MEDICINE AND THE PUBLIC.*
WE are indebted to Dr. Squire Sprigge for an extremely able exposition, not merely of the difficulties, problems, and aspirations of the medical profession, but also of the public interests involved in the various questions which are now agitating the profession. We trust that his book will be widely read outside the medical world, because we feel sure that if it is, it will enlighten the public on many matters in regard to which they greatly require enlightenment. It will show how ignorant the wider public are, and how often that ignorance leads to gross injustice.
If the ordinary man could be interrogated as to what he wants from the medical profession, we are confident that the answer would be something of this kind. In the first place, the ordinary man would say that he desires to be preserved from quackery in medicine. He wants to feel sure, when on an emergency he calls a doctor into his house, that the doctor is a properly qualified person, and that he can safely rely upon his skill and advice. Next—pre- suming, of course, that he has given a little thought to the matter—the householder would say that he likes to feel that his doctor belongs to a calling in which there is a high standard of professional honour, a standard of honour which will secure him and the members of his family from being unfairly exploited at times and in circumstances when he is least able to protect himself and those dear to him by ordinary worldly precautions. He would say :—"I want to feel that I can trust my medical adviser not to take advantage of my anxiety and nervousness when I am prostrated by illness. I want to feel that he will not lead me on to think that he has some patent means of curing me when perhaps my case is incurable, and that he will not play upon the weakness of my wife or my children, and so involve me in useless expenditure or in domestic complications which may be the ruin of my happiness and my home." Next, the ordinary man—presuming again that he is a thinking man— would say :—" I want to see provision made that all medical men shall be well educated. I cannot attempt to judge between a whole host of different qualifications. What I want to know is that every man who is licensed to practise medicine for gain has, in order to obtain that license, gone through a good medical education. If the State allows a man to call himself a doctor and to practise and take fees for the exercise of his skill, there should be a reasonable certainty that he has learned his work thoroughly." Lastly, the ordinary man would say :—"I want to be assured that the system under which doctors are paid is one which allows to all who work steadily at their profession a reasonable livelihood. It is impossible for medical men to do justice to their arduous and terribly responsible work if they are badly paid, and feel that the public does not do them justice because it does not ensure them receiving the remuneration due to special skill and learning."
We do not think that any reasonable man could say in the abstract that he cared for none of these things, and that it was not a matter of public interest (1) to prevent un- qualified quacks practising, (2) to maintain a high standard of honour in the profession, (3) to secure and maintain a high level of medical education for all practitioners, and (4) to secure just remuneration for the rank-and-file of the profes- sion. But if this is what the public wants, or ought to want, and must want if the matter is properly considered, it is also most certainly what the profession itself wants. There is a great deal of very unfair and very stupid talk about medical
• Medicine and the Public. By S. Squire Sprigge, M.A., M.D. London : W" ECi11013111II12. [6e. net.) Trade-Unionism, and about the desire of doctors to prevent the public having liberty of action in medical matters. If, how- ever, any unprejudiced person will take the trouble to dis- cover what the medical profession really desires—he cannot ascertain it better than by reading carefully the book which is the subject of this review—he will find that the doctors themselves only ask for the very things which, as we have shown, an enlightened public asks for. As a matter of fact, there is no conflict whatever between the demands of the profession as a whole and those of the public. It is conceivable, of course, that a small and selfish section of the medical profession may, as in the case of other professions, demand what is contrary to the public interests; but if so, such demands find no support from the majority, but remain those of an entirely unimportant and obscure minority. All that the articulate and responsible spokes- men of the medical world ask for is, in effect, what we have laid down. The demand that the Acts of Parliament governing the practice of medicine shall be so amended as to make it easier to prevent unqualified persons practising is, in our belief, an especially reasonable one. It is certainly framed in the interests of the public. At present quacks with no proper qualification can by a subterfuge make use of the Joint Stock Companies Acts to evade the Medical Acts. We cannot believe that it is wise to allow unqualified persons to make money by trading on the hopes and fears of the public. We admit, of course, that the difficulty of drafting an efficient prohibitory clause is very great; but unquestionably something more can be done, and ought to be done, in the way of prohibition than is done at present. Again, we believe that the maintenance of a reasonable professional etiquette is essential to the true interests of the public. Imagine the misery which would be caused if the members of the profession were allowed to vaunt their skill one against the other, and to yield to the temptation of declaring that they, and they alone, had the secret of healing this or that disease, and of promising instant relief to sufferers. There is no profession in which the excesses of unrestrained competition would do such terrible injury to the public as that of medicine. Again, all persons of experience must realise the need for a strict etiquette to prevent the weaker brethren among medical men yielding to the other great temptations to which they are inevitably exposed in the course of their work. The fact that they so seldom do yield is a sign of how strong and efficacious are the rules of honour by which the profession is bound. But those rules of honour must be understood, respected, and loyally supported by the public, or they will not last. Take, for example, the fact that there is practically no instance on record of a British medical man keeping to himself and exploiting for profit any discovery in the art of healing. Yet the keeping secret of a new drug or a new treatment might easily secure great wealth to the author of an important medical discovery. The etiquette of his profession obliges a doctor to place his discovery at once at the disposal of the whole world. Marconi may patent wireless telegraphy. Simpson would have felt himself dishonoured at the bare suggestion that he might have kept the secret of chloroform to himself for a few years as a reward for his skill and good fortune. In truth, medical etiquette, instead of being kept up, as people so often imagine, in the interests of the doctors, is maintained in the interests of the public. It is they, not the doctors, who would suffer most were it done away with.
