George Bernard Shaw.

The Doctor's Dilemma: Preface on Doctors online

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that are barred to all men of honor. Again, has the silliest burglar
ever pretended that to put a stop to burglary is to put a stop to
industry? All the vivisections that have been performed since the world
began have produced nothing so important as the innocent and honorable
discovery of radiography; and one of the reasons why radiography was not
discovered sooner was that the men whose business it was to discover
new clinical methods were coarsening and stupefying themselves with the
sensual villanies and cutthroat's casuistries of vivisection. The law of
the conservation of energy holds good in physiology as in other things:
every vivisector is a deserter from the army of honorable investigators.
But the vivisector does not see this. He not only calls his methods
scientific: he contends that there are no other scientific methods.
When you express your natural loathing for his cruelty and your natural
contempt for his stupidity, he imagines that you are attacking science.
Yet he has no inkling of the method and temper of science. The point at
issue being plainly whether he is a rascal or not, he not only insists
that the real point is whether some hotheaded antivivisectionist is a
liar (which he proves by ridiculously unscientific assumptions as to the
degree of accuracy attainable in human statement), but never dreams of
offering any scientific evidence by his own methods.

There are many paths to knowledge already discovered; and no enlightened
man doubts that there are many more waiting to be discovered. Indeed,
all paths lead to knowledge; because even the vilest and stupidest
action teaches us something about vileness and stupidity, and may
accidentally teach us a good deal more: for instance, a cutthroat learns
(and perhaps teaches) the anatomy of the carotid artery and jugular
vein; and there can be no question that the burning of St. Joan of Arc
must have been a most instructive and interesting experiment to a good
observer, and could have been made more so if it had been carried out by
skilled physiologists under laboratory conditions. The earthquake in San
Francisco proved invaluable as an experiment in the stability of giant
steel buildings; and the ramming of the Victoria by the Camperdown
settled doubtful points of the greatest importance in naval warfare.
According to vivisectionist logic our builders would be justified in
producing artificial earthquakes with dynamite, and our admirals in
contriving catastrophes at naval manoeuvres, in order to follow up the
line of research thus accidentally discovered.

The truth is, if the acquisition of knowledge justifies every sort of
conduct, it justifies any sort of conduct, from the illumination
of Nero's feasts by burning human beings alive (another interesting
experiment) to the simplest act of kindness. And in the light of that
truth it is clear that the exemption of the pursuit of knowledge
from the laws of honor is the most hideous conceivable enlargement of
anarchy; worse, by far, than an exemption of the pursuit of money or
political power, since there can hardly be attained without some regard
for at least the appearances of human welfare, whereas a curious devil
might destroy the whole race in torment, acquiring knowledge all the
time from his highly interesting experiment. There is more danger in one
respectable scientist countenancing such a monstrous claim than in fifty
assassins or dynamitards. The man who makes it is ethically imbecile;
and whoever imagines that it is a scientific claim has not the faintest
conception of what science means. The paths to knowledge are countless.
One of these paths is a path through darkness, secrecy, and cruelty.
When a man deliberately turns from all other paths and goes down that
one, it is scientific to infer that what attracts him is not knowledge,
since there are other paths to that, but cruelty. With so strong and
scientific a case against him, it is childish for him to stand on
his honor and reputation and high character and the credit of a noble
profession and so forth: he must clear himself either by reason or by
experiment, unless he boldly contends that evolution has retained
a passion of cruelty in man just because it is indispensable to the
fulness of his knowledge.


I shall not be at all surprised if what I have written above has induced
in sympathetic readers a transport of virtuous indignation at the
expense of the medical profession. I shall not damp so creditable and
salutary a sentiment; but I must point out that the guilt is shared by
all of us. It is not in his capacity of healer and man of science that
the doctor vivisects or defends vivisection, but in his entirely vulgar
lay capacity. He is made of the same clay as the ignorant, shallow,
credulous, half-miseducated, pecuniarily anxious people who call him in
when they have tried in vain every bottle and every pill the advertizing
druggist can persuade them to buy. The real remedy for vivisection is
the remedy for all the mischief that the medical profession and all the
other professions are doing: namely, more knowledge. The juries which
send the poor Peculiars to prison, and give vivisectionists heavy
damages against humane persons who accuse them of cruelty; the
editors and councillors and student-led mobs who are striving to make
Vivisection one of the watchwords of our civilization, are not doctors:
they are the British public, all so afraid to die that they will cling
frantically to any idol which promises to cure all their diseases, and
crucify anyone who tells them that they must not only die when their
time comes, but die like gentlemen. In their paroxysms of cowardice and
selfishness they force the doctors to humor their folly and ignorance.
How complete and inconsiderate their ignorance is can only be realized
by those who have some knowledge of vital statistics, and of the
illusions which beset Public Health legislation.


