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George Bernard Shaw.

The Doctor's Dilemma: Preface on Doctors online

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question of the condition of the patient. The discoveries of Sir Almroth
Wright have shown that the appalling results which led to the hasty
dropping in 1894 of Koch's tuberculin were not accidents, but perfectly
orderly and inevitable phenomena following the injection of dangerously
strong "vaccines" at the wrong moment, and reinforcing the disease
instead of stimulating the resistance to it. To ascertain the right
moment a laboratory and a staff of experts are needed. The general
practitioner, having no such laboratory and no such experience, has
always chanced it, and insisted, when he was unlucky, that the results
were not due to the inoculation, but to some other cause: a favorite
and not very tactful one being the drunkenness or licentiousness of
the patient. But though a few doctors have now learnt the danger of
inoculating without any reference to the patient's "opsonic index"
at the moment of inoculation, and though those other doctors who are
denouncing the danger as imaginary and opsonin as a craze or a fad,
obviously do so because it involves an operation which they have neither
the means nor the knowledge to perform, there is still no grasp of the
economic change in the situation. They have never been warned that the
practicability of any method of extirpating disease depends not only on
its efficacy, but on its cost. For example, just at present the world
has run raving mad on the subject of radium, which has excited our
credulity precisely as the apparitions at Lourdes excited the credulity
of Roman Catholics. Suppose it were ascertained that every child in the
world could be rendered absolutely immune from all disease during its
entire life by taking half an ounce of radium to every pint of its
milk. The world would be none the healthier, because not even a Crown
Prince - no, not even the son of a Chicago Meat King, could afford
the treatment. Yet it is doubtful whether doctors would refrain from
prescribing it on that ground. The recklessness with which they now
recommend wintering in Egypt or at Davos to people who cannot afford to
go to Cornwall, and the orders given for champagne jelly and old port in
households where such luxuries must obviously be acquired at the cost of
stinting necessaries, often make one wonder whether it is possible for a
man to go through a medical training and retain a spark of common sense.
This sort of inconsiderateness gets cured only in the classes where
poverty, pretentious as it is even at its worst, cannot pitch its
pretences high enough to make it possible for the doctor (himself often
no better off than the patient) to assume that the average income of an
English family is about 2,000 pounds a year, and that it is quite easy
to break up a home, sell an old family seat at a sacrifice, and retire
into a foreign sanatorium devoted to some "treatment" that did not
exist two years ago and probably will not exist (except as a pretext
for keeping an ordinary hotel) two years hence. In a poor practice the
doctor must find cheap treatments for cheap people, or humiliate and
lose his patients either by prescribing beyond their means or sending
them to the public hospitals. When it comes to prophylactic inoculation,
the alternative lies between the complete scientific process, which can
only be brought down to a reasonable cost by being very highly organized
as a public service in a public institution, and such cheap,
nasty, dangerous and scientifically spurious imitations as ordinary
vaccination, which seems not unlikely to be ended, like its equally
vaunted forerunner, XVIII. century inoculation, by a purely reactionary
law making all sorts of vaccination, scientific or not, criminal
offences. Naturally, the poor doctor (that is, the average doctor)
defends ordinary vaccination frantically, as it means to him the bread
of his children. To secure the vehement and practically unanimous
support of the rank and file of the medical profession for any sort of
treatment or operation, all that is necessary is that it can be easily
practised by a rather shabbily dressed man in a surgically dirty room in
a surgically dirty house without any assistance, and that the materials
for it shall cost, say, a penny, and the charge for it to a patient with
100 pounds a year be half-a-crown. And, on the other hand, a hygienic
measure has only to be one of such refinement, difficulty, precision and
costliness as to be quite beyond the resources of private practice, to
be ignored or angrily denounced as a fad.

