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But whether this provision be construed as mandatory, or as advisory, it does not necessarily imply the adoption of a formal schedule of charges, such as we find in what we call our fee bills. Any general agreement, whether tacit or expressed, no matter how arrived at, and no matter how flexible or how inflexible, it may be, is sufficient to fulfill the requirements of the code. As a matter of fact, fee bills have never been practicable at all in large cities; have never been much needed in country neighborhoods; and have been mostly patronized in small towns and in country villages. In my opinion, they have never been of much advantage anywhere. The rigorous uniformity of charges which they are intended to establish is always and everywhere impossible of accomplishment-impossible in the nature of things, and impossible because there are unreliable men in the medical as well as in other professions. In settling accounts for medical services physicians are obliged, by laws of higher obligation than the provisions of fee bills, to consider the financial condition of their patients; and in the feverish struggle for practice, which is but too often also a struggle for bread, there are always men who will take unfair advantages.
I do not believe that any fee bill was ever exactly observed; and I will say also that I do not believe that there ever has been a fee bill that ought to have been exactly observed. Indeed, the disadvantages in many directions of these procrustean devices are so many and so obvious, that they would long ago have fallen into complete disuse, but for the fact, that notwithstanding failure heaped upon failure, like Pelion upon Ossa, stares them everywhere in the face, physicians still entertain the delusive hope that in some way, by some cunning manipulation of professional charges, they can make additions-additions most devoutly to be desired—to their scanty professional incomes. They might as well try to lift themselves up to the moon by pulling at the tugs of their boots.
The evils they desire to remove are not to be reached in this way. A demoralized professional sentiment, added to a still more demoralized public sentiment, must of necessity lead to many unpleasant consequences.
For these there is but one remedy, and that remedy is not to be found in any miraculous powers attaching to idle resolutions, and to schedules of fees, no matter how adroitly contrived.
Nay, verily. The true remedy, the only true remedy, will then be found when the medical profession is purified of the dross and alloy which it contains in its own membership, when it comes to be a company of high-toned, honorable men.
But while I have gone somewhat out of my way to expose the inherent weaknesses of our prevalent fee bill system, I do not forget that in many localities it is regarded as the only available way of carrying out the injunctions of that article of the Code of Ethics which I have quoted, and that, to the average American doctor, indeed, the thought never occurs that uniformity of professional charges can be obtained in any other way than by the promulgation of a fee bill. I take it for granted,
therefore, that for some time to come fee bills must be more or less accepted amongst us as necessary evils.
But while this question of medical fees and fee bills must continue to vex the medical profession, as such, there is no reason why it should be allowed to introduce discord into our medical organizations, and to embarrass them in their relations with the profession and with the nonprofessional public. It is to prevent these discords and embarrassments that I venture to ask that the association give its endorsement to the ordinance which I have presented for its consideration.
I know that it has been the custom for medical societies in this state to adopt fee bills for the guidance of their members. But in my judgment this has always been a custom of questionable propriety, and one that is far more honored in the breach than in the observance. It certainly finds no warrant in the Code of Ethics.
The Code of Ethics, indeed, ignores medical societies altogether. All of its provisions, from the first to the last, are intended for the behoof of the medical profession, as such, and for individual physicians simply as members of the medical profession.
The relations which exist, and which of right ought to exist, between the medical profession and the numerous medical societies which have sprung up in its bosom, is a problem which deserves more consideration than it has heretofore received, but it is one that I can not now undertake to discuss.
It is not upon medical societies that the code imposes the obligation of regulating fees, but upon the "faculty of the town or district," and the word "faculty" is always used in the code as a short designation for the collective medical profession. So that it seems plain to me that when medical societies undertake to enact fee bills, they place themselves in direct antagonism with the profession's fundamental law.
But still further. The end aimed at by the provisions of the Code of Ethics which I have quoted, is obviously to secure uniformity of charges in every town or district; and consequently any mode of procedure in the adoption of a fee bill which is calculated to defeat the accomplishment of this end, would be, on that account, inconsistent with the spirit of the ethics.
