THE NEW ORDER IN MEDICINE

New Zealand Listener, Volume 11, Issue 283, 24 November 1944, Page 12

THE NEW ORDER IN MEDICINE

Reflections of An American Lawyer

HE other week we published an article in which the State Medical Service idea was supported by an admiral. He was the Medical Director-General of the British Navy. Now a reader has drawn our attention to an article in the "British Medical Journal" in which the idea is supported by an eminent lawyer. He is Wendell Berge, Assistant Attorney-General of the United States, whose address on "Justice and the Future of Medicine,’ delivered recently to the American Urological Association, is reported here. eel --

thing, strictly speaking, as the private practice of medicine (began Mr. Berge). From the earliest ‘days, although the doctor held no public office, his service was "clothed with public interest." At a time when any man was free to enter the trade of his choice, a licence was ° required of the doctor, who had to prove his knowledge, integrity, and skill. He was not free to select or reject patients at will; he must hold himself out to serve all in need to the limit of his. capacity. "TL never was such a

The law not only refused to crowd the relation of doctor and patient within the elementary forms of trade, but went to lengths unknown in other relations to make certain that the common health was preserved. In the wares of trade the law of a single price usually held, but to ensure adequacy of service a special law was decreed for the doctor: he was permitted to charge different fees to patients differently situated, thus elevating medicine above commerce and giving legal recognition to the principle that persons were to be served according to their needs. Public Character of the Physician Mr. Berge gave examples of the public character of the physician’s office. The Royal College of Physicians held a charter from the English Crown which conferred upon it the right to license and discipline its members and otherwise as a corporate body to secure the common health. He next surveyed the great trends which converged upon medicine, The art of medicine refused to stand still, The family doctor was once the very epitome of the art of healing; he had been succeeded by the general practitioner, who was the focus of a group of specialists, now more than a score, each with its own jurisdiction, Consultation had grown into an essential of practice, And behind all this was medicine, as a science and art, on the march, continuing to capture provinces hitherto beyond its frontiers. Health became "an aspect of the operation of the national economy." Finally, not so long ago the old-fash-joned doctor could be depended on to administer medicine for the community. To-day the doctor was in no position to discharge that office. His practice comprehended not the whole community but a fraction of it, and if he was a specialist the fraction was highly selective. In the larger ‘tities, and even in smaller places,

there was a tendency towards fashionable, middle-class, or industrial practices, and here the sliding scale, which was a legacy from a smaller society, no longer operated, for different doctors served persons in -different income groups. ; The Doctor’s Bill Moreover, the doctor’s charges were quite out of accord with the ordinary standards of life. As medicine had advanced its arts had become more intricate; yet very little attention had been paid to making up-to-date facilities available at prices which the common people could afford. Not that physicians

were paid too much, rather the contrary; but there was waste, failure fully to use facilities, a lag in getting the most out of a trained personnel. The result was that the rich, who did not have to consider price, were often pampered with a medical care which they did not need, paupers were often indulged with a service which rose far above their ordinary way of life, while the middle class found the charges as a whole beyond its ability to meet, with the result that a great part of the population reduced its demand for medical service to the very minimum, and a great volume of cases reached the doctor in an aggravated condition, although in the early stages they could have been easily, handled. Here was a challenge. A new medical order was inevitable. As men groped’ after it many doubts and fears were expressed. Doctors were justly fearful that the quality of the service would be compromised. Mr. Berge confessed that he was unable to follow the argument that a casual relation .existed between Government auspices and poor medicine. The truth was that a new system brought medical care to hosts of people who previously had had no access to it, but it also brought about a situation in which the provision of doctors and facilities almost always fell short of the new and enlarged demand. The "Shibboleth". of Free Choice Much had been said: about the maintenance of a personal relation between doctor and patient and the right of the patient freely to choose his doctor. "As a patient," said. Mr. Berge, "I am quite willing to have this right qualified for my own good." Under a well-recognised principle of economics, freedom of choice should be limited where the consumer was not a "proper judge of the quality of the ware," and if there was one field where freedom should be qualified it (continued on next page)

"(continued from previous page) Was medicine. The layman possessed neither the facts about the distinctive competence of particular physicians nor trustworthy norms to guide his judgment. Competence did not wholly accord with ability to. attract patients. Far more important to the patient than a personal choice was the assurance of a high standard of competence. Nor was wide-open freedom fair to the physician, who should advance in his profession on sheer merit. His work should be judged by men of his own craft, able to judge brilliant from routine work, not by the laity, to whom medicine, with its highly technical services, was still a mystery. Free choice of doctor had become a shibboleth which would not stand analysis. Mr. Berge also poured scorn on the theory that to work fot a salary deadened initiative and lowered the standard of efficiency. The age-long traditions of the medical profession denied the truth of the argument that method of remuneration would affect quality of work. The mightiest urge to which a doctor responded was the pride, the drive, the keeping faith with his calling. The progress of science and the useful atts was mainly the product of men on salary. In the institutions of higher learning research as well as teaching fell to salatied employees. In medicine just now, thousands of the best doctors were giving their all without stint in the service of the Forces. The State’s Venture Into Medicine The speaker said he had no more fear of the venture of the State into

medicine than .of the venture of the State into law. The venture into lawjudges, public counsel, and so forthwas old; the venture into medicine was néw. But the traditions and high standards which had long operated in the one realm could be established in the other. Standards of medical care were not inherent in any type of orgarisation; they depended largely on adequacy of resources, The new medical order would come even if they did not will it, even if they stubbornly resisted it. For the medical order, like other institutions, could not insulate itself against impinging culture, The form of organisation might follow an agency of the State, the university pattern, the hospital set-up, or a combination of these. The Government might dominate the system, become one of a number of parties to its management, or be excluded: from it altogether. The form of organisation might be a public health authority, a non-profit-making corporation, a group of co-dperatives, a mutual association of the profession and the laity. Direction might be with a tripartite board, representing the Government, the public, and the profession, or the public and the profession might assume joint responsibility. It might or. might not be State medicine; it could not escape being social medicine. ’ "I can hand to you no ready-made medical order on a silver platter. If I could, it would do you no good. I can only suggest to you, whose minds have long been busied with the subject, some reflections of a man of another profession. And I am positive that a service adequate to the times cannot be

brought into being without the doctors’ creative participation ... The ends of medicine remain unchanged; ways and means must be found to adapt its practice to the conditions of present-day society." This was no time for petty doubts and timid moves. An instrument of the common health, such as had never before been offered to a people, was within our feach.