TRADE UNIONISM AND SCIENCE

Here we have the explanation of the savage rancor that so amazes people
who imagine that the controversy concerning vaccination is a scientific
one. It has really nothing to do with science. The medical profession,
consisting for the most part of very poor men struggling to keep up
appearances beyond their means, find themselves threatened with the
extinction of a considerable part of their incomes: a part, too, that
is easily and regularly earned, since it is independent of disease,
and brings every person born into the nation, healthy or not, to the
doctors. To boot, there is the occasional windfall of an epidemic,
with its panic and rush for revaccination. Under such circumstances,
vaccination would be defended desperately were it twice as dirty,
dangerous, and unscientific in method as it actually is. The note of
fury in the defence, the feeling that the anti-vaccinator is doing a
cruel, ruinous, inconsiderate thing in a mood of indignant folly: all
this, so puzzling to the observer who knows nothing of the economic side
of the question, and only sees that the anti-vaccinator, having
nothing whatever to gain and a good deal to lose by placing himself in
opposition to the law and to the outcry that adds private persecution to
legal penalties, can have no interest in the matter except the interest
of a reformer in abolishing a corrupt and mischievous superstition,
becomes intelligible the moment the tragedy of medical poverty and the
lucrativeness of cheap vaccination is taken into account.

In the face of such economic pressure as this, it is silly to expect
that medical teaching, any more than medical practice, can possibly
be scientific. The test to which all methods of treatment are finally
brought is whether they are lucrative to doctors or not. It would be
difficult to cite any proposition less obnoxious to science, than that
advanced by Hahnemann: to wit, that drugs which in large doses produce
certain symptoms, counteract them in very small doses, just as in more
modern practice it is found that a sufficiently small inoculation with
typhoid rallies our powers to resist the disease instead of prostrating
us with it. But Hahnemann and his followers were frantically persecuted
for a century by generations of apothecary-doctors whose incomes
depended on the quantity of drugs they could induce their patients to
swallow. These two cases of ordinary vaccination and homeopathy are
typical of all the rest. Just as the object of a trade union under
existing conditions must finally be, not to improve the technical
quality of the work done by its members, but to secure a living wage
for them, so the object of the medical profession today is to secure an
income for the private doctor; and to this consideration all concern for
science and public health must give way when the two come into conflict.
Fortunately they are not always in conflict. Up to a certain point
doctors, like carpenters and masons, must earn their living by doing the
work that the public wants from them; and as it is not in the nature
of things possible that such public want should be based on unmixed
disutility, it may be admitted that doctors have their uses, real as
well as imaginary. But just as the best carpenter or mason will resist
the introduction of a machine that is likely to throw him out of work,
or the public technical education of unskilled laborers' sons to compete
with him, so the doctor will resist with all his powers of persecution
every advance of science that threatens his income. And as the advance
of scientific hygiene tends to make the private doctor's visits rarer,
and the public inspector's frequenter, whilst the advance of scientific
therapeutics is in the direction of treatments that involve highly
organized laboratories, hospitals, and public institutions generally, it
unluckily happens that the organization of private practitioners which
we call the medical profession is coming more and more to represent, not
science, but desperate and embittered antiscience: a statement of things
which is likely to get worse until the average doctor either depends
upon or hopes for an appointment in the public health service for his
livelihood.

So much for our guarantees as to medical science. Let us now deal with
the more painful subject of medical kindness.




