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
“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.
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).
As the standard of living in the colonies rose, sons of the privileged class could afford a fashionable medical education in Europe. There they received liberal instruction in the medical classics and in whatever therapeutic theory (of the many, equally invalid ones) was in favor at a particular school at a particular time. Dr. Cullen of Edinburgh, for example, a teacher who influenced generations of American physicians, regarded disease as an imbalance of “the motions of the system” involving “asthenic” and “sthenic” debility and “spasms of the extreme arteries.”
Returning home, the students founded medical schools after the European model, and by the close of the eighteenth century the nation’s three largest cities had university-affiliated institutions which were laboring to raise the American medical profession from what Benjamin Rush called its “slavish rank.” This meant, in effect, a return to the concept of a medical elite. “Where a proper subordination is wanting,” Dr. John Morgan wrote in A Discourse upon the Institution of Medical Schools in America, “there is a perversion of all practical knowledge. No more then is a physician obliged, from his office, to handle a knife with a surgeon; to cull herbs with the botanist…or to compound drugs with the apothecary.”
Morgan, a founder of the University of Pennsylvania School of Medicine, pressed for a graded premedical curriculum, examinations of competence, licensing procedures for “real” physicans, medical “research,” and professional control of practice. Richard Harrison Shryock has noted that Morgan “prized the social distinction then implicit in the very concept of a physician…. He seems to have realized that in the long run the claim of physicians to guild superiority could be best justified by expanding scientific knowledge and so widening the gap between them and the ‘mere empirics.”‘ 6
The primary consequence of academic medical education, however, seemed to be that it produced practitioners of vast immodesty, who eagerly followed the current practice of bleeding. Dr. Benjamin Rush, for example, a professor at Pennsylvania and a signer of the Declaration of Independence, taught his classes that all infirmity was caused by excessive, convulsive, or wrong action of the vessels, and that, therefore, there was really “only one disease in the world.” To correct the tension of his patient’s vessels, Rush would occasionally remove four-fifths of his patient’s blood. The euphemism for this was “heroic” treatment. Rush’s somewhat intemperate bleeding and purging during the Yellow Fever epidemic of 1793 prompted a colleague to label it “one of those great discoveries which are made from time to time for the depopulation of the earth.”
Five years before, a “Doctors Mob” of New York citizenry had registered its discontent with academic practitioners by attempting to lynch those engaged in human dissection. And as late as the mid-nineteenth century medical efficacy had not much improved, as even physicians themselves would occasionally acknowledge. “If the entire Materia Medica were thrown into the sea,” Dr. Oliver Wendell Holmes remarked in 1861, “it would be all the better for mankind and all the worse for the fishes.”
The American Medical Association was founded in 1847. Comprised largely of academically trained “regular” physicians, the Association was, in the words of its charter, dedicated to promoting “the science and art of medicine and the betterment of public health.”7 In fact, however, it was at least as dedicated to promoting the idea that doctors with a particular kind of education (i.e., with M.D. degrees) were better than other doctors. The physician’s prestige in the latter half of the nineteenth century was conspicuously low, and competition was severe. Proprietary medical schools were common: they would admit anyone for the correct fee and, after a year more or less of occasional lectures, would certify him as a doctor.
The “poisoning and surgical butchery” of medical practitioners was denounced in the press, students were termed “coarse” and “licentious,” and physicians delivered lectures with such titles as “To What Cause Are We to Attribute the Diminished Respectability of the Medical Profession in the Estimation of the American Public?” In this light it is possible to view the Association’s early “reforming” efforts—to rid the profession of unorthodox healers, for example, and to protect the public from nostrum remedies—as less than wholly selfless. They may in fact be understood as part of a systematic attempt by a troubled medical elite to secure its social and economic status.
During the middle of the nineteenth century public hostility to the medical profession seems to have been common. In Jacksonian rhetoric “doctor-craft” was as anathematized as was “priestcraft.” Hydropathy, homeopathy, and other sects flourished; and editors warned their readers, according to Charles E. Rosenberg, that “every American must study the laws of health and disease for himself.” As the twentieth century approached, however, science began to provide the regular practitioner with the new legitimacy which Shaw recognized. The “laws of health and disease” were said now to be beyond the layman’s capability. So the stage was set, at last, for the doctors’ coup.
Abraham Flexner’s famous 1910 Report on Medical Education in the United States and Canada, sponsored by the Carnegie Commission and the AMA’s Council on Education, has been credited with “exposing” the proprietary medical school, forcing “quacks” from recognized practice, “rationalizing” and “standardizing” medical education, rescuing the profession from the dark pit of superstition, and raising it to the brilliant heights of science.
