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The Coming Medical War

Shaw and the Doctors

by Roger Boxill
Basic Books, 199 pp., $5.95

The Quality of Mercy: A Report on the Critical Condition of Hospital and Medical Care in America

by Selig Greenberg
Atheneum, 385 pp., $6.95

In Failing Health: The Medical Crisis and the A.M.A.

by Ed Cray
Bobbs-Merrill, 257 pp., $7.95

A Sacred Trust

by Richard Harris
Penguin, 230 pp., $1.45 (paper)

Women in Medicine

by Carol Lopate
Johns Hopkins, 204 pp., $5.95

Negroes for Medicine

by Lee Cogan
Johns Hopkins, 71 pp., $4.95

Medicine in the Ghetto

edited by John C. Norman
Appleton-Century-Crofts, 331 pp., $6.95

Higher Education and the Nation’s Health: Policies for Medical and Dental Education Higher Education

a special report and recommendations by The Carnegie Commission on
McGraw-Hill, 128 pp., $2.95 (paper)

The American Health Empire: Power, Profits and Politics prepared by

a Report from the Health Policy Advisory Center, Barbara Ehrenreich, by John Ehrenreich
Random House, 279 pp., $1.95 (paper)

RIDGEON: I think I did. It really comes to that…. I suppose—yes: I killed him.

JENNIFER: And you tell me that! to my face! callously! You are not afraid!

RIDGEON: I am a doctor: I have nothing to fear.

—George Bernard Shaw
The Doctor’s Dilemma

I

Let us not wantonly weaken that persistent delusion,” Dr. Filerin urges a colleague in L’Amour médecin, “which fortunately provides so many of us with our daily bread and enables us, from the money of those we put under sod, to build a noble heritage—for ourselves.” Today, however, it is not Molière, but Shaw who seems to have the squirming physician and surgeon by the collar. In the United States, where most medical practitioners are private entrepreneurs and good health is regarded as a commodity, Shaw’s criticism remains fresh after half a century. “It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity,” he wrote in the Preface to The Doctor’s Dilemma.

That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.

The medical profession, Shaw was fond of saying, “is a conspiracy to exploit popular credulity and human suffering.” As medical care becomes increasingly difficult to find, to pay for, and to be reasonably satisfied with, some of his most cantankerous accusations appear very like the truth.

Shaw emerges from the pages of Roger Boxill’s excellent study as an articulate and compassionate critic of the medical profession. Modern “medical sociologists” should be measured against the standard he set. “The course of Bernard Shaw’s life (1856-1950) coincides with an eventful chapter in the history of medicine,” Mr. Boxill writes. Shaw was a concerned witness to the unprecedented joining of medicine and science—if not in fact, at least (and most important) in the public imagination. The physiological investigations of Claude Bernard, the discoveries of Pasteur and Koch, the methods of Lister and Jenner combined during Shaw’s lifetime to invest the art of medicine with the authority of the laboratory. Or so it seemed. In fact the germ theory, antisepsis, and even vaccination have done less than we had supposed to improve the health of anyone, as not only Shaw but, most recently and authoritatively, René Dubos has observed.1

But at the time, and for the first time, the traditional arrogance of doctors was said to have some basis in demonstrable truth; and there, for Shaw, lay the danger. The pretentious physician might, with the sanction of science and technology, begin to take himself seriously; and, worse, he might be taken seriously by others. When in Britain the Medical Act of 1886 created rigid licensing criteria and a consequent monopoly for the regular, “scientific” practitioners, Shaw complained:

The assumption is that the registered doctor or surgeon knows everything that is to be known and can do everything that can be done. This means that the dogmas of omniscience, omnipotence, and something very like the apostolic succession and kingship by anointment, have recovered in medicine the grip they have lost in theology and politics.