DOCTORS AND VIVISECTION

The importance to our doctors of a reputation for the tenderest humanity
is so obvious, and the quantity of benevolent work actually done by them
for nothing (a great deal of it from sheer good nature) so large, that
at first sight it seems unaccountable that they should not only throw
all their credit away, but deliberately choose to band themselves
publicly with outlaws and scoundrels by claiming that in the pursuit of
their professional knowledge they should be free from the restraints of
law, of honor, of pity, of remorse, of everything that distinguishes
an orderly citizen from a South Sea buccaneer, or a philosopher from
an inquisitor. For here we look in vain for either an economic or a
sentimental motive. In every generation fools and blackguards have
made this claim; and honest and reasonable men, led by the strongest
contemporary minds, have repudiated it and exposed its crude rascality.
From Shakespear and Dr. Johnson to Ruskin and Mark Twain, the natural
abhorrence of sane mankind for the vivisector's cruelty, and the
contempt of able thinkers for his imbecile casuistry, have been
expressed by the most popular spokesmen of humanity. If the medical
profession were to outdo the Anti-Vivisection Societies in a general
professional protest against the practice and principles of the
vivisectors, every doctor in the kingdom would gain substantially by the
immense relief and reconciliation which would follow such a reassurance
of the humanity of the doctor. Not one doctor in a thousand is a
vivisector, or has any interest in vivisection, either pecuniary or
intellectual, or would treat his dog cruelly or allow anyone else to do
it. It is true that the doctor complies with the professional fashion of
defending vivisection, and assuring you that people like Shakespear and
Dr. Johnson and Ruskin and Mark Twain are ignorant sentimentalists,
just as he complies with any other silly fashion: the mystery is, how
it became the fashion in spite of its being so injurious to those who
follow it. Making all possible allowance for the effect of the brazen
lying of the few men who bring a rush of despairing patients to their
doors by professing in letters to the newspapers to have learnt from
vivisection how to cure certain diseases, and the assurances of the
sayers of smooth things that the practice is quite painless under the
law, it is still difficult to find any civilized motive for an attitude
by which the medical profession has everything to lose and nothing to
gain.




THE PRIMITIVE SAVAGE MOTIVE

I say civilized motive advisedly; for primitive tribal motives are easy
enough to find. Every savage chief who is not a Mahomet learns that if
he wishes to strike the imagination of his tribe - and without doing that
he can rule them - he must terrify or revolt them from time to time by
acts of hideous cruelty or disgusting unnaturalness. We are far from
being as superior to such tribes as we imagine. It is very doubtful
indeed whether Peter the Great could have effected the changes he made
in Russia if he had not fascinated and intimidated his people by
his monstrous cruelties and grotesque escapades. Had he been a
nineteenth-century king of England, he would have had to wait for some
huge accidental calamity: a cholera epidemic, a war, or an insurrection,
before waking us up sufficiently to get anything done. Vivisection helps
the doctor to rule us as Peter ruled the Russians. The notion that the
man who does dreadful things is superhuman, and that therefore he can
also do wonderful things either as ruler, avenger, healer, or what not,
is by no means confined to barbarians. Just as the manifold wickednesses
and stupidities of our criminal code are supported, not by any general
comprehension of law or study of jurisprudence, not even by simple
vindictiveness, but by the superstition that a calamity of any sort must
be expiated by a human sacrifice; so the wickednesses and stupidities
of our medicine men are rooted in superstitions that have no more to do
with science than the traditional ceremony of christening an ironclad
has to do with the effectiveness of its armament. We have only to turn
to Macaulay's description of the treatment of Charles II in his last
illness to see how strongly his physicians felt that their only chance
of cheating death was by outraging nature in tormenting and disgusting
their unfortunate patient. True, this was more than two centuries ago;
but I have heard my own nineteenth-century grandfather describe the
cupping and firing and nauseous medicines of his time with perfect
credulity as to their beneficial effects; and some more modern
treatments appear to me quite as barbarous. It is in this way that
vivisection pays the doctor. It appeals to the fear and credulity of the
savage in us; and without fear and credulity half the private doctor's
occupation and seven-eighths of his influence would be gone.




THE HIGHER MOTIVE. THE TREE OF KNOWLEDGE.

But the greatest force of all on the side of vivisection is the mighty
and indeed divine force of curiosity. Here we have no decaying tribal
instinct which men strive to root out of themselves as they strive to
root out the tiger's lust for blood. On the contrary, the curiosity of
the ape, or of the child who pulls out the legs and wings of a fly
to see what it will do without them, or who, on being told that a cat
dropped out of the window will always fall on its legs, immediately
tries the experiment on the nearest cat from the highest window in
the house (I protest I did it myself from the first floor only), is as
nothing compared to the thirst for knowledge of the philosopher, the
poet, the biologist, and the naturalist. I have always despised Adam
because he had to be tempted by the woman, as she was by the serpent,
before he could be induced to pluck the apple from the tree of
knowledge. I should have swallowed every apple on the tree the moment
the owner's back was turned. When Gray said "Where ignorance is bliss,
'tis folly to be wise," he forgot that it is godlike to be wise; and
since nobody wants bliss particularly, or could stand more than a very
brief taste of it if it were attainable, and since everybody, by the
deepest law of the Life Force, desires to be godlike, it is stupid, and
indeed blasphemous and despairing, to hope that the thirst for knowledge
will either diminish or consent to be subordinated to any other end
whatsoever. We shall see later on that the claim that has arisen in this
way for the unconditioned pursuit of knowledge is as idle as all dreams
of unconditioned activity; but none the less the right to knowledge must
be regarded as a fundamental human right. The fact that men of science
have had to fight so hard to secure its recognition, and are still so
vigorously persecuted when they discover anything that is not quite
palatable to vulgar people, makes them sorely jealous for that right;
and when they hear a popular outcry for the suppression of a method of
research which has an air of being scientific, their first instinct is
to rally to the defence of that method without further consideration,
with the result that they sometimes, as in the case of vivisection,
presently find themselves fighting on a false issue.




THE FLAW IN THE ARGUMENT

I may as well pause here to explain their error. The right to know
is like the right to live. It is fundamental and unconditional in its
assumption that knowledge, like life, is a desirable thing, though any
fool can prove that ignorance is bliss, and that "a little knowledge is
a dangerous thing" (a little being the most that any of us can attain),
as easily as that the pains of life are more numerous and constant than
its pleasures, and that therefore we should all be better dead. The
logic is unimpeachable; but its only effect is to make us say that if
these are the conclusions logic leads to, so much the worse for logic,
after which curt dismissal of Folly, we continue living and learning by
instinct: that is, as of right. We legislate on the assumption that no
man may be killed on the strength of a demonstration that he would be
happier in his grave, not even if he is dying slowly of cancer and
begs the doctor to despatch him quickly and mercifully. To get killed
lawfully he must violate somebody else's right to live by committing
murder. But he is by no means free to live unconditionally. In society
he can exercise his right to live only under very stiff conditions. In
countries where there is compulsory military service he may even have to
throw away his individual life to save the life of the community.

It is just so in the case of the right to knowledge. It is a right that
is as yet very imperfectly recognized in practice. But in theory it
is admitted that an adult person in pursuit of knowledge must not be
refused it on the ground that he would be better or happier without
it. Parents and priests may forbid knowledge to those who accept their
authority; and social taboo may be made effective by acts of legal
persecution under cover of repressing blasphemy, obscenity, and
sedition; but no government now openly forbids its subjects to pursue
knowledge on the ground that knowledge is in itself a bad thing, or that
it is possible for any of us to have too much of it.




LIMITATIONS OF THE RIGHT TO KNOWLEDGE

But neither does any government exempt the pursuit of knowledge, any
more than the pursuit of life, liberty, and happiness (as the American
Constitution puts it), from all social conditions. No man is allowed
to put his mother into the stove because he desires to know how long an
adult woman will survive at a temperature of 500 degrees Fahrenheit,
no matter how important or interesting that particular addition to the
store of human knowledge may be. A man who did so would have short work
made not only of his right to knowledge, but of his right to live and
all his other rights at the same time. The right to knowledge is not
the only right; and its exercise must be limited by respect for other
rights, and for its own exercise by others. When a man says to Society,
"May I torture my mother in pursuit of knowledge?" Society replies,
"No." If he pleads, "What! Not even if I have a chance of finding out
how to cure cancer by doing it?" Society still says, "Not even then." If
the scientist, making the best of his disappointment, goes on to ask may
he torture a dog, the stupid and callous people who do not realize that
a dog is a fellow-creature and sometimes a good friend, may say Yes,
though Shakespear, Dr. Johnson and their like may say No. But even those
who say "You may torture A dog" never say "You may torture MY dog." And
nobody says, "Yes, because in the pursuit of knowledge you may do as
you please." Just as even the stupidest people say, in effect, "If
you cannot attain to knowledge without burning your mother you must do
without knowledge," so the wisest people say, "If you cannot attain to
knowledge without torturing a dog, you must do without knowledge."




