The Doctor’s Dilemma

George Bernard Shaw

The Society of Authors, on behalf of the Bernard Shaw Estate. Reprinted with permission.


    Extracts from Preface on Doctors
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. 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. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas,1 except when he does it to a poor person for practice.

Scandalized voices murmur that these operations are necessary. They may be. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the housebreaker the judges of that. If we did, no man’s neck would be safe and no man’s house stable. But we do make the doctor the judge, and fine him anything from sixpence to several hundred guineas if he decides in our favour. I cannot knock my shins severely without forcing on some surgeon the difficult question, ‘Could I not make a better use of a pocketful of guineas than this man is making of his leg? Could he not write as well—or even better—on one leg than on two? And the guineas would make all the difference in the world to me just now. My wife—my pretty ones2—the leg may mortify—it is always safer to operate—he will be well in a fortnight—artificial legs are now so well made that they are really better than natural ones—evolution is towards motors and leglessness, &c., &c., &c.’

.../


    Why doctors do not differ
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
The truth is, there would never be any public agreement among doctors if they did not agree to agree on the main point of the doctor being always in the right. Yet the two guinea man never thinks that the five shilling man is right: if he did, he would be understood as confessing to an overcharge of £1:17s; and on the same ground the five shilling man cannot encourage the notion that the owner of the sixpenny surgery3 round the corner is quite up to his mark. Thus even the layman has to be taught that infallibility is not quite infallible, because there are two qualities of it to be had at two prices.

But there is no agreement even in the same rank at the same price. During the first great epidemic of influenza towards the end of the nineteenth century a London evening paper sent round a journalist-patient to all the great consultants of that day, and published their advice and prescriptions: a proceeding passionately denounced by the medical papers as a breach of confidence of these eminent physicians. The case was the same; but the prescriptions were different, and so was the advice. Now a doctor cannot think his own treatment right and at the same time think his colleague right in prescribing a different treatment when the patient is the same. Anyone who has ever known doctors well enough to hear medical shop talked without reserve knows that they are full of stories about each other’s blunders and errors, and that the theory of their omniscience and omnipotence no more holds good among themselves than it did with Molière4 and Napoleon.5 But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor’s livelihood or reputation would be worth a year’s purchase. I do not blame him: I should do the same myself. But the effect of this state of things is to make the medical profession a conspiracy to hide its own shortcomings. No doubt the same may be said of all professions. They are all conspiracies against the laity; and I do not suggest that the medical conspiracy is either better or worse than the military conspiracy, the legal conspiracy, the sacerdotal conspiracy, the pedagogic conspiracy, the royal and aristocratic conspiracy, the literary and artistic conspiracy, and the innumerable industrial, commercial, and financial conspiracies, from the trade unions to the great exchanges, which make up the huge conflict which we call society. But it is less suspected. The Radicals6 who used to advocate, as an indispensable preliminary to social reform, the strangling of the last king with the entrails of the last priest, substituted compulsory vaccination for compulsory baptism without a murmur.

.../


    Medical poverty
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
To make matters worse, doctors are hideously poor. The Irish gentleman doctor of my boyhood, who took nothing less than a guinea, though he might pay you four visits for it, seems to have no equivalent nowadays in English society. Better be a railway porter than an ordinary English general practitioner. A railway porter has from eighteen to twenty-three shillings a week from the company merely as a retainer; and his additional fees from the public, if we leave the third-class twopenny tip out of account (and I am by no means sure that even this reservation need be made), are equivalent to doctor’s fees in the case of second-class passengers, and double doctor’s fees in the case of first. Any class of educated men thus treated tends to become a brigand7 class, and doctors are no exception to the rule. They are offered disgraceful prices for advice and medicine. Their patients are for the most part so poor and so ignorant that good advice would be resented as impracticable and wounding. When you are so poor that you cannot afford to refuse eighteenpence from a man who is too poor to pay you any more, it is useless to tell him that what he or his sick child needs is not medicine, but more leisure, better clothes, better food, and a better drained and ventilated house. It is kinder to give him a bottle of something almost as cheap as water, and tell him to come again with another eighteenpence if it does not cure him. When you have done that over and over again every day for a week, how much scientific conscience have you left? If you are weak-minded enough to cling desperately to your eighteenpence as denoting a certain social superiority to the sixpenny doctor, you will be miserably poor all your life; whilst the sixpenny doctor, with his low prices and quick turnover of patients, visibly makes much more than you do and kills no more people.