The pattern which Shaw discerned has perhaps been most fully developed in the United States. Since the turn of the century the American medical profession has enjoyed increasing affluence, the highest social status of any occupational group, and unchallenged control over not merely the social and economic conditions of its work but, as Eliot Freidson points out, its definition as well.2 By greatly expanding the definition of “medical,” the doctors have thereby significantly augmented their own status and power. And, at the same time, they have so restricted access to their domain that not only patients are disenfranchised but, ironically, most of the profession may soon be as well.

Much of this situation derives from that alliance of medicine and technology which began in Shaw’s day and whose frightening consequences he foresaw. The medical profession of the United States is extraordinarily rich and its medical scientists are dominant in international research. Citizens of the United States, however, are among the least healthy people in the industrialized world.

Depressing statistics and even entire phrases are becoming familiar: fourteen nations have lower rates of infant mortality (in one Boston slum one of every nine babies dies); in the past decade health care expenditures have doubled while the life expectancy of American males has fallen from thirteenth to twenty-second place in the world; health personnel are badly distributed and in short supply. Five thousand American communities have no doctor at all; the poor and non-white populations are effectively denied equal access to health facilities; hospital room rates, doctors’ fees, drug and laboratory costs are rising more rapidly than the cost of living; convalescent and old age homes are a disgrace; doctors refuse to make house calls; the incidence of malpractice suits is rising sharply. Patients enrolled in pre-paid medical plans are half as likely to lose an appendix or uterus or a pair of tonsils as patients consulting private practitioners.

Medicaid has failed; Medicare is inadequate; Blue Cross and private insurance premiums are going up annually; hospitals are closing their emergency rooms for lack of funds, and some are in danger of being shut down completely. Even Mr. Nixon claims it’s “a massive crisis”; CBS News warns “Don’t Get Sick in America”;3 liberal hospital physicians say the AMA is to blame; urban ghetto communities which surround the hospitals say the hospitals are to blame.

A stream of books on such themes began to appear in the mid-Sixties accompanying the national debate over Medicare. Now there are even more books to accompany the news that National Health Insurance is on its way.4 “Energetic leadership” from the “progressive” elements of the profession, we are told, together with help and ingenuity from the “private sector” and the government, will make us all better again.

In his Foreword to The Quality of Mercy, Dr. Robert H. Ebert, the Dean of Harvard Medical School, writes:

Mr. Greenberg provides a panoramic view of the status of health care in this country, and the reader may well be shocked by what he reads. Still he need not despair, for if one reflects for a moment on the intellectual and economic resources of this nation, one cannot but agree that all of the problems catalogued by Mr. Greenberg can be resolved….

And who will help to marshal these resources and direct them most effectively? That new breed of academic medical men—of which Dr. Ebert is a formidable representative. They know that change must come and are aware, Mr. Greenberg reports, that “it is not only foolhardy to try to stay the revolution but that the profession is duty-bound to provide constructive leadership in shaping its course.”

To Dr. Ebert and his colleagues the prognosis seems excellent. But is it? Can we trust the doctors? “All that can be said for medical popularity,” Shaw wrote in 1911, “is that until there is a practicable alternative to blind trust in the doctor, the truth about the doctor is so terrible that we dare not face it.”

The books under review, taken together, reveal much about modern doctors. Indeed, they convince one that the “legacy of neglect,” as Selig Greenberg calls it, is genuine and terrible. They make it clear that our present difficulties are in large measure the result of what “organized medicine” has done in the past, and of what it has not done; or, more precisely, the result of what the American people have permitted the doctors to do and permitted them not to do. These books also demonstrate—more by their very existence than by anything they explicitly state—that the apparently monolithic profession of American medicine is in fact sharply divided.

While it remains generally true, as Shaw noted, that “there would never be any public agreement among doctors if they did not agree on the main point of the doctor being always in the right,” even that most professional of courtesies is being seriously threatened for the first time in nearly a century. American medicine is divided roughly into three factions: the politically conservative American Medical Association, representing generally the interests of the traditional, fee-for-service entrepreneur; the academic, generally “liberal,” hospital- and medical-school-based practitioners, with their complicated affiliations and sources of power; and a third faction loosely defined as a “health movement” of radical professionals, consumer, community, worker, and student groups, which is beginning to emerge.

Finally, these books suggest what is perhaps most important of all: that the medical battleground is likely to be the ground of more than merely medical battles. Hospitals, clinics, and doctors’ offices may become the center of a debate over critical questions about the uses of technology, the function of expertise, the rights of individuals to control their own lives and deaths, the distribution of social and political power, and the very quality of our lives and our relationships with others.

II

In eighteenth-century England the practice of medicine was divided between three guilds: physicians were trained in universities, practiced generally among the upper classes, and, considering themselves gentlemen and scholars, refused to work with their hands as surgeons did or to engage in the sale of drugs. Surgeons rarely held degrees, were trained (if at all) by an apprenticeship system, were addressed as Mister (as they still are in Britain), and were of lower social status than physicians. Apothecaries were likewise “unlearned,” selling drugs at first and eventually prescribing them, becoming in effect general practitioners in rural areas and small towns and, in metropolitan areas, doctors to the working classes.5

In colonial America these distinctions were abandoned, probably owing not so much to any egalitarian ethic as to simple pragmatism and the fact that few real physicians chose to leave England. In any case, to become a doctor in the colonies one needed only to announce oneself as one. There was no dearth of willing practitioners. “Few physicians among us are eminent for their skill,” one New Yorker complained in 1757. “Quacks abound like locusts in Egypt.”

By no means, however, were these “quacks” less effective than academically trained physicians; and, happily, they were often less dangerous. At least during the Revolutionary period most citizens could find someone to hold their hand, catch their babies, and administer what is referred to often disdainfully in medical schools and hospitals today as T.L.C. (Tender Loving Care). In 1775 the ratio of doctors to general population was, according to one estimate, 1:600 nationally, and as high as 1:250 in some cities. It is interesting to compare these figures with those for the Watts section of Los Angeles at present (1:2,500) or even all of Los Angeles County (1:800).

  1. 1

    Dubos’s The Mirage of Health: Utopias, Progress, and Biological Change was first published in 1959, and remains an important book. It is available in a new paperback edition (Harper & Row, $1.25).

  2. 2

    Profession of Medicine: A Study of the Sociology of Applied Knowledge, Dodd, Mead, 409 pp., $12.50. This is a new, interesting book which is partly a provocative study, partly a depressing reminder of the sorry state of medical sociology; I shall discuss it in a future essay.

  3. 3

    Daniel Schorr, Don’t Get Sick in America, Aurora, 224 pp., $5.95.

  4. 4

    Of the earlier group, Roul Tunley, The American Health Scandal, Harper and Row, 282 pp., $5.95 (1966), Selig Greenberg, The Troubled Calling, Macmillan, 398 pp., $6.95 (1965), and Richard Harris, A Sacred Trust, now reprinted, are the best.

  5. 5

    For this section I have relied primarily upon Richard Harrison Shryock, Medicine and Society in America: 1660-1860, Cornell, 182 pp., $1.75 (paper), as well as a collection of that author’s essays, Medicine in America, Johns Hopkins, 346 pp., $7.50, and on Charles E. Rosenberg, The Cholera Years, Chicago, 257 pp., $2.95 (paper), 1962. These are excellent medical and social histories (Professor Rosenberg’s reads like Hofstadter at his best). But most medical history has been written from the top, emphasizing the glory of various physicians and surgeons and their discoveries, and has had very little to say about the critical social aspects of medical practice as it was experienced by the American people (on this point see Rosenberg, “The Medical Profession, Medical Practice and the History of Medicine,” in Edward Clarke, ed., Methods in the History of Medicine, University of London, 1970, pp. 22-35.)

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