T CHAPTER XVII THE CONFLICT OF INTERESTS IN MEDICINE, DENTISTRY, AND ARCHITECTURE THE MEDICAL PROFESSION HE medical profession is concerned with problems of illness, which require, above everything else, a careful diagnosis. Every case the doctor visits in his daily rounds differs from every other. Even in epidemics the treatment of a case depends not only on the nature of the disease but also on the constitution of the patient. Hence the professional attitude of the physician is inductive and not deductive, as is that of the lawyer. Where life is to be saved the essential aim is not apt to be to preserve the authority of formulas that constitute the learning of a profession. The problems of the physician are such as to stir a keen intellectual interest, but his busy life, his frequent loss of sleep, the prolonged periods of work during the seasons when most illness occurs, make habits of intellectual thoroughness difficult to maintain. And, above all, the indifference of patients to the ultimate causes of an illness, their lack of selfcontrol and common sense in avoiding illness, discourage a doctor from attempting to do more than help the patient over the immediate illness. The work of the physician appeals also to the sympathetic disposition. His life is given to responding to calls for help and he is a friend in need. The pleasure of such service to be sure weakens as it becomes habitual and more or less mechanical, much as sympathetic behaviour in the family tends to become mechanical and less satisfying than doing good outside the family. Nevertheless there is a constant appeal to the sympathetic disposition not afforded by other professions. The physician's response to appeals would be more satisfying if patients and their families were less whimsical and more intelligent, for his aim is to get results and this requires that patients co-operate by following his directions. Also, patients seldom show the proper gratitude for the faithful and conscientious service of a physician. The work of the physician enlists the intellectual and sympathetic dispositions, nevertheless one finds plenty of physicians who are more alive to the financial returns than to medical problems. There is, also, in many physicians, a noticeable reaction against new ideas, a disposition to distrust young physicians entering the profession with new ideas. The rank and file of professional men generally seem to think it inconsistent with their amour propre to acknowledge that there is any professional knowledge worth knowing which they do not know. In addition to this rivalrous assertion of superiority and disposition to dominate those who question it, there is the fear of losing practice to the men with new ideas and methods, if once the public becomes convinced that the services of these men are superior. The ethical code of the medical profession not only, like that of the legal profession, imposes restraints on individual rivalry, in the matter of advertising,1 soliciting practice,2 seeking the practice of another physician,3 indulging in personalities,* but also enjoins free care of the sick poor 5 and co-operation in the medical societies and on behalf of the public health. 7 The co-operation of physicians is seen at its best in consultations. "In every consultation, the benefit to be derived by the patient is of first importance. All the physicians interested in the case should be frank and candid with a patient and his family. There never is occasion for insincerity, rivalry or envy and these should never be permitted between consultants." 8 The purpose of a consultation is to bring about a co-operation of minds in the study of the causes of the illness and the action of remedies, not to get a verdict favourable to one or another of the parties to a controversy, as in the law. The rules for a consultation are intended to facilitate this end. 9 In addition to the conflict of interests within the medical profession between egoistic and altruistic, conservative and progressive physicians, there is more or less conflict between the profession and the 1 American Medical Association, Principles of Medical Ethics, Ch. I, Sec. 4. 2 Ibid. Ch. II, Art. I, Sec. 4. 3 Ibid. Ch. II, Art. IV, Sec. 2. 5 Ibid. Ch. II, Art. VI, Sec. I. public. This is due to the popular distrust of physicians and to physicians' distrust of the people. The latter is due in part to the ресиliar experience of physicians and in part to their own ignorance. They are in constant contact with human nature in its weakest and most apprehensive moments, and much of their contact is with the weakest, most stupid and unfit specimens of human nature. They find a sufficient explanation of the misfortunes of people in their own weaknesses and stupidities and are slow to take an interest in social or industrial causes of, and remedies for illness. From his specialized contact with people the physician thinks he understands human nature, and does in a superficial but not in a scientific way, as he understands medicine. Because he distrusts the power of self-control and the common sense of patients, he lacks the insight and skill to appeal to their self-control and instruct their common sense. 10 His distrust also stands in the way of a proper consideration of the social and economic. and psychological antecedents of the condition he is called on to diag As the ignorance of the physician causes a more extreme distrust of human nature than is warranted, so the ignorance of people causes a distrust of the physician. "Among the causes of the present distrust of medicine I would place . . . the appalling ignorance which people possess of their own bodies and their bodily processes. . . . Of how to maintain his health he thinks he knows much. . . . But if he has so little clear conception of what goes on within himself normally, how does he behave when disease comes. . . . He feels certain symptoms, but he does not understand their diagnostic significance. He trusts blindly to the hope that if he neglects them they will pass away. If they persist, he diagnoses his own disease and attempts to treat it. . . . And so, from the beginning to the end, there is ignorance of the body and of what the physician can do for it." 12 Owing to this ignorance the public fail to understand the problems of the physician and to appreciate the necessary uncertainties of diagnosis. 