The demands of this poor public are not reasonable, but they are quite
simple. It dreads disease and desires to be protected against it. But it
is poor and wants to be protected cheaply. Scientific measures are too
hard to understand, too costly, too clearly tending towards a rise in
the rates and more public interference with the insanitary, because
insufficiently financed, private house. What the public wants,
therefore, is a cheap magic charm to prevent, and a cheap pill or potion
to cure, all disease. It forces all such charms on the doctors.


Thus it was really the public and not the medical profession that took
up vaccination with irresistible faith, sweeping the invention out of
Jenner's hand and establishing it in a form which he himself repudiated.
Jenner was not a man of science; but he was not a fool; and when he
found that people who had suffered from cowpox either by contagion in
the milking shed or by vaccination, were not, as he had supposed, immune
from smallpox, he ascribed the cases of immunity which had formerly
misled him to a disease of the horse, which, perhaps because we do not
drink its milk and eat its flesh, is kept at a greater distance in our
imagination than our foster mother the cow. At all events, the public,
which had been boundlessly credulous about the cow, would not have the
horse on any terms; and to this day the law which prescribes Jennerian
vaccination is carried out with an anti-Jennerian inoculation because
the public would have it so in spite of Jenner. All the grossest lies
and superstitions which have disgraced the vaccination craze were taught
to the doctors by the public. It was not the doctors who first began to
declare that all our old men remember the time when almost every face
they saw in the street was horribly pitted with smallpox, and that all
this disfigurement has vanished since the introduction of vaccination.
Jenner himself alluded to this imaginary phenomenon before the
introduction of vaccination, and attributed it to the older practice
of smallpox inoculation, by which Voltaire, Catherine II. and Lady
Mary Wortley Montagu so confidently expected to see the disease made
harmless. It was not Jenner who set people declaring that smallpox, if
not abolished by vaccination, had at least been made much milder: on the
contrary, he recorded a pre-vaccination epidemic in which none of the
persons attacked went to bed or considered themselves as seriously ill.
Neither Jenner, nor any other doctor ever, as far as I know, inculcated
the popular notion that everybody got smallpox as a matter of course
before vaccination was invented. That doctors get infected with these
delusions, and are in their unprofessional capacity as members of the
public subject to them like other men, is true; but if we had to decide
whether vaccination was first forced on the public by the doctors or on
the doctors by the public, we should have to decide against the public.


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 over-whelming statistical
evidence in favor 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 acti), 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

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 advertizing
purposes. There is, for example, the percentage dodge. 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
antivaccinists 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 Mall
might be proved in the same way to have the like sovereign 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 laborers enjoy,
can be statistically palmed off as a magic-spell conferring all sorts of

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 case-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.


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 instal 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 devize 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 Cromwell 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.


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 favor 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 diseases were not "catching." 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 up 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 in 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. The vaccination controversy is full of such
contentions. So is the controversy as to the docking of horses' tails
and the cropping of dogs' ears. So is the less widely known controversy
as to circumcision and the declaring certain kinds of flesh unclean by
the Jews. To advertize 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 Shakespear's time and for long
after it, mummy was a favorite 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.


Another difficulty about statistics is the technical difficulty
of calculation. Before you can even make a mistake in drawing your
conclusion from the correlations established by your statistics you must
ascertain the correlations. When I turn over the pages of Biometrika,
a quarterly journal in which is recorded the work done in the field of
biological statistics by Professor Karl Pearson and his colleagues, I am
out of my depth at the first line, because mathematics are to me only a
concept: I never used a logarithm in my life, and could not undertake to
extract the square root of four without misgiving. I am therefore unable
to deny that the statistical ascertainment of the correlations between
one thing and another must be a very complicated and difficult technical
business, not to be tackled successfully except by high mathematicians;
and I cannot resist Professor Karl Pearson's immense contempt for, and
indignant sense of grave social danger in, the unskilled guesses of the
ordinary sociologist.

Now the man in the street knows nothing of Biometrika: all he knows is
that "you can prove anything by figures," though he forgets this the
moment figures are used to prove anything he wants to believe. If he did
take in Biometrika he would probably become abjectly credulous as to all
the conclusions drawn in it from the correlations so learnedly worked
out; though the mathematician whose correlations would fill a Newton
with admiration may, in collecting and accepting data and drawing
conclusions from them, fall into quite crude errors by just such popular
oversights as I have been describing.


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 countenance 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 Papers 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

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Online LibraryGeorge Bernard ShawThe Doctor's Dilemma: Preface on Doctors → online text (page 5 of 7)