Chapter Twelve. "Dehumanizing Medicine"

C HAP T E R T W E L V E "Dehumanizing"Medicine ABUSESgo hand in hand with "mechanization" of the patient-doctor··relation. Four factors combine to distort that relationship. In different degrees, all four are common to every obligatory scheme: first, the attempt of the beneficiaries.to make the most of the schemes, thereby overstraining the medical and auxiliary services; second, the comparatively low pay of the medical per sonnel and the keen competition among its members; third, the necessity of bureaucratic controls over the per sonnel of the service as well as its beneficiaries, and . fourth, the reaction of the medical practice to the impact of these conditions. MEDICAL. PRACTICE Of cour~e, abuses, such as overchar~ing UNDER INFLATED the patIents, occur ?~ a free medIcal DEMAND market. But competItIon and the pres. sure of public opinion help to eliminate them or at least to keep them within bounds. Under compul sion, on the other hand, ·motive-forces come into operation which ,create and perpetuate abuses. They in tum lead into modifying the medical·practice in.a direction highly unfavor able to its very objective.

The schemes operate essentially as permanent price-fixing devices of anexttaordinary kind. Disregarding some ex~ep-, tions, the prices of a broad range of valuable goods and serv ices are fixed at or near zero. In addition, cash benefits are forthcoming, provided the doctor is understanding or conniv101 COMPULSORY MEDICAL CARE AND THE WELFARE STAT£ [ 102 ing, if he is not being fooled. The unavoidable happens. The demand skyrockets, as it would if a department store advertised that all wage earners and salaried people in town, plus their families, and (in Britain) everybody else, might "purchase" to their hearts' desire, and free of charge. Moral exhortations do as little to stop the buying spree as does the fact that payroll deductions, employer contributions, or taxes on the community at large have to pay the bill. Actually, the fact of contributing something may be an incentive to the beneficiary to do more "buying" rather than less, so as to get the maximum equivalent of his or her contribution. The resulting inflation of demand tends to vitiate the purpose of the compulsory system-of the medical function itself.

Unfortunately, no scientific technique exists that would per mit one fully to appraise the results of one kind of medical sys tem as against the other-free vs. compulsory systems. But certain tendencies of the latter are evident and have to be pointed out. Appraisal of the former does not belong in the framework of this study. DOCTORS' The practitioner has been called the patient's REAL servant.! His oath binds him to his patient and to DILEMMA no one else. So do or should do his professional ethics and presumably his personal sympathy. To expect any other attitude from him than that of undiluted medical service to those who seek it perverts the meaning of his vocation. What is to be expected is, rather, a natural'inclina tion to please the patient by fulfilling his demands beyond the "necessary" measure, whatever that may be. To serve the panels or the government against the patient is as unethical for a doctor as it would be immoral.for a lawyer to protect the interests opposed to those of his client.

Moreover, the doctor depends economically on the clientele as any businessman does. On a free market, the quality of his performance, as the patient sees it, and the "personal touch," are supposed to be the prime measure of his reputation. Even there, his refusal to tolerate preconceived medical ideas and to support lay requests is often more intensely resented by the patient than are errors in diagnosis or treatment. In compul sory schemes, the prime interest of the patient is not medical aid per see With or without it, he wants cash and other benefits 103 ] ''DEHUMANIZING'' MEDICINE from the health organization. Naturally, the sick person looks at the institution from the one center that occupies his mind. The one who feigns sicknessdoes SO,·too. But the problem childrellQf the' paneJsneed be neither liars nor frauds. The worst to deal with is the imaginary patient, as indicated before. A. prominent German expert (a staunch believerin the compulsorysystem)·formulatedit sharply:.the patient's "critical ability is more or less reduced. For this reason, he expects from the physician above all a generous handling of his own wishes which he considers basically·justi fled, and the more so the more his sicknessis •psychologically rather than physiologicallydetermined. The imaginary patients raise the greatest demands, and it is virtually impossible to make them understand that somehow they ought to limit their requests for the sake of the community."2 True, in no scheme is the number of·imaginaryillnesses esti mated above 20 per cent of the total. That alone might be sufficientto block the legitimate medical traffic. But far more important is the imaginary or exaggerated portion in the "nor..