.../


    Are doctors men of science?
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
I presume nobody will question the existence of a widely spread popular delusion that every doctor is a man of science. It is escaped only in the very small class which understands by science something more than conjuring with retorts and spirit lamps, magnets and microscopes, and discovering magical cures for disease. To a sufficiently ignorant man every captain of a trading schooner is a Galileo, every organ-grinder a Beethoven, every piano-tuner a Helmholtz,8 every Old Bailey barrister a Solon,9 every Seven Dials10 pigeon-dealer a Darwin, every scrivener a Shakespeare, every locomotive engine a miracle, and its driver no less wonderful than George Stephenson.11 As a matter of fact, the rank and file of doctors are no more scientific than their tailors; or, if you prefer to put it in the reverse way, their tailors are no less scientific than they. Doctoring is an art, not a science: any layman who is interested in science sufficiently to take in one of the scientific journals and follow the literature of the scientific movement, knows more about it than those doctors (probably a large majority) who are not interested in it, and practise only to earn their bread. Doctoring is not even the art of keeping people in health (no doctor seems able to advise you what to eat any better than his grandmother or the nearest quack): it is the art of curing illnesses. It does happen exceptionally that a practising doctor makes a contribution to science; but it happens much oftener that he draws disastrous conclusions from his clinical experience because he has no conception of scientific method, and believes, like any rustic, that the handling of evidence and statistics needs no expertness. The distinction between a quack doctor and a qualified one is mainly that only the qualified one is authorized to sign death certificates, for which both sorts seem to have about equal occasion. Unqualified practitioners now make large incomes as hygienists, and are resorted to as frequently by cultivated amateur scientists who understand quite well what they are doing as by ignorant people who are simply dupes. Bone-setters make fortunes under the very noses of our greatest surgeons from educated and wealthy patients; and some of the most successful doctors on the register use quite heretical methods of treating disease, and have qualified themselves solely for convenience. Leaving out of account the village witches who prescribe spells and sell charms, the humblest professional healers in this country are the herbalists. These men wander through fields on Sunday seeking for herbs with magic properties of curing disease, preventing childbirth, and the like. Each of them believes that he is on the verge of a great discovery, in which Virginia Snake Root will be an ingredient, heaven knows why! Virginia Snake Root fascinates the imagination of the herbalist as mercury used to fascinate the alchemists. On week days he keeps a shop in which he sells packets of pennyroyal, dandelion, &c. labelled with little lists of the diseases they are supposed to cure, and apparently do cure to the satisfaction of the people who keep on buying them. I have never been able to perceive any distinction between the science of the herbalist and that of the duly registered doctor. A relative of mine recently consulted a doctor about some of the ordinary symptoms which indicate the need for a holiday and a change. The doctor satisfied himself that the patient’s heart was a little depressed. Digitalis being a drug labelled as a heart specific by the profession, he promptly administered a stiff dose. Fortunately the patient was a hardy old lady who was not easily killed. She recovered with no worse result than her conversion to Christian Science, which owes its vogue quite as much to public despair of doctors as to superstition. I am not, observe, here concerned with the question as to whether the dose of digitalis was judicious or not: the point is, that a farm labourer consulting a herbalist would have been treated in exactly the same way.

/...

/...


    Statistical illusions
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
Public ignorance of the laws of evidence and of statistics can hardly be exaggerated. There may be a doctor here and there who in dealing with the statistics of disease has taken at least the first step towards sanity by grasping the fact that as an attack of even the commonest disease is an exceptional event, apparently overwhelming statistical evidence in favour of any prophylactic can be produced by persuading the public that everybody caught the disease formerly. Thus if a disease is one which normally attacks fifteen per cent of the population, and if the effect of a prophylactic is actually to increase the proportion to twenty per cent, the publication of this figure of twenty per cent will convince the public that the prophylactic has reduced the percentage by eighty per cent instead of increasing it by five, because the public, left to itself and to the old gentlemen who are always ready to remember, on every possible subject, that things used to be much worse than they are now (such old gentlemen greatly outnumber the laudatores tempori acti12), will assume that the former percentage was about 100. The vogue of the Pasteur treatment of hydrophobia, for instance, was due to the assumption by the public that every person bitten by a rabid dog necessarily got hydrophobia. I myself heard hydrophobia discussed in my youth by doctors in Dublin before a Pasteur Institute existed, the subject having been brought forward there by the scepticism of an eminent surgeon as to whether hydrophobia is really a specific disease or only ordinary tetanus induced (as tetanus was then supposed to be induced) by a lacerated wound. There were no statistics available as to the proportion of dog bites that ended in hydrophobia; but nobody ever guessed that the cases could be more than two or three per cent of the bites. On me, therefore, the results published by the Pasteur Institute produced no such effect as they did on the ordinary man who thinks that the bite of a mad dog means certain hydrophobia. It seemed to me that the proportion of deaths among the cases treated at the Institute was rather higher, if anything, than might have been expected had there been no Institute in existence. But to the public every Pasteur patient who did not die was miraculously saved from an agonizing death by the beneficent white magic of that most trusty of all wizards, the man of science.