13 Another cause of distrust of physicians is that little or no effort is made by them to educate the public in the care of their health; and the public infers from this lack of interest in the public health that physicians are interested in keeping the public in ignorance "in order to 10 Alexander, Man's Supreme Inheritance, Ch. V. 11 Cabot, Social Service and the Art of Healing, 18-19; Cabot, Social Work, Chs. I-V. 12 Lee, Scientific Features of Modern Medicine, 167-169. 13 Ibid. 169-170. have something to do." Another cause of the popular distrust is that, in their relations with their patients, physicians are often not so frank as they should be. They do not frankly tell their patients what is the matter with them nor explain carefully why they should do as directed. The patient should be made to realize that he must co-operate with the physician and should feel in honour bound to do his best inasmuch as on the outcome of his case depends, in a measure, the reputation of the physician. However, the patient seldom looks at it from this point of view, but considers his relation with his physician merely a commercial one, and the physician seldom makes an effort to indicate to the family that he has any other relation in mind. Both on the side of the physicians and on the side of the public, therefore, there is ignorance and "traditional criticism" 14 and distrust, where there might be, with the proper education, mutual understanding and cooperation. The cultivation of high professional character in the medical profession should not be left to chance. 15 Students are given a long grind of months in memorizing the names of muscles and other masses of facts, which they will soon forget, while the attitudes that will determine their efficiency are scarcely brought to their attention. To be sure, the strongest influence for the formation of right attitudes is the influence of great teachers; right attitudes are formed in the course of work as students, if it is directed by great teachers. But, in opposition to these influences, there are the contrary outside influences, the examples of physicians who are charging big fees and "making loads of money," the lack of interest in the public health and preventive measures on the part of physicians, except when they are driven to it in an emergency. These outside influences have a marked effect in determining the attitudes of students. Students are largely left to determine their own professional attitudes, and yet these are what will determine their professional careers and their reaction on society at large. More than one young physician's career has been marred initially, sometimes permanently, by lack of wise training in professional attitudes. He may err thoughtlessly from lack of training, and, when the lesson is learned, it may not happen again. It is to be regretted that these lessons are not learned in the school where other lessons are. It may be said that these lessons must be learned 14 Ibid. 157. 15 Ross, op. cit., 77. by experience, but this cannot be accepted until a more serious effort has been made to reach them in the schools. THE DENTAL PROFESSION The dental profession, in its code of ethics, formulates rules to restrain rivalry for the sake of efficient work and the public welfare. As the public "are in most cases unable correctly to estimate the character of his operations, his own sense of right must guarantee faithfulness in their performance." 16 The code requires the dentist not to advertise conspicuously,17 not to claim superiority over rival practitioners, 18 and not to speak disparagingly of a rival. 19 But the codes of both the physician and the dentist enjoin the practitioner to expose, without fear or favour before the proper professional or legal tribunal, corrupt or dishonest behaviour of a member of the profession. 20 This is rarely done in either profession. 21 Nor do physicians or dentists frankly tell a patient of an injury or of poor work that they find has been done. The failure of reputable practitioners to expose those who have done disreputable work is contrary to the public welfare. However, in extenuation of this short-coming, it must be considered that many patients would assign a discreditable motive to a conscientious doctor's or dentist's exposure of the disreputable work of another. Many patients would infer that he was "running down" a rival in his own interest and would not take his criticism seriously. Doctor and dentist are, therefore, entitled to use their best judgment as to the patients to whom they should reveal defective work. As a matter of fact the prevailing practice is neither to disparage a rival nor to disclose poor work for the benefit of patients. Doctors and dentists often seem over-solicitous to avoid the appearance of professional jealousy. As in the medical profession, so in dentistry, the rivalrous disposition tends to cause egoistic behaviour which is contrary to the public welfare. The rivalrous dentist works for money and a big practice and does much poor work; the conscientious dentist does only good work, for the satisfaction both of his intellectual disposition, which 16 National Dental Association, Code of Ethics, 1914, 34. 17 Ibid. 35. 18 Ibid. 35. 19 Ibid. 35. 20 Ibid. 37; American Medical Association, op. cit., Ch. II, Art. I, Sec. 7. 21 On the failure of the medical profession see Hendrick, How Should a Doctor Behave, The World's Work, December, 1916, 215. |