The Doctor's Dilemma: Problems That Do Not Go Away

THE DOCTOR'S DILEMMA: PROBLEMS THAT DO NOT GO AWAY WILLIAM M. LANDAU* George Bernard Shaw's The Doctor's Dilemma was first produced in London in 1906. It was first published with its explanatory preface in 1911. The diatribes in the preface against vivisection and vaccination indicate both prejudice and considerable knowledge of the data base then available. Also of historical interest are Shaw's concerns for the poverty of English physicians who did not work on Harley Street, and his unqualified support for the ideal concept of socialized medicine. Yet many of the issues that he confronted fourscore years ago are as current as next week's New EnglandJournal ofMedicine, albeit his critical perception and clever aphorisms surpass that magazine's editorial standard: "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. "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. *Department of Neurology and Neurological Surgery (Neurology), Washington University School of Medicine, 660 Euclid Avenue, Box 8111, St. Louis, Missouri 63110. Copyright is not claimed for this article. Perspectives in Biology and Medicine, 32, 4 ¦ Summer 1989 \ 505 "The medical profession has not a high character; it has an infamous character. ... As to the honor 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 ofthe enemy. ... It is simply unscientific to allege or believe that doctors do not under existing circumstances perform unnecessary operations and manufacture and prolong lucrative illness. "Doctors arejust 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. "When your child is ill or your wife dying, and you happen to be very fond ofthem, or even when, ifyou are not fond ofthem, 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.' "Thus everything is on the side of the doctor. When men die of disease they are said to die from natural causes...