GB Shaw: The Doctors Dilemma--Never More Pertinent!

[Guest guest]

Frank, this is very long. I am not sure you will want all of it on

the board or not. It is 81 pages. But it is priceless. If you want me

to post only the link, I will. Let me know. There was a front-page

article in Time Magazine in 1987 that discussed the erosion of

clients' trust in doctors, even with all the new diagnostic/treatment

machinery that is appearing all the time. In my opinion, things have

not changed since Shaw wrote his treatise. I'm not sure when

anesthesia was invented. That made a difference, of course, because

it made it easier for clients to go along with surgeons'

recommendations...

 

http://www.hn.psu.edu/faculty/jmanis/gbshaw.htm

 

THE DOCTOR'S

DILEMMA:

PREFACE ON DOCTORS

By

BERNARD SHAW

1909

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3

GB Shaw

THE DOCTOR'S

DILEMMA:

PREFACE ON

DOCTORS

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 unnecessary.

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—

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The Doctor's Dilemma: Preface on Doctors

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

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GB Shaw

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.

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The Doctor's Dilemma: Preface on Doctors

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

7

GB Shaw

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.

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The Doctor's Dilemma: Preface on Doctors

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.

9

GB Shaw

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

10

The Doctor's Dilemma: Preface on Doctors

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.

11

GB Shaw

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

12

The Doctor's Dilemma: Preface on Doctors

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

13

GB Shaw

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.

14

The Doctor's Dilemma: Preface on Doctors

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 hardestheaded

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 house with their fee in their pockets

before the patient has recovered consciousness, and who

therefore see nothing of the suffering witnessed by the general

practitioner and the nurse, occasionally talk of operations

very much as the hangman in Barnaby Rudge talked of

executions, as if being operated on were a luxury in sensation

as well as in price.

15

 

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