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THE DOCTOR'S DILEMMA: PREFACE ON DOCTORS


By Bernard Shaw


1909



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,
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 favor.
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
ones - 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, etc., etc., etc."

Now there is no calculation that an engineer can make as to the behavior
of a girder under a strain, or an astronomer as to the recurrence of a
comet, more certain than the calculation that under such circumstances
we shall be dismembered unnecessarily in all directions by surgeons
who believe the operations to be necessary solely because they want to
perform them. The process metaphorically called bleeding the rich man
is performed not only metaphorically but literally every day by surgeons
who are quite as honest as most of us. After all, what harm is there
in it? The surgeon need not take off the rich man's (or woman's) leg or
arm: he can remove the appendix or the uvula, and leave the patient none
the worse after a fortnight or so in bed, whilst the nurse, the general
practitioner, the apothecary, and the surgeon will be the better.




DOUBTFUL CHARACTER BORNE BY THE MEDICAL PROFESSION

Again I hear the voices indignantly muttering old phrases about the
high character of a noble profession and the honor and conscience of
its members. I must reply that the medical profession has not a
high character: it has an infamous character. I do not know a single
thoughtful and well-informed person who does not feel that the tragedy
of illness at present is that it delivers you helplessly into the hands
of a profession which you deeply mistrust, because it not only advocates
and practises the most revolting cruelties in the pursuit of knowledge,
and justifies them on grounds which would equally justify practising the
same cruelties on yourself or your children, or burning down London to
test a patent fire extinguisher, but, when it has shocked the public,
tries to reassure it with lies of breath-bereaving brazenness. That
is the character the medical profession has got just now. It may be
deserved or it may not: there it is at all events, and the doctors who
have not realized this are living in a fool's paradise. As to the humor
and conscience of doctors, they have as much as any other class of men,
no more and no less. And what other men dare pretend to be impartial
where they have a strong pecuniary interest on one side? Nobody supposes
that doctors are less virtuous than judges; but a judge whose salary
and reputation depended on whether the verdict was for plaintiff or
defendant, prosecutor or prisoner, would be as little trusted as a
general in the pay of the enemy. To offer me a doctor as my judge, and
then weight his decision with a bribe of a large sum of money and a
virtual guarantee that if he makes a mistake it can never be proved
against him, is to go wildly beyond the ascertained strain which human
nature will bear. It is simply unscientific to allege or believe
that doctors do not under existing circumstances perform unnecessary
operations and manufacture and prolong lucrative illnesses. The only
ones who can claim to be above suspicion are those who are so much
sought after that their cured patients are immediately replaced by fresh
ones. And there is this curious psychological fact to be remembered: a
serious illness or a death advertizes the doctor exactly as a hanging
advertizes the barrister who defended the person hanged. Suppose, for
example, a royal personage gets something wrong with his throat, or has
a pain in his inside. If a doctor effects some trumpery cure with a wet
compress or a peppermint lozenge nobody takes the least notice of him.
But if he operates on the throat and kills the patient, or extirpates
an internal organ and keeps the whole nation palpitating for days whilst
the patient hovers in pain and fever between life and death, his fortune
is made: every rich man who omits to call him in when the same symptoms
appear in his household is held not to have done his utmost duty to
the patient. The wonder is that there is a king or queen left alive in
Europe.