mal" patient's real ailment. It is likely to be excessiveunder a systemthat in effect puts a premium on being sick-or on being sicker than "necessary." What to do about that is the doctors' real dilemma. MECHANIZING TIlE In Germany, where two generations of MEDICAL PRACTICE experience and debate have·helped to destroy illusions, responsible doctors and panel officials-not the neo-liberal politicians and literati -are deeply worried about the results in terms of medical service. Not all patients and doctors are equally affected, of course; But by and large, the general.practitioner tends to be come a general agent to fill out forms and to distribute medica tions on a level which is sometimes little short of· charlatanry. Visualize his position. To refuse the patients' requests may or may not be ethical; it is certainly not expedient. They would go to his less scrupulous competitor. Given the very low rate of remuneration and the progressive elimination of private practice, the number of patients is, to use a cliche, his to-be-or not-to-bequestion.Thatnumber depends on his reputtition in obliging the patient who, under the compulsory system,may COMPULSORY MEDICAL CARE AND THE WELFARE STATE [104 be as much interested in its benefits as in being cured, if not more so.3 An illustration, one among many, is provided by the German panels themselves, which are well aware of the fact that a newly-established general practitioner at once draws away the panel patients from old established ones. The public expects more "generous" response from the newcomer who still has to build up his business. It may be true, too, that the older prac titioner already knows his clientele and recognizes at once some of the malingerers and hypochondriacs.

The result is what has been called doctoring on the conveyor belt. Overcrowded offices,long waiting by patients, and "quick" service-often two and three minutes only per patient, some times by phone in lieu of officeappointment-characterize the successful health panel or scheme doctor's office in every com pulsory scheme (other than the French-type). The tplsuccess ful ones, naturally, have more time, but they are compelled to take the old and "unhealthy," the unpleasant and cantanker ous whom their luckier colleagues have shaken off.4.- So, the fewer patients the more work and trouble with each, on top of insufficient remuneration. And financial worries do not increase the professional proficiency. Typically, the scheme practitioner (outside France) is over worked, due also to the additional strain put on him through the inflated number of visits to ~atients. The British Medical Association estimates that under the old panel system five con sultations and visits had to be counted per year for the average insured. Now, the number of potential patients has doubled, and more of them ask more often for the doctor, which means probably as many as 100 cases per workday for a "successful"

practitioner with, say, 3,000 registrants. That many he needs in order to earn an annual net, before taxes, equivalent to $4,000-$5,000. The same holds for his German colleague who is called a "panel lion" if he makes that grade. By .contrast, the average number of daily consultations and visits of a Parisian doctor who works for the scheme is estimated at 20. SPECIALISM AND The general practitioner devotes as much IRRESPONSIBILITY as one-fourth to one-third of his time, dependmg on the scheme and the number of patients, to bureaucratic transactions: writing out pre105 ] "»EHUMANIZING" M~DICIiE scriptions, filling in official forms, writing letters to specialists and •. hospitals, keeping elaborate records and accounts, etc. The·combination of time shortage, due to an excessivenumber of patients and of paper work and the fact that his fee is virtu ally fixed (except in the French system) results not only in a physical and mental pressure· but· also in the··unavoidable tendency to· get rid of the patient.Th~ sooner he or she is switched over to a specialist or toa hospital ward, the less work and responsibility burdens the general·practitioner who should be the heart· and soul of the profession. Instead, he is in the process·of slowly being demoted to the status of an allocating· agent, sending patients to pharmacists, specialists, hospitals and sanatoria.

The outcome is that a tendency toward a dangerous and in many ways unproductive sort of specialism rules the govern mentalized services (outside France). The· danger is that the most important function may be neglected-the diagnosisand treatment of the patient. as a personality rather than asa mechanical sum of individual and unconnected diseases. The trend is toward dealing with cases of disease rather than with sick individuals. .Overburdening the specialist and the public hospitals, in tum reducing their efficiencyas wen, is the further consequence. The leaning toward specialism is inherent· in modem medicine itself. It is fostered by the popular press, and by the fact that medical education ··is almost totally monop olized by specialists. Govemmentalization tends to make it dominant. Responsibility toward the patient ceases the moment the practitