplies of oxygen -currently provided at no charge- for a patient with emphysema who continues to smoke? Should grossly obese patients have to lose weight before being eligible for a hip joint replacement?

It's one thing for philosophers to discuss such questions in a seminar; effectively to make health policy is much more exciting, and much more challenging.