The general desire which we have noticed among the public that, since they cannot distinguish between one medical qualification and another, the license to practise should mean that its recipient had attained to a certain fixed standard of medical education, is known to the medical world as "the demand for the one-portal system." Daring the last ten or twelve years the profession has been gradually coming to the conclusion that we should adopt this system. At present, as may be found set forth in Dr. Squire Sprigge's book, there are a dozen ways in which a medical man may obtain a qualification; and owing to the growth of new Universities, each with a Medical Faculty, the tendency at present is in the direction of a further multipli- cation of qualifications. What the medical profession as a whole, and distinguished from the Medical Faculties in the Universities and the great medical corporations,
now ask for is that there should be a "one-portal system." , They ask, that the State should institute a single exami- nation which shall carry with it the title of Doctor and the right to practise, and that only those who qualify them- selves by passing this examination should have the privilege of practising medicine for gain. The arguments pro and con. set forth in the work before us are too long to analyse, but for ourselves we must say that we are convinced that the time has come for the adoption of the "one-portal system."
As to the remuneration of doctors, it is shown by Dr. Squire Sprigge that, on the whole, the position is not so bad as is sometimes asserted. That is, the private prac- titioner can as a rule make a living wage. At the same time, it cannot be doubted that the public posts held by medical men are very often underpaid, and have not that security of tenure attached to them which should belong to all who discharge arduous and responsible public func- tions. Medical men, to their great honour, seldom yield to the temptations to which all men in public employment are from time to time exposed ; but this is no reason for refusing them the security and the reasonable pay which are demanded, and rightly demanded, in similar cases, civil and military. It is an old and most sound aphorism that it is not safe for the State to pay poorly a man who is exposed to serious pecuniary temptations in the course of the regular discharge of his duties. Why should , doctors be an exception to this rule? Again, medical men have constantly thrown upon them by Act of Parliament all sorts of new duties, and yet no provision is made for any payment for the discharge of these duties. And here we may note that the public has in this respect set a very bad example to Parliament. We are all far too apt to expect doctors to do professional work without payment merely because the subjects of that work are poor. We seldom, if ever, hear of barristers working without fees, not because they are. personally interested in the case, but because the litigants are poor. Yet the public regards it as a breach of humanity when in very rare cases a doctor refuses to attend a patient unless he has some security for his fees. As a rule, if there is illness, or pain, or danger, the doctor considers it his duty to do the humane work of healing first, and to leave the question of remuneration to be settled as best it may. We admit that this problem of a more adequate remuneration of the general practitioner is an exceedingly difficult one ; but at any rate the State could set a good example by giving proper payment and proper security to all doctors in public employment, and by insisting that wherever work is imposed on medical men, either directly or indirectly, by statute, pro- vision should be made for adequate payment for services required and done.
In conclusion, we must point out once more that the essential thing to remember in regard to these medical ques- tions is that the interests of the public and the profession are not in conflict, and that the doctors are only asking for what in the general interest should be granted, Especially is this true of medical etiquette. Occasionally, no doubt, such etiquette may become formal, pedantic, petrified, and so injurious; but taken as a whole it is the antiseptic of a profession which could not be corrupted without the most serious injury to the public interests.
THE AFRICAN NORTH-WEST.*
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