DOCTOR'S CONSCIENCES

There is another difficulty in trusting to the honor and conscience of
a doctor. Doctors are just like other Englishmen: most of them have
no honor and no conscience: what they commonly mistake for these is
sentimentality and an intense dread of doing anything that everybody
else does not do, or omitting to do anything that everybody else
does. This of course does amount to a sort of working or rule-of-thumb
conscience; but it means that you will do anything, good or bad,
provided you get enough people to keep you in countenance by doing it
also. It is the sort of conscience that makes it possible to keep order
on a pirate ship, or in a troop of brigands. It may be said that in
the last analysis there is no other sort of honor or conscience in
existence - that the assent of the majority is the only sanction known to
ethics. No doubt this holds good in political practice. If mankind knew
the facts, and agreed with the doctors, then the doctors would be in
the right; and any person who thought otherwise would be a lunatic. But
mankind does not agree, and does not know the facts. All that can
be said for medical popularity 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. Moliere saw through the doctors;
but he had to call them in just the same. Napoleon had no illusions
about them; but he had to die under their treatment just as much as the
most credulous ignoramus that ever paid sixpence for a bottle of strong
medicine. In this predicament most people, to save themselves from
unbearable mistrust and misery, or from being driven by their conscience
into actual conflict with the law, fall back on the old rule that if you
cannot have what you believe in you must believe in what you have. When
your child is ill or your wife dying, and you happen to be very fond of
them, or even when, if you are not fond of them, you are human enough to
forget every personal grudge before the spectacle of a fellow creature
in pain or peril, what you want is comfort, reassurance, something to
clutch at, were it but a straw. This the doctor brings you. You have a
wildly urgent feeling that something must be done; and the doctor does
something. Sometimes what he does kills the patient; but you do not know
that; and the doctor assures you that all that human skill could do
has been done. And nobody has the brutality to say to the newly bereft
father, mother, husband, wife, brother, or sister, "You have killed your
lost darling by your credulity."




THE PECULIAR PEOPLE

Besides, the calling in of the doctor is now compulsory except in cases
where the patient is an adult - and not too ill to decide the steps to
be taken. We are subject to prosecution for manslaughter or for criminal
neglect if the patient dies without the consolations of the medical
profession. This menace is kept before the public by the Peculiar
People. The Peculiars, as they are called, have gained their name by
believing that the Bible is infallible, and taking their belief quite
seriously. The Bible is very clear as to the treatment of illness.
The Epistle of James; chapter v., contains the following explicit
directions:

14. Is any sick among you? let him call for the elders of the Church;
and let them pray over him, anointing him with oil in the name of the
Lord:

15. And the prayer of faith shall save the sick, and the Lord shall
raise him up; and if he have committed sins, they shall be forgiven him.

The Peculiars obey these instructions and dispense with doctors. They
are therefore prosecuted for manslaughter when their children die.

When I was a young man, the Peculiars were usually acquitted. The
prosecution broke down when the doctor in the witness box was asked
whether, if the child had had medical attendance, it would have lived.
It was, of course, impossible for any man of sense and honor to assume
divine omniscience by answering this in the affirmative, or indeed
pretending to be able to answer it at all. And on this the judge had to
instruct the jury that they must acquit the prisoner. Thus a judge with
a keen sense of law (a very rare phenomenon on the Bench, by the way)
was spared the possibility of leaving to sentence one prisoner (under
the Blasphemy laws) for questioning the authority of Scripture, and
another for ignorantly and superstitiously accepting it as a guide to
conduct. To-day all this is changed. The doctor never hesitates to claim
divine omniscience, nor to clamor for laws to punish any scepticism on
the part of laymen. A modern doctor thinks nothing of signing the death
certificate of one of his own diphtheria patients, and then going into
the witness box and swearing a peculiar into prison for six months
by assuring the jury, on oath, that if the prisoner's child, dead of
diphtheria, had been placed under his treatment instead of that of St.
James, it would not have lived. And he does so not only with impunity,
but with public applause, though the logical course would be to
prosecute him either for the murder of his own patient or for perjury
in the case of St. James. Yet no barrister, apparently, dreams of asking
for the statistics of the relative case-mortality in diphtheria among
the Peculiars and among the believers in doctors, on which alone any
valid opinion could be founded. The barrister is as superstitious as the
doctor is infatuated; and the Peculiar goes unpitied to his cell, though
nothing whatever has been proved except that his child does without
the interference of a doctor as effectually as any of the hundreds of
children who die every day of the same diseases in the doctor's care.




RECOIL OF THE DOGMA OF MEDICAL INFALLIBILITY ON THE DOCTOR

On the other hand, when the doctor is in the dock, or is the defendant
in an action for malpractice, he has to struggle against the inevitable
result of his former pretences to infinite knowledge and unerring skill.
He has taught the jury and the judge, and even his own counsel, to
believe that every doctor can, with a glance at the tongue, a touch
on the pulse, and a reading of the clinical thermometer, diagnose with
absolute certainty a patient's complaint, also that on dissecting a dead
body he can infallibly put his finger on the cause of death, and, in
cases where poisoning is suspected, the nature of the poison used. Now
all this supposed exactness and infallibility is imaginary; and to
treat a doctor as if his mistakes were necessarily malicious or corrupt
malpractices (an inevitable deduction from the postulate that the
doctor, being omniscient, cannot make mistakes) is as unjust as to
blame the nearest apothecary for not being prepared to supply you with
sixpenny-worth of the elixir of life, or the nearest motor garage for
not having perpetual motion on sale in gallon tins. But if apothecaries
and motor car makers habitually advertized elixir of life and perpetual
motion, and succeeded in creating a strong general belief that they
could supply it, they would find themselves in an awkward position if
they were indicted for allowing a customer to die, or for burning a
chauffeur by putting petrol into his car. That is the predicament the
doctor finds himself in when he has to defend himself against a charge
of malpractice by a plea of ignorance and fallibility. His plea is
received with flat credulity; and he gets little sympathy, even from
laymen who know, because he has brought the incredulity on himself. If
he escapes, he can only do so by opening the eyes of the jury to the
facts that medical science is as yet very imperfectly differentiated
from common curemongering witchcraft; that diagnosis, though it means in
many instances (including even the identification of pathogenic bacilli
under the microscope) only a choice among terms so loose that they would
not be accepted as definitions in any really exact science, is, even at
that, an uncertain and difficult matter on which doctors often differ;
and that the very best medical opinion and treatment varies widely from
doctor to doctor, one practitioner prescribing six or seven scheduled
poisons for so familiar a disease as enteric fever where another will
not tolerate drugs at all; one starving a patient whom another would
stuff; one urging an operation which another would regard as unnecessary
and dangerous; one giving alcohol and meat which another would sternly
forbid, etc., etc., etc.: all these discrepancies arising not between
the opinion of good doctors and bad ones (the medical contention is,
of course, that a bad doctor is an impossibility), but between
practitioners of equal eminence and authority. Usually it is impossible
to persuade the jury that these facts are facts. Juries seldom notice
facts; and they have been taught to regard any doubts of the omniscience
and omnipotence of doctors as blasphemy. Even the fact that doctors
themselves die of the very diseases they profess to cure passes
unnoticed. We do not shoot out our lips and shake our heads, saying,
"They save others: themselves they cannot save": their reputation
stands, like an African king's palace, on a foundation of dead bodies;
and the result is that the verdict goes against the defendant when the
defendant is a doctor accused of malpractice.

Fortunately for the doctors, they very seldom find themselves in this
position, because it is so difficult to prove anything against them. The
only evidence that can decide a case of malpractice is expert evidence:
that is, the evidence of other doctors; and every doctor will allow a
colleague to decimate a whole countryside sooner than violate the bond
of professional etiquet by giving him away. It is the nurse who gives
the doctor away in private, because every nurse has some particular
doctor whom she likes; and she usually assures her patients that all the
others are disastrous noodles, and soothes the tedium of the sick-bed
by gossip about their blunders. She will even give a doctor away for the
sake of making the patient believe that she knows more than the doctor.
But she dare not, for her livelihood, give the doctor away in public.
And the doctors stand by one another at all costs. Now and then some
doctor in an unassailable position, like the late Sir William Gull, will
go into the witness box and say what he really thinks about the way a
patient has been treated; but such behavior is considered little short
of infamous by his colleagues.




WHY DOCTORS DO NOT DIFFER

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 one pound seventeen shillings; and on the same ground
the five shilling man cannot encourage the notion that the owner of the
sixpenny surgery 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 Moliere
and Napoleon. 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 would 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 Radicals 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.