Even trained statisticians often fail to appreciate the extent to which statistics are vitiated by the unrecorded assumptions of their interpreters. Their attention is too much occupied with the cruder tricks of those who make a corrupt use of statistics for advertising purposes. There is, for example, the percentage dodge.13 In some hamlet, barely large enough to have a name, two people are attacked during a smallpox epidemic. One dies: the other recovers. One has vaccination marks: the other has none. Immediately either the vaccinists or the anti-vaccinists publish the triumphant news that at such and such a place not a single vaccinated person died of smallpox whilst 100 per cent of the unvaccinated perished miserably; or, as the case may be, that 100 per cent of the unvaccinated recovered whilst the vaccinated succumbed to the last man. Or, to take another common instance, comparisons which are really comparisons between two social classes with different standards of nutrition and education are palmed off as comparisons between the results of a certain medical treatment and its neglect. Thus it is easy to prove that the wearing of tall hats and the carrying of umbrellas enlarges the chest, prolongs life, and confers comparative immunity from disease; for the statistics show that the classes which use these articles are bigger, healthier, and live longer than the class which never dreams of possessing such things. It does not take much perspicacity to see that what really makes this difference is not the tall hat and the umbrella, but the wealth and nourishment of which they are evidence, and that a gold watch or membership of a club in Pall Mall14 might be proved in the same way to have the like sovereign15 virtues. A university degree, a daily bath, the owning of thirty pairs of trousers, a knowledge of Wagner’s music, a pew in church, anything, in short, that implies more means and better nurture than the mass of labourers enjoy, can be statistically palmed off16 as a magic-spell conferring all sorts of privileges.

In the case of a prophylactic enforced by law, this illusion is intensified grotesquely, because only vagrants can evade it. Now vagrants have little power of resisting any disease: their death-rate and their race-mortality rate is always high relatively to that of respectable folk. Nothing is easier, therefore, than to prove that compliance with any public regulation produces the most gratifying results. It would be equally easy even if the regulation actually raised the death-rate, provided it did not raise it sufficiently to make the average householder, who cannot evade regulations, die as early as the average vagrant who can.


    The suprises of attention and neglect
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
There is another statistical illusion which is independent of class differences. A common complaint of houseowners is that the Public Health Authorities frequently compel them to install costly sanitary appliances which are condemned a few years later as dangerous to health, and forbidden under penalties. Yet these discarded mistakes are always made in the first instance on the strength of a demonstration that their introduction has reduced the death-rate. The explanation is simple. Suppose a law were made that every child in the nation should be compelled to drink a pint of brandy per month, but that the brandy must be administered only when the child was in good health, with its digestion and so forth working normally, and its teeth either naturally or artificially sound. Probably the result would be an immediate and startling reduction in child mortality, leading to further legislation increasing the quantity of brandy to a gallon. Not until the brandy craze had been carried to a point at which the direct harm done by it would outweigh the incidental good, would an anti-brandy party be listened to. That incidental good would be the substitution of attention to the general health of children for the neglect which is now the rule so long as the child is not actually too sick to run about and play as usual. Even if this attention were confined to the children’s teeth, there would be an improvement which it would take a good deal of brandy to cancel.