Important changes were in any event forthcoming early in the present century. The German model of a rigidly organized scientific medical education, with a strict curriculum and formal entrance requirements (which Johns Hopkins, founded only a few years before Flexner’s report, typified in this country), was adopted and remains standard today. Accordingly, Flexner has been revered as a catalyst of medicine’s great leap forward; and, to be sure, the new emphasis on laboratory science and research has had useful medical results.
But this much publicized consequence has its Shavian side. By 1930 the number of functioning medical schools in this country had dropped from over 200 (in 1900) to seventy-six. Doctors became richer, more self-important, more exclusive, and harder to find. The new medical priesthood, which for John Morgan was a dream and for Bernard Shaw a nightmare, was firmly invested at last.8
American medical history since the Second World War, which some of the books under review obliquely trace, suggests that the attempt to establish an ever more narrow and more influential medical elite has not been abandoned. Indeed, only now are the heirs of Dr. Morgan beginning to fight back—and in these battles all of us are engaged.
The mobilization of scientific and technological resources during World War II, including the development of large-scale medical programs for prophylaxis and treatment, stimulated unprecedented federal expenditures for medical research at the war’s end.9 Although the AMA vigorously opposed federal aid to medical education on the ground that “socialized medicine” would inevitably follow, the financing of medical-school-based research projects was apparently deemed harmless and even useful, probably because each new medical miracle could be expected to augment the status and power of the practicing physician (as well as because, one assumes, the Association’s membership thought disease was bad and health was good). The effects of federal financing, however, seem not to have been wholly anticipated.
First, government support (however indirect) of medical schools and hospitals began to enable these institutions to function independently of the community-based private practitioners upon whom they had previously relied. Second, as medical science and technology grew increasingly complex, a serious “town-gown” dichotomy developed between the private practitioner and his academic colleague. A second medical establishment, in many ways more powerful than the first, began to emerge: the urban university medical center. And just as the regular physicians of 1765 and 1847 and 1910 attempted rather arbitrarily to define other practitioners as incompetent and illegitimate, so the university medical elite is attempting today to dismiss the ordinary physician as someone unable to use or understand the most advanced techniques of modern medicine, unable to deal with the problems of the “social aspects” of medicine, unable to “allocate resources” systematically, and so on. The new medical priests are more sophisticated than the old, more powerful, and they have computers.
Most of the books under review are best understood as expressions of the current medical war. Most are part of the offensive of the urban medical centers, which has two goals. The first, and simpler, is to blame the acknowledged crisis on “organized medicine,” the American Medical Association. This dead horse is beaten at some length in In Failing Health, by Ed Cray. Five years ago Richard Harris did that job more effectively in A Sacred Trust, an account of the AMA leadership’s fight to stop Medicare. That book remains useful and is now available in paper.
The second goal of the offensive is to identify the academic medical elite as separate from and superior to the AMA, as aware of the difficulties faced by medicine today and energetically involved in finding new solutions. On this ground Women in Medicine, Negroes for Medicine, and Medicine in the Ghetto are important primarily because they exist; they are designed to serve as evidence of liberal awareness and concern.10 Each is the result of a conference.
Carol Lopate’s book on women concludes that the “manpower” crisis in medicine might be solved by making greater use of “womanpower.” But Miss Lopate hardly touches on the sexist character of American medical education and the society it “serves.” Lee Cogan’s book similarly avoids any real analysis of the reasons why blacks account for only 2.2 percent of American doctors. (Incidentally, blacks have always been used “for” medicine as research subjects and teaching material.) Dr. Norman’s book compiles the speeches delivered at a conference on “ghetto medicine,” sponsored by Harvard Medical School and the Boston Globe and held, according to the book, in Portsmouth, New Hampshire. In fact it was held at a shore resort spa called “Wentworth-by-the-Sea,” on the deck of a hotel which was a make-believe boat. Medical students invited to attend were so offended by the absence of poor people that they slept on the beach in protest. 11
The Carnegie Commission’s report, Higher Education and the Nation’s Health: Policies for Medical and Dental Education, is a more serious matter. It is the latest in a series of attempts to provide a “new Flexner Report,” something the spokesmen of the new medical elite have been advocating for years in their journals and in popular magazine articles for reasons strikingly similar to those of 1910.12 Respect for doctors is again low as a result of widespread public dissatisfaction with medical care. Partly as a result of this dissatisfaction, non-elite physicians will be less able to resist a move by the elite to consolidate power. (“The professional associations are open to new ideas and are anxious to find better ways to provide better health care—to their great credit and to the nation’s great advantage,” the report notes.) Most important, the medical generals are ready (“Existing medical and dental schools are expanding…. The medical and dental schools have a number of remarkably able leaders”).
Certainly the reasons for the Carnegie Commission’s concern may be less devious than my reading of the report suggests; as they may have been in 1910: the academic medical elite may be interested not only in power and prestige but in the nation’s health. That of course is the claim and doubtless many well-intentioned doctors sincerely believe it. Perhaps it is true that placing control of health facilities and resources in the hands of a narrow, powerful group of “experts” is the best way to make people healthy, although the evidence gathered in The American Health Empire would seem to contradict that claim. However, the university doctors and their supporters are not culpable simply because they are advocating the formation of a new elite. They are guilty of hypocrisy and manipulation precisely because they have not taken such a position openly.
If, as the Carnegie Commission suggests, we need “to provide more health personnel of the right kinds” and “to achieve a better geographic distribution,” “to provide more appropriate training,” and “to relate health care education more effectively to health care delivery,” then we will also need to decide some very difficult and important questions: what is “right”? What is “more appropriate”? What is “effective”? Will the new medical elite make these decisions because it alone has the information and the expertise to do so? Modern medicine is, after all, very complicated, so complicated that the G.P. trained ten years ago can’t keep up (if we are to believe the academics).
But what is good medicine? Who defines it? Will patients, consumers, citizens make decisions about health and doctors? Or will such people pretend to make medical policy while in fact the medical elite makes it (as, for example, we make military policy with the help and advice of the Pentagon)? These cannot be trivial questions. But the liberal medical establishment has been unable to raise them because it has refused to acknowledge openly what it is doing. (“As to the honor and conscience of doctors,” Shaw warned, “they have as much as any other class of men, no more and no less.”)
So we must attempt to understand what these doctors are doing and to raise questions about their work. Selig Greenberg, a medical reporter for many years and author of the excellent The Troubled Calling, might have been expected to do this. But in his new book The Quality of Mercy, he has seen only what the doctors he interviewed intended him to see—not what hospitals really are like. Mr. Greenberg is infatuated with the academic medical profession. The university hospital has evolved, he writes, into “the nexus of medical care.”
With the growing complexity of medicine and the consequent need for a concentration of specialized skills and sophisticated equipment, the hospital has increasingly become the place where the latest benefits of science can best be obtained. Here the emotion-charged struggle between life and death is a daily occurrence and new weapons of healing are forged.
This is where the exploration of the grim terrain of disease presents the great intellectual challenge and where apprentice physicians are trained to shift the balance in favor of the prolongation of life and vigor.
With equal fervor he concentrates upon Beth Israel Hospital, one of the Harvard “family,” which “has a notable history of service, education, research and innovation” and which is “a germinative center of both men and ideas.” The chief of surgery at Beth Israel is “a dedicated perfectionist”; the chief of psychiatry frequently voices “passionate concern” about things and is “level-headed”; and the man who edits the prestigious New England Journal of Medicine (“one of the brightest jewels in the diadem of Boston medicine…widely regarded as the best medical publication in the United States and probably in the world…a unique blend of passionate zeal and the cool poise of the Boston Brahmin”) is “a robust, hearty, articulate and endlessly inquisitive man…and a prominent gastro-enterologist.” There is no unfavorable portrait of an academic physician in this book.
Unfortunately, not only has Mr. Greenberg been misled, but he is also in a position to mislead others:
In the meantime a ceaseless battle against death was being waged in the medical and respiratory-surgical intensive-care units set aside for acutely ill patients requiring close monitoring of vital signs and constant care by physicians and nurses…. It is generally believed that use of the monitors can reduce deaths from initial heart attacks by at least half.
That statement, like many others in the book, requires closer scrutiny. The battle may be ceaseless, but it soon ends: even if a patient recovers from the “initial” heart attack (and the statistic here is questionable and offered without documentation), a second cardiac arrest often follows soon after. Those of us who have worked on an intensive care unit know how difficult it can be to “bring back” a cardiac patient two or three or four times in the course of a few days, only to “lose” him to another attack that no amount of intracardiac epinephrine and bicarbonate and chest pounding could dissuade. The cost is $200 per day—if it can be measured in money.
Moreover, while Greenberg reports that these units are “set aside for acutely ill patients,” in fact they are as often used to prolong the life of chronically ill patients in the terminal stages of their disease (as were two of the three patients Greenberg describes as being on the unit at Beth Israel). These chronic patients merely die a bit more slowly and painfully on the unit than they would elsewhere; and there is significant evidence of “ICU psychosis.” Intensive, expensive care has some advantages, but many fewer than Mr. Greenberg and the doctors he spoke to would have us believe.13
Mr. Greenberg refers to “the grasping self-interest of the medical profession”—the other medical profession, that is:
For purely selfish reasons, the AMA for more than 30 years sedulously fostered a shortage of doctors through its monopolistic stranglehold on the standards and admissions procedures of the nation’s medical schools….
Largely because of such a “stranglehold,” the book suggests, in cities like Boston there is now “the gross divergence between the bright technological potential and the grim reality” in medical care. We do not learn why the guilt is not shared by the “brilliant activists in important positions in the medical schools and teaching hospitals” who have never served the urban—generally ghetto—communities that are literally at their doorsteps. Nor are we told that the staffs of such hospitals have physically ejected black and poor people from their emergency rooms. We learn merely that these “activists” have “innovative ideas” and are “glimmers of hope in the ferment.”
Where precisely is the academic medical elite headed? What will happen when the “bright technological potential” is realized? First, Greenberg says, the doctors will have to stay in control because “much of this research is far too arcane for the untutored layman even to attempt to understand.” “But,” he adds, “all of it is aimed at alleviating pain and warding off premature death.” This is not true. There is little current medical research of which the essentials cannot be understood by anyone capable of reading Scientific American. Much of this research is aimed more at alleviating pressures to publish and rise in the profession than at alleviating pain.
Second, we learn that in the new and more “rational” health care delivery system, “The proper role for the great medical center…is to serve as the pinnacle of the pyramid…a sort of umbrella under which all the other parts function.” At the pinnacle, the university physician will “act as captain of the health team while aides working under his supervision assume some of the duties he is now performing.” It becomes clear that to Greenberg and to the leaders of the profession the primary obligation of the patient will be to recognize his own inadequacy and to follow, as always, the doctor’s orders.
Here the Orwellian implications of the plan become clear. “Much of the pleading for a resuscitation of general practice,” Mr. Greenberg tells us, speaking for the doctors, “is little more than a nostalgic harking back to the legendary old doc of yesteryear.” But that day “is gone forever,” and our hopes are a product of “our atavistic longing for personal attention,” a failure to recognize that “the pressures for change are relentless, and doctors as well as patients will eventually have to bow to them.”
…now there are diagnostic procedures which can penetrate the core of the body’s processes and yield evidence that makes the patient’s feelings superfluous…. Patients will have to be educated to a more realistic perception of quality.
“What’s the good of free choice to a patient who is unable to make the proper choice?” a prominent medical spokesman wants to know. If ICU nurses become depressed over a dying patient being kept temporarily (and sometimes unwillingly) alive by machines, a staff psychiatrist can be “called in to give them an opportunity to talk out their pity and concern.” If patients feel neglected in the modern hospital, that is simply because, Mr. Greenberg assures us, “The patient often regresses to an infantile, egocentric dependence in which he tends to invest his doctor with omniscient ability and at the same time to fret that he is not getting enough attention.” In other words, stop complaining! As one doctor put it, “Which would you rather have—warm compassionate care to usher you into the next world or cool scientific care to pull you back into this one?”
The difficulty is that “scientific care” may pull very few people back into this world for long, and can pull no one back permanently. Here a distinction should be drawn between certain advances—antibiotics, insulin, diuretics, and some others—which by no means need to be administered impersonally, and care which is more detached and machinelike by its very nature. In fact, a great deal of expensive, “cool” medical technology causes as much suffering as it prevents, kills or hurts as many people as it “saves.”
Heart transplantation, which costs some $40,000 per patient, is a case in point. In a period of two years since the first operation, over 150 transplants were performed: 80 percent of the patients died within four months; the rest lived limited, uncomfortable, fearful lives; and, in view of the imprecision of diagnostic techniques, it is likely that many of these patients would have lived longer with no operation at all, lived in less agony and with less expense to their families and society.
Mr. Greenberg and his academic sources admit as much, but they fail to admit that a similar, if less immediately apparent, case can be made against the efficacy and humanity of many of the most widely publicized medical “advances” upon which their claims of superiority rest: intensive care units, hyperbaric chambers, expensive diagnostic, surgical, and laboratory procedures (some of them unnecessarily painful), esoteric and useless research. There is the serious question, too, of priorities. Even if hyperbaric chambers were of great therapeutic value, which is doubtful, they are still of limited utility and immensely expensive. A chamber costs about three-quarters of a million dollars and some $600,000 each year to operate. In its five years of operation the unit at Mt. Sinai Hospital in New York, according to the authors of The American Health Empire, has been used for fewer than 900 patients.
For the same amount of money, the hospital might have handled 20,000 outpatient visits each year, or set up a vast screening program in East Harlem to detect lead poisoning and anemia in children. But such equipment is fashionable and modern, and a “good” hospital must have it if it is to keep up with the others. Doctors have, according to Shaw, “an intense dread of doing anything that everybody else does not do, or omitting to do anything that everybody else does.” So, apparently, do hospitals.
Of course, some of the new medical machines and procedures can help some patients if they are humanely used and if the public has an equitable chance to be treated by them. To criticize the excesses of the medical technocracy is not to deny the real achievements of the profession, or the potential of serious medical research. Certainly doctors will always need to be competent diagnosticians and skilled therapists. But they will also need to be concerned with the quality of their patients’ lives as well as their length, with the patient as a person and even a friend, as well as an intriguing collection of organs.
The management of a problem like juvenile diabetes, for example, requires less erudition about metabolism than social and psychological sensitivity. To know the protein structure of insulin may be useful, but to know intimately the child’s family situation, to be aware of and able to ameliorate feelings of guilt and dependency and fear, may be crucial. The rise of the medical elite, which denigrates the experience of the patient in the way Greenberg describes, distorts the very nature of healing.
The American Health Empire: Power, Profits and Politics, a report from the Health Policy Advisory Center (Health-PAC) in New York City, is the most solid criticism of American health care now available. It may make its readers feel terrible, which is right, because that is how it feels to be a patient, an orderly or technician, a nurse, and even a doctor these days. The “diagnosis” which the authors supply is not of the familiar health care crisis which Mr. Cray and even the AMA are now at last discovering, but of the very solutions which the sophisticated medical experts have begun noisily to offer.
Health-PAC is a research and action collective in New York City which grew out of the Institute for Policy Studies in Washington, D.C., and which for over two years has conducted inquiries into municipal and national health care policies.14 This book is a selection from the monthly Health-PAC bulletins in a revised and readable form. The authors present the problem of health care as follows:
Traditionally, liberals have explained that America is not a healthy place to live, in either a medical or a social sense, simply because health and other social services are low priority items in a nation whose resources are committed to military and economic expansion. “If we could only spend the money we spend in Vietnam on hospitals, housing, schools…” goes the refrain.
So we have reasoned. But on looking closer, we began to understand that national priorities are only part of the problem, perhaps the more manageable part. Billions of dollars could be diverted from America’s aggressive, defensive, and interplanetary enterprises with no appreciable effect on the quality of health care. For even within the institutions that make up America’s health system—hospitals, doctors, medical schools, drug companies—health care does not take the top priority. Health is no more a priority of the American health industry than safe, cheap, efficient, pollution-free transportation is a priority of the American automobile industry. [italics added]
The victims, then, are not just the poor, the blacks, the Puerto Ricans, who cannot afford to buy what the health industry is selling, but also all the millions of middle-class and working-class people who try to extract health services from the health industry.
Health-PAC’s description of New York City wholly undermines Mr. Greenberg’s description of Boston. “Increasingly,” the authors note, “control of health resources and facilities has become centralized in a few towering medical-school-linked systems…. At least two million New Yorkers are wholly dependent, and another four million partially dependent, on these medical empires for their health and strength.” The authors then show that “the private, university-connected empires have failed to deliver in all areas of promised performance.” Not only do they contend that there has been demonstrable malfeasance involving large sums of federal, state, and municipal funds, but that “in many cases, the narrow research, teaching, and profit priorities of the private empires have actually led to worsened conditions in the public hospitals, greater fragmentation, dehumanization, and neglect of basic health services.”
These are strong accusations indeed, and they are supported by ample documentation in the text. (Neither footnotes nor bibliography nor index are supplied, however; these are serious omissions, not because the authors’ statistics are questionable but because the sources used here might provoke further investigations.) The authors expose Medicare and Medicaid, each of the current proposals for National Health Insurance, the Blue Cross Associations, the federal Regional Medical Programs, and Comprehensive Health Planning legislation as constituting “openhanded public subsidy of the unregulated health system [which] is not only wasteful, but leaves permanent distortions.” And on the evidence of the New York experience they conclude that the medical elite’s current attempt to secure control of American health care is based upon “the philosophy guiding the American effort in Vietnam: if something was a mistake in the past, it deserves another try, but on a much bigger scale.” This seems an appropriate comment on the hope Mr. Greenberg saw glimmering in Boston.