A FALSE ALTERNATIVE

But in practice you cannot persuade any wise man that this alternative
can ever be forced on anyone but a fool, or that a fool can be trusted
to learn anything from any experiment, cruel or humane. The Chinaman who
burnt down his house to roast his pig was no doubt honestly unable to
conceive any less disastrous way of cooking his dinner; and the
roast must have been spoiled after all (a perfect type of the average
vivisectionist experiment); but this did not prove that the Chinaman
was right: it only proved that the Chinaman was an incapable cook and,
fundamentally, a fool.

Take another celebrated experiment: one in sanitary reform. In the days
of Nero Rome was in the same predicament as London to-day. If some one
would burn down London, and it were rebuilt, as it would now have to be,
subject to the sanitary by-laws and Building Act provisions enforced
by the London County Council, it would be enormously improved; and the
average lifetime of Londoners would be considerably prolonged. Nero
argued in the same way about Rome. He employed incendiaries to set it
on fire; and he played the harp in scientific raptures whilst it was
burning. I am so far of Nero's way of thinking that I have often said,
when consulted by despairing sanitary reformers, that what London needs
to make her healthy is an earthquake. Why, then, it may be asked, do not
I, as a public-spirited man, employ incendiaries to set it on fire,
with a heroic disregard of the consequences to myself and others? Any
vivisector would, if he had the courage of his opinions. The reasonable
answer is that London can be made healthy without burning her down; and
that as we have not enough civic virtue to make her healthy in a humane
and economical way, we should not have enough to rebuild her in that
way. In the old Hebrew legend, God lost patience with the world as Nero
did with Rome, and drowned everybody except a single family. But the
result was that the progeny of that family reproduced all the vices of
their predecessors so exactly that the misery caused by the flood might
just as well have been spared: things went on just as they did before.
In the same way, the lists of diseases which vivisection claims to have
cured is long; but the returns of the Registrar-General show that people
still persist in dying of them as if vivisection had never been
heard of. Any fool can burn down a city or cut an animal open; and an
exceptionally foolish fool is quite likely to promise enormous benefits
to the race as the result of such activities. But when the constructive,
benevolent part of the business comes to be done, the same want of
imagination, the same stupidity and cruelty, the same laziness and want
of perseverance that prevented Nero or the vivisector from devising or
pushing through humane methods, prevents him from bringing order out of
the chaos and happiness out of the misery he has made. At one time
it seemed reasonable enough to declare that it was impossible to find
whether or not there was a stone inside a man's body except by exploring
it with a knife, or to find out what the sun is made of without visiting
it in a balloon. Both these impossibilities have been achieved, but not
by vivisectors. The Rontgen rays need not hurt the patient; and
spectrum analysis involves no destruction. After such triumphs of humane
experiment and reasoning, it is useless to assure us that there is no
other key to knowledge except cruelty. When the vivisector offers us
that assurance, we reply simply and contemptuously, "You mean that you
are not clever or humane or energetic enough to find one."

CRUELTY FOR ITS OWN SAKE

It will now, I hope, be clear why the attack on vivisection is not
an attack on the right to knowledge: why, indeed, those who have the
deepest conviction of the sacredness of that right are the leaders of
the attack. No knowledge is finally impossible of human attainment; for
even though it may be beyond our present capacity, the needed capacity
is not unattainable. Consequently no method of investigation is the only
method; and no law forbidding any particular method can cut us off
from the knowledge we hope to gain by it. The only knowledge we lose by
forbidding cruelty is knowledge at first hand of cruelty itself, which
is precisely the knowledge humane people wish to be spared.

But the question remains: Do we all really wish to be spared that
knowledge? Are humane methods really to be preferred to cruel ones? Even
if the experiments come to nothing, may not their cruelty be enjoyed
for its own sake, as a sensational luxury? Let us face these questions
boldly, not shrinking from the fact that cruelty is one of the primitive


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Online LibraryGeorge Bernard ShawThe Doctor's Dilemma: Preface on Doctors → online text (page 3 of 7)