Now, it is evident that if a portion of the faculty in any town or district should adopt a schedule of charges without consultation with the rest of the faculty in said town or district, they would, by such exclusive action, furnish to the excluded party just cause of complaint, and at the same time subject themselves to the imputation of failing in the proper discharge of the duties which physicians owe to each other and to the profession at large.
Again. If one medical society has the right to adopt a fee bill, another medical society might also adopt a fee bill; and if there should be twenty medical societies in the same town or district, then every one of the twenty might also enact a fee bill; and no matter how widely these several fee bills might differ among themselves, they would all be equally legitimate.
And still again. If medical societies are entitled to the prerogative of making fee bills, then any other bodies of physicians may also assume the right to make fee bills, and it does not matter, so far as the principle is concerned, whether these bodies be large or small. The physicians of any town or district might, therefore, get together in little squads of ten or twelve, or of five or six, or even two or three. and every separate squad would have the ethical privilege of adopting for itself special rates of charges. Indeed, if this reasoning is to be allowed, every individual member of the profession might consistently claim the right to make his own fee bills according to his own will and pleasure. In the smoke of this reductio ad absurdum, the authority of the Ethics is blotted out, and the result is the same as if there existed no ethical rule at all. From all these considerations, it seems to me that there is no safe position to be taken upon this subject, except the plain and simple rule of construction, that the provision of the Ethics in relation to pecuniary acknowledgments means exactly what it says, namely, that professional charges should be regulated by the "faculty, in every town or district," and not by separate sections of the faculty, whether these separate sections be large or small, or whether they be organized into medical societies or not.
But it is not alone upon the grounds of the abstract and general propriety of the principles which I have developed in the foregoing discussion, that I invoke the favorable consideration of the Association for the ordinance that I have presented, although this general argument seems to me to be quite conclusive. Some of the evils which I have indicated as possible, when medical societies undertake the regulation of fee bills, have already, in the State of Alabama, passed from the region of possibilities into the region of actualities, into the region of accomplished facts. It would, perhaps, serve no good purpose to make a record of these cases here, but some of them are known to some of the members of this Association. This question, therefore, has become one of present and practical importance, and it is therefore eminently proper that this Association should take it in hand and settle it so far as the State of Alabama is concerned.
In at least one other state, as has been indicated in another part of this paper, it has been settled already-namely, in the great State of New York.
Of the special circumstances which led the medical society of the State of New York to consider this question, I have no knowledge whatever. But that they were regarded as of very great importance is evident from the character of the action of a very remarkable clause in the society's constitution.
This clause I quote uerbatim, as follows:
WHEREAS, It is inconsistent with the dignity of the medical profession for physicians and surgeons, in their corporate capacities, to arrange and fix professional charges
"Be it therefore ordained, That any member of this society who shall hereafter be guilty of promoting, favoring or encouraging the members
of any medical society in their corporate capacity, to form, support and fix medical charges, and who shall be convicted therefore before the said society, at any anniversary meeting, to the satisfaction of a majority of the members present, shall forever after be debarred from being received as a member thereof.
"Be it further ordained, That no corporate county medical society shall fix any medical charges, and such proceedings are hereby declared to be discountenanced by this society, and to be null and void and of no effect."
THE OATH OF HIPPOCRATES.
"I swear by Apollo, the physician, and Æsculapius, and Hygiea, and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this oath and its stipulation—to reckon him who taught this art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this oath, may the reverse be my lot!"
THE CODE OF ORDINANCES FOR THE GOVERNMENT OF THE ASSOCIA
An Ordinance in Relation to the Roll and Records.
An Ordinance in Relation to the Revision of the Rolls..
The Revision of the Roll of the Officers..
The Committee of Publication and its Duties...
The Omnibus Discussion...
The Sessions of the Association..
The President and his Duties..
The Vice-Presidents and their Duties.