A chapter of The American Health Empire provides a documented description of the vastly expanding and almost completely unregulated health industries: the pharmaceutical and hospital supplies firms, proprietary nursing homes, and the growing medical technology business. The authors note, “Trustees and upper-level staff of medical schools and hospitals are always welcome on the boards and top staffs of health industry firms and vice versa,” and conclude that “the consumer can expect no mercy from the new Medical-Industrial Complex.”
But I think the analysis of this alliance, which Shaw was able to foresee, is not carried as far as it can go. If, as it has done in the past, the medical elite continues to rely upon its technological expertise as an excuse for consolidating its power and for continually narrowing and elevating its ranks, the stage will soon be set for a new and unprecedented coup: the technocrats will assume unchallenged control of American medical practice. Our doctors will be computers. This is not humorously intended.
In Medicines for Man,15 Harry F. Dowling, a knowledgeable physician, documents the American pharmaceutical industry’s remarkable, almost dictatorial, power over the prescribing habits of physicians as well as its exorbitant profit structure.16 In the Health-PAC book we are reminded not only that (in the words of one trade journal) “Medicare is the computer manufacturer’s friend” but that, because physicians are ill-equiped to evaluate new medical machines, they are willing to buy almost anything; the flashier it looks and sounds, the better. (“As a matter of fact,” Shaw said, “the rank and file of doctors are no more scientific than their tailors.”) In The Quality of Mercy, Dr. Howard L. Bleich, a young researcher, “provides a glimpse into the future of medicine as he communed with a small computer console, no bigger than an electric typewriter.” Dr. Bleich entered information about the patient, but neglected to enter the patient’s weight.
The computer promptly called attention to this omission. After the weight was given, it printed out its evaluation of the patient’s acid-base disorder along with the recommended therapy, the appropriate drug dosage and two references to the literature bearing on the condition. It also politely thanked Dr. Bleich “for referring this interesting patient to us.”
To the old arrogance of doctors, then, has been added the arrogance of machines, of technology, of the corporate and governmental forces which control them, which increasingly control the doctors, and indeed all of us. The relationship between doctor and patient is very old, and was considered a “sacred trust” centuries before the AMA thought to insist that its sanctity depended upon the exchange of money. But where is sanctity in an era of medical systems analysis? If we want to touch and be touched by another person when we are sick or hurt or dying are we being immature? Should we “talk it out” with a psychiatrist? with a computer? (They can be programmed now to say “I see” and “Tell me more” and prescribe Librium in a lifelike voice.) If we have difficulty accepting doctors’ assurances that we “need not despair,” are we guilty, as Selig Greenberg suggests, of trusting our superfluous feelings, of failing to bow to the relentless pressure for change?
I think the Health-PAC analysis is not clear enough on this point. It rightly criticizes the academic medical leaders for subordinating the health needs of people to narrow research, “education,” and institutional priorities. The authors speak (as even the “liberals” now do) of the “ironic” contrast “between the promise of bio-medical technology and the tawdry reality of medical care.” They recall the liberal vows (in the case of the Regional Medical Program, for example) that “medical excellence would be decentralized from the current handful of major medical centers to a whole network of little pockets of excellence, all under the general guidance of the medical centers.” And, finally, they document the miserable failure of the medical elite to deliver on its promises.
The argument seems to run as follows: the “liberal” answer has not worked; therefore it will not work; and it cannot work, because the liberal doctors and their new corporate colleagues are not interested in making it work; they have other priorities. Therefore “profits must be phased out, for they have no place in an enterprise in which human life is at stake. A publicly accountable system must replace private enterprise in providing all health care and health products.”
That conclusion is inescapable. But the medical elite will insist that their “solutions” have not been given enough of a chance; that more money should be allocated for them; that the people then will be served. The Health-PAC position would be enhanced, I think, if it argued that even if the new doctors could, at great expense, fulfill their promises, the consequences would be disastrous; that what is considered “medical excellence” is, for the most part, not excellent at all; that the new medical priesthood, by the nature of its increasing dependence upon a complex technology it neither fully understands nor wholly controls, cannot have truly human priorities.