This imaginary case explains the actual case of the sanitary appliances which our local sanitary authorities prescribe today and condemn tomorrow. No sanitary contrivance which the mind of even the very worst plumber can devise could be as disastrous as that total neglect for long periods which gets avenged by pestilences that sweep through whole continents, like the black death and the cholera. If it were proposed at this time of day to discharge all the sewage of London crude and untreated into the Thames, instead of carrying it, after elaborate treatment, far out into the North Sea, there would be a shriek of horror from all our experts. Yet if Cromwell17 had done that instead of doing nothing, there would probably have been no Great Plague of London. When the Local Health Authority forces every householder to have his sanitary arrangements thought about and attended to by somebody whose special business it is to attend to such things, then it matters not how erroneous or even directly mischievous may be the specific measures taken: the net result at first is sure to be an improvement. Not until attention has been effectually substituted for neglect as the general rule, will the statistics begin to show the merits of the particular methods of attention adopted. And as we are far from having arrived at this stage, being as to health legislation only at the beginning of things, we have practically no evidence yet as to the value of methods. Simple and obvious as this is, nobody seems as yet to discount the effect of substituting attention for neglect in drawing conclusions from health statistics. Everything is put to the credit of the particular method employed, although it may quite possibly be raising the death-rate by five per thousand whilst the attention incidental to it is reducing the death-rate fifteen per thousand. The net gain of ten per thousand is credited to the method, and made the excuse for enforcing more of it.


    Stealing credit from civilization
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
There is yet another way in which specifics which have no merits at all, either direct or incidental, may be brought into high repute by statistics. For a century past civilization has been cleaning away the conditions which favour bacterial fevers. Typhus, once rife, has vanished: plague and cholera have been stopped at our frontiers by a sanitary blockade. We still have epidemics of smallpox and typhoid; and diphtheria and scarlet fever are endemic in the slums. Measles, which in my childhood was not regarded as a dangerous disease, has now become so mortal that notices are posted publicly urging parents to take it seriously. But even in these cases the contrast between the death and recovery rates in the rich districts and in the poor ones has led to the general conviction among experts that bacterial diseases are preventable; and they already are to a large extent prevented. The dangers of infection and the way to avoid it are better understood than they used to be. It is barely twenty years since people exposed themselves recklessly to the infection of consumption and pneumonia in the belief that these disease were not ‘catching’.18 Nowadays the troubles of consumptive patients are greatly increased by the growing disposition to treat them as lepers. No doubt there is a good deal of ignorant exaggeration and cowardly refusal to face a human and necessary share of the risk. That has always been the case. We now know that the medieval horror of leprosy was out of all proportion to the danger of infection and was accompanied by apparent blindness to the infectiousness of smallpox, which has since been worked up19 by our disease terrorists into the position formerly held by leprosy. But the scare of infection, though it sets even doctors talking as if the only really scientific thing to do with a fever patient is to throw him into the nearest ditch and pump carbolic acid on him from a safe distance until he is ready to be cremated on the spot, has led to much greater care and cleanliness. And the net result has been a series of victories over disease.

Now let us suppose that in the early nineteenth century somebody had come forward with a theory that typhus fever always begins at the top joint of the little finger; and that if this joint be amputated immediately after birth, typhus fever will disappear. Had such a suggestion been adopted, the theory would have been triumphantly confirmed; for as a matter of fact, typhus fever has disappeared. On the other hand cancer and madness have increased (statistically) to an appalling extent. The opponents of the little finger theory would therefore be pretty sure to allege that the amputations were spreading cancer and lunacy.

.../

To advertise any remedy or operation, you have only to pick out all the most reassuring advances made by civilization, and boldly present the two in the relation of cause and effect: the public will swallow the fallacy without a wry face. It has no idea of the need for what is called a control experiment. In Shakespeare’s time and for long after it, mummy was a favourite medicament. You took a pinch of the dust of a dead Egyptian in a pint of the hottest water you could bear to drink; and it did you a great deal of good. This, you thought, proved what a sovereign healer mummy was. But if you had tried the control experiment of taking the hot water without the mummy, you might have found the effect exactly the same, and that any hot drink would have done as well.

/...

.../


    Patient-made therapeutics
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
To all these blunders and ignorances doctors are no less subject than the rest of us. They are not trained in the use of evidence, nor in biometrics, nor in the psychology of human credulity, nor in the incidence of economic pressure. Further, they must believe, on the whole, what their patients believe, just as they must wear the sort of hat their patients wear. The doctor may lay down the law despotically enough to the patient at points where the patient’s mind is simply blank; but when the patient has a prejudice the doctor must either keep it in countenance20 or lose his patient. If people are persuaded that night air is dangerous to health and that fresh air makes them catch cold, it will not be possible for a doctor to make his living in private practice if he prescribes ventilation. We have to go back no further than the days of The Pickwick Papers21 to find ourselves in a world where people slept in four-post beds with curtains drawn closely round to exclude as much air as possible. Had Mr Pickwick’s doctor told him that he would be much healthier if he slept on a camp bed by an open window, Mr Pickwick would have regarded him as a crank and called in another doctor. Had he gone on to forbid Mr Pickwick to drink brandy and water whenever he felt chilly, and assured him that if he were deprived of meat or salt for a whole year, he would not only not die, but would be none the worse, Mr Pickwick would have fled from his presence as from that of a dangerous madman. And in these matters the doctor cannot cheat his patient. If he has no faith in drugs or vaccination, and the patient has, he can cheat him with coloured water and pass his lance through the flame of a spirit lamp before scratching his arm. But he cannot make him change his daily habits without knowing it.


    The reforms also come from the laity
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
In the main, then, the doctor learns that if he gets ahead of the superstitions of his patients he is a ruined man; and the result is that he instinctively takes care not to get ahead of them. That is why all the changes come from the laity. It was not until an agitation had been conducted for many years by laymen, including quacks and faddists22 of all kinds, that the public was sufficiently impressed to make it possible for the doctors to open their minds and their mouths on the subject of fresh air, cold water, temperance, and the rest of the new fashions in hygiene. At present the tables have been turned on many old prejudices. Plenty of our most popular elderly doctors believe that cold tubs in the morning are unnatural, exhausting, and rheumatic; that fresh air is a fad, and that everybody is the better for a glass or two of port wine every day; but they no longer dare say as much until they know exactly where they are; for many very desirable patients in country houses have lately been persuaded that their first duty is to get up at six in the morning and begin the day by taking a walk barefoot through the dewy grass. He who shows the least scepticism as to this practice is at once suspected of being ‘an old-fashioned doctor,’ and dismissed to make room for a younger man.

In short, private medical practice is governed not by science but by supply and demand; and however scientific a treatment may be, it cannot hold its place in the market if there is no demand for it; nor can the grossest quackery be kept off the market if there is a demand for it.


    Fashions and epidemics
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
A demand, however, can be inculcated. This is thoroughly understood by fashionable tradesmen, who find no difficulty in persuading their customers to renew articles that are not worn out, and to buy things they do not want. By making doctors tradesmen, we compel them to learn the tricks of trade; consequently we find that the fashions of the year include treatments, operations, and particular drugs, as well as hats, sleeves, ballads and games. Tonsils, vermiform appendices, uvulas, even ovaries are sacrificed because it is the fashion to get them cut out, and because the operations are highly profitable. The psychology of fashion becomes a pathology; for all the cases have every air of being genuine: fashions, after all, are only induced epidemics, proving that epidemics can be induced by tradesmen, and therefore by doctors.

.../


    The social solution of the medical problem
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
The social solution of the medical problem, then, depends on that large, slowly advancing, pettishly resisted integration of society called generally Socialism. Until the medical profession becomes a body of men trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credulity and human suffering. Already our M.O.H.s (Medical Officers of Health) are in the new position; what is lacking is appreciation of the change, not only by the public but by the private doctors. For, as we have seen, when one of the first-rate posts becomes vacant in one of the great cities, and all the leading M.O.H.s compete for it, they must appeal to the good health of the cities of which they have been in charge, and not to the size of the incomes the local private doctors are making out of the ill-health of their patients. If a competitor can prove that he has utterly ruined every sort of medical private practice in a large city except obstetric practice and the surgery of accidents, his claims are irresistible; and this is the ideal at which every M.O.H. should aim. But the profession at large should none the less welcome him and set its house in order23 for the social change which will finally be its own salvation. For the M.O.H. as we know him is only the beginning of that army of Public Hygiene which will presently take the place in general interest and honour now occupied by our military and naval forces. It is silly that an Englishman should be more afraid of a German soldier than of a British disease germ, and should clamour for more barracks in the same newspapers that protest against more school clinics, and cry out that if the state fights disease for us it makes us paupers, though they never say that if the State fights the Germans for us it makes us cowards. Fortunately, when a habit of thought is silly it only needs steady treatment by ridicule from sensible and witty people to be put out of countenance and perish. Every year sees an increase in the number of persons employed in the Public Health Service, who would formerly have been mere adventurers in the Private Illness Service. To put it another way, a host of men and women who have now a strong incentive to be mischievous and even murderous rogues will have a much stronger, because a much honester, incentive to be not only good citizens but active benefactors to the community. And they will have no anxiety whatever about their incomes.