THE CRAZE FOR OPERATIONS

Thus everything is on the side of the doctor. When men die of disease
they are said to die from natural causes. When they recover (and they
mostly do) the doctor gets the credit of curing them. In surgery all
operations are recorded as successful if the patient can be got out of
the hospital or nursing home alive, though the subsequent history of the
case may be such as would make an honest surgeon vow never to recommend
or perform the operation again. The large range of operations which
consist of amputating limbs and extirpating organs admits of no direct
verification of their necessity. There is a fashion in operations as
there is in sleeves and skirts: the triumph of some surgeon who has at
last found out how to make a once desperate operation fairly safe
is usually followed by a rage for that operation not only among the
doctors, but actually among their patients. There are men and women whom
the operating table seems to fascinate; half-alive people who through
vanity, or hypochondria, or a craving to be the constant objects of
anxious attention or what not, lose such feeble sense as they ever had
of the value of their own organs and limbs. They seem to care as little
for mutilation as lobsters or lizards, which at least have the excuse
that they grow new claws and new tails if they lose the old ones. Whilst
this book was being prepared for the press a case was tried in the
Courts, of a man who sued a railway company for damages because a train
had run over him and amputated both his legs. He lost his case because
it was proved that he had deliberately contrived the occurrence himself
for the sake of getting an idler's pension at the expense of the railway
company, being too dull to realize how much more he had to lose than
to gain by the bargain even if he had won his case and received damages
above his utmost hopes.

Thus amazing case makes it possible to say, with some prospect of
being believed, that there is in the classes who can afford to pay
for fashionable operations a sprinkling of persons so incapable
of appreciating the relative importance of preserving their bodily
integrity, (including the capacity for parentage) and the pleasure of
talking about themselves and hearing themselves talked about as the
heroes and heroines of sensational operations, that they tempt
surgeons to operate on them not only with large fees, but with personal
solicitation. Now it cannot be too often repeated that when an operation
is once performed, nobody can ever prove that it was unnecessary. If I
refuse to allow my leg to be amputated, its mortification and my death
may prove that I was wrong; but if I let the leg go, nobody can ever
prove that it would not have mortified had I been obstinate. Operation
is therefore the safe side for the surgeon as well as the lucrative
side. The result is that we hear of "conservative surgeons" as a
distinct class of practitioners who make it a rule not to operate if
they can possibly help it, and who are sought after by the people who
have vitality enough to regard an operation as a last resort. But no
surgeon is bound to take the conservative view. If he believes that an
organ is at best a useless survival, and that if he extirpates it the
patient will be well and none the worse in a fortnight, whereas to
await the natural cure would mean a month's illness, then he is clearly
justified in recommending the operation even if the cure without
operation is as certain as anything of the kind ever can be. Thus the
conservative surgeon and the radical or extirpatory surgeon may both
be right as far as the ultimate cure is concerned; so that their
consciences do not help them out of their differences.




CREDULITY AND CHLOROFORM

There is no harder scientific fact in the world than the fact that
belief can be produced in practically unlimited quantity and intensity,
without observation or reasoning, and even in defiance of both, by the
simple desire to believe founded on a strong interest in believing.
Everybody recognizes this in the case of the amatory infatuations of
the adolescents who see angels and heroes in obviously (to others)
commonplace and even objectionable maidens and youths. But it holds good
over the entire field of human activity. The hardest-headed materialist
will become a consulter of table-rappers and slate-writers if he loses
a child or a wife so beloved that the desire to revive and communicate
with them becomes irresistible. The cobbler believes that there is
nothing like leather. The Imperialist who regards the conquest of
England by a foreign power as the worst of political misfortunes
believes that the conquest of a foreign power by England would be a boon
to the conquered. Doctors are no more proof against such illusions than
other men. Can anyone then doubt that under existing conditions a great
deal of unnecessary and mischievous operating is bound to go on,
and that patients are encouraged to imagine that modern surgery and
anesthesia have made operations much less serious matters than they
really are? When doctors write or speak to the public about operations,
they imply, and often say in so many words, that chloroform has made
surgery painless. People who have been operated on know better.
The patient does not feel the knife, and the operation is therefore
enormously facilitated for the surgeon; but the patient pays for the
anesthesia with hours of wretched sickness; and when that is over there
is the pain of the wound made by the surgeon, which has to heal like any
other wound. This is why operating surgeons, who are usually out of the


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