The dilemma of Shaw’s Dr. Ridgeon was whether he ought to use his cure for tuberculosis to “save” Jennifer’s husband, a brilliant young artist whom he detested and of whom he was jealous, or to “save” someone else and let the young man die: He chooses the latter and, in the final scene, presents himself to the widow, certain she will now become his wife. Jennifer has, however, remarried. “Oh, doctor, doctor!” she exclaims. “Sir Patrick is right; you do think you are a little god. How can you be so silly?” And all along, to be sure, Ridgeon’s “opsonin” was no cure for tuberculosis at all.
Were Shaw alive today, he would probably understand that the modern medical scientist works not merely for fame and money and power but because he believes that if cancer and heart disease are “conquered” the pain of being alive and mortal will be lessened, the potential for being human will be enlarged. Clearly this is what Shaw hoped for too, but he hoped differently. “Please do not class me,” he wrote
as one who “doesn’t believe in doctors.” One of our most pressing social needs is a national staff of doctors whom we can believe in, and whose prosperity shall depend not on the nation’s sickness but on its health.
But Shaw’s faith was less in science and machines than—as simple as it seems—in people living together more sensibly. This is how the health movement’s struggle for the community control of health institutions, described briefly at the end of The American Health Empire and now intensifying throughout the country, must be understood. “The social solution of the medical problem,” Shaw insisted, “depends on that large, slowly advancing, pettishly resisted integration of society called generally Socialism.”
And it was not the doctors, Shaw believed—as arrogant as they might be—who would make the decisions, but the patients themselves and the communities the doctors serve. Shaw hoped that we would learn to insist on certain things: on nationalizing the medical profession, on taking the profits out of dealing in people’s health and pain. What was needed in his view was “not really medicine or operations, but money…better food and better clothes…well-ventilated and well-drained houses.” “Otherwise,” he wrote in the final sentence of the Preface on Doctors, “you will be what most people are at present: an unsound citizen of an unsound nation, without sense enough to be ashamed or unhappy about it.”
We might remember Shaw as the medical war intensifies and more people become angry. Precisely because American medicine is in such a mess it presents unique opportunities. The rise of the new medical elite, ominous as it is, is only a relatively recent development. The technocrats may have less of a foothold in the medical system than in any other aspect of our society; by a concerted effort, they may still be stopped. In addition, although the Health-PAC people assert that “the age of the guild-dominated, individual medical craftsman is over” and although AMA membership is rapidly declining, the victory of the medical elite has not been assured.17
It is at least possible that the community practitioners may begin to understand that whatever remains sacred in medical practice cannot be preserved by clinging to the idea of fee-for-service, but that it may indeed be saved by aligning with the movement to provide medical care in thousands of small community free clinics. The fact is that free clinics are springing up across the country (there are an estimated 200 functioning now or in preparation). The struggle for community control of health facilities is gathering momentum. Workers and patients and students and professionals are beginning to work for the first time as colleagues.18
More than the war in Indochina, the military, even the schools, the issue of better and more democratic health care may provide a focus for constructive political action. In the past few years and even months the health movement has grown impressively. Several new chapters of the Medical Committee for Human Rights have been founded (there are now about forty) and the organization is increasingly finding a national voice; meanwhile its local affiliates staff free clinics, perform draft physicals, arrange abortions, provide medical care at antiwar demonstrations, collect medical supplies and literature for North Vietnam, organize within the military itself and in prisons. (Jane Kennedy, a nurse and past national vice-chairwoman of MCHR, remains in the Detroit House of Correction for her part in a raid on the Dow Chemical Research Center in Midland, Michigan, on November 6, 1969, during which magnetic tapes containing critical information about napalm were erased; Dow now produces antihistamines and other pharmaceuticals.)19
The Health-PAC collective is now at work on a documentary history of the movement, and similar groups are active in other large cities, such as the Health Information Project in Philadelphia and the Northwestern Health Collective in Chicago. Women, who constitute the majority of both health care “consumers” and workers, but who are especially victimized by the current system, are beginning to press for changes. (Pregnancy and childbirth are now treated by male doctors as routine diseases; the medical hierarchy is exclusively male-dominated; many hysterectomies and even mastectomies are performed without sound medical reasons; labor is too often induced, especially in the case of poor and black women, by oxytocin—an unsafe procedure when unnecessarily done—so that the woman will deliver at the doctor’s convenience.) Doctors are resisting the draft which takes them away from patients and from seriously understaffed hospitals. Not only ghetto organizers such as the Black Panthers and the Young Lords, but, increasingly, middle-class church and community groups are becoming interested in the idea of neighborhood clinics.
At the same time, hospital and insurance rates continue to rise, doctors become even harder to find. The air grows more difficult to breathe. The brains of black babies are poisoned by paint. The war for a decent chance to live a healthy life has started too late; but there are signs, at least, that it has started.
July 1, 1971
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). ↩
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. ↩
Daniel Schorr, Don’t Get Sick in America, Aurora, 224 pp., $5.95. ↩
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. ↩
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.) ↩
The growth of the academic medical elite in this country did provide an important link with European medical circles. Beginning with the study of pathologic anatomy in Paris during the nineteenth century, European physicians were largely responsible for working out the mechanistic view of the human body which prevails today and which has been in many respects fruitful (though in many ways dangerous too). For the purpose of this essay I have emphasized the generally neglected social and political consequences of the rise of a medical elite in this country. ↩
See James G. Burrow, A.M.A.: Voice of American Medicine, Johns Hopkins, 430 pp., $12.00 (1963). ↩
See Julius B. Richmond, Currents in American Medicine, Harvard, 138 pp., $5.50 (1969), and John H. Knowles, ed., The Teaching Hospital: Evolution and Contemporary Issues, Harvard, 152 pp., $4.50 (1969). ↩
More details are available in Richmond, Currents in American Medicine. ↩
John Kosa, Aaron Antonovsky and Irving Kenneth Zola, Poverty and Health: A Sociological Analysis, Harvard, 447 pp., $12.50 (1970), is a more accomplished example of this sort of book. I have examined it, along with Dr. Richmond’s book, in “The Failure of American Medicine,” The American Scholar, Autumn, 1970. ↩
A firsthand report of this tragicomic conference is available in Health Rights News, a publication of the Medical Committee for Human Rights, November, 1969. ↩
Dr. Alex Gerber (The Gerber Report, McKay, 242 pp., $6.95.) obviously intends, at least with his title, to fill this gap. He seems most concerned that Russia exports more physicians than we do and so is sneakily winning the cold war. He reduces the diverse and important radical health movement to “medical students going through the wards of municipal hospitals wearing turtleneck sweaters and dangling peace medallions in the faces of sick old ladies.” The initials M.D., F.A.C.S. (Fellow of the American College of Surgeons) appear after his name on the jacket in large yellow block letters. I hope someone is suitably impressed. ↩
In addition to exaggerating the efficiency of the new medical practitioner and his complex tools, the academics are conspicuously unfair to their colleagues outside the university hospitals. “There is evidence to suggest,” according to one physician cited by Greenberg, “that the actual medical performance of a significant number of American physicians is, within a few years of their departure from medical school and postgraduate training, grossly unscientific and dangerously close to ineptitude and incompetence.” ↩
Contributing to this book were: Robb Burlage, Barbara and John Ehrenreich, Oliver Fein, Maxine Kenny, Mills Matheson, Phil Wolfson, Leslie Cagan, Vicki Cooper, Ruth Glick, Kenneth Kimerling, Howard Levy. ↩
Harry F. Dowling, Medicines for Man, Knopf, 347 pp., $7.95. ↩
The pharmaceutical industry boasts of ratios of net income/sales and of net income/invested capital which are roughly twice as great as the national industrial median. The companies collectively spend nearly a billion dollars for promotional purposes, more than $3,000 per year on every doctor in the country. About half goes for printed journal ads and circulars (notoriously misleading, discriminatory, or blatantly false), more than a third for “detail men” assigned to push drugs to individual physicians on a personal basis (according to the maxim, as a former Squibb physician has testified, “If you can’t convince them, confuse them.”) ↩
Voluntary membership in the AMA is now under 50 percent of practicing physicians nationally, but the organization remains rather more strong than the Health-PAC book suggests. There can be no doubt that the medical elite in New York City is more advanced than it is in other cities. ↩
There is a partial listing of national free clinics in the January-February Health Rights News. Copies are available at request from HRN, 1613 E. 53rd Street, Chicago, Illinois 60615. The cost of a single issue is fifty cents; a one year subscription is three dollars. ↩
While in prison, Jane has worked actively to improve health conditions. One of her most recent campaigns was to improve dental treatment in the jail. According to her warden, interviewed in the Chicago Sun-Times: “She keeps telling everybody she’s a political prisoner. I’ve been in prison work more than forty years and I’ve never seen anything like her. Every time she’s told to do something, she has to ask why . She started a lot of trouble about the dentist we have here. She said the prisoners didn’t like the dentist and wanted a new one. It was her idea they had a right to pick their own dentist because he was working on their teeth. Well, that’s none of their business. We pick the dentist we want.” ↩