.../


    The latest theories
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
.../

Lest this should seem too rhetorical a conclusion for our professional men of science, who are mostly trained not to believe anything unless it is worded in the jargon of those writers who, because they never really understand what they are trying to say, cannot find familiar words for it, and are therefore compelled to invent a new language of nonsense for every book they write, let me sum up my conclusions as dryly as is consistent with accurate thought and live conviction.

  1. Nothing is more dangerous than a poor doctor: not even a poor employer or a poor landlord.
  2. Of all the anti-social vested interests the worst is the vested interest in ill-health.
  3. Remember that an illness is a misdemeanour; and treat the doctor as an accessory unless he notifies every case to the Public Health Authority.
  4. Treat every death as a possible, and under our present system, a probable murder, by making it the subject of a reasonably conducted inquest; and execute the doctor, if necessary as a doctor, by striking him off the register.
  5. Make up your mind how many doctors the community needs to keep it well. Do not register more or less than this number; and let registration constitute the doctor a civil servant with a dignified living wage paid out of public funds.
  6. Municipalize Harley Street.
  7. Treat the private operator exactly as you would treat a private executioner.
  8. Treat persons who profess to be able to cure disease as you treat fortune tellers.
  9. Keep the public carefully informed, by special statistics and announcements of individual cases, of all illnesses of doctors or in their families.
  10. Make it compulsory for a doctor using a brass plate24 to have inscribed on it, in addition to the letters indicating his qualifications, the words ‘Remember that I too am mortal’.
  11. In legislation and social organization, proceed on the principle that invalids, meaning persons who cannot keep themselves alive by their own activities, cannot, beyond reason, expect to be kept alive by the activity of others. There is a point at which the most energetic policemen or doctor, when called upon to deal with an apparently drowned person, gives up artificial respiration, although it is never possible to declare with certainty, at any point short of decomposition, that another five minutes of the exercise would not effect resuscitation. The theory that every individual alive is of infinite value is legislatively impracticable. No doubt the higher the life we secure to the individual by wise social organization, the greater his value is to the community, and the more pains we shall take to pull him through any temporary danger or disablement. But the man who costs more than he is worth is doomed by sound hygiene as inexorably as by sound economics.
  12. Do not try to live for ever. You will not succeed.
  13. Use your health, even to the point of wearing it out. That is what it is for. Spend all you have before you die; and do not outlive yourself.
  14. Take the utmost care to get well born and well brought up. This means that your mother must have a good doctor. Be careful to go to a school where there is what they call a school clinic, where your nutrition and teeth and eyesight and other matters of importance to you will be attended to. Be particularly careful to have all this done at the expense of the nation, as otherwise it will not be done at all, the chances being about forty to one against your being able to pay for it directly yourself, even if you know how to set about it. Otherwise 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.

.../

The following notes are offered for assistance;


    References
 Top
 Extracts from Preface on...
 Why doctors do not...
 Medical poverty
 Are doctors men of...
 Statistical illusions
 The suprises of attention...
 Stealing credit from...
 Patient-made therapeutics
 The reforms also come...
 Fashions and epidemics
 The social solution of...
 The latest theories
 References
 
1 English gold coin, no longer in use, value £1: 1 shilling, at a time when there were 20 shillings to £1 sterling and 12 pennies to 1 shilling.

2 Parents’ term of affection for ‘my children’.

3 Indicating the amount a doctor at the time might charge in very poor districts.

4 French comic playwright (1622–73).

5 Emperor of France with great sense of status, subsequently exiled.

6 Name formerly given to extreme political left-wing in Britain.

7 Unscrupulous opportunist.

8 19th century German philosopher, scientist and mathematician.

9 Solomon—famous Greek law maker 5th Century BC.

10 Area of London which was a notorious resort of bad characters.

11 British engineer and inventor of the railway engine.

12 Those who praise the past.

13 Trick.

14 A street in London occupied by expensive and exclusive clubs.

15 In this context, ‘beneficial’.

16 Colloquial term for fraudulently imposed.

17 Lord Protector of England, Scotland and Ireland in the 17th century during which there were several epidemics of plague culminating in the Great Plague of London in 1665.

18 Infectious.

19 ‘Worked up’ meaning inflated.

20 ‘keep it in countenance’ meaning to take notice of.

21 A novel of life in 19th century England by Charles Dickens.

22 Followers of current fashions or trends.

23 ‘set its house in order’ meaning prepare itself.

24 At the time, a doctor would buy a ‘brass plate’ meaning that he would purchase a group of patients from another doctor and put up a sign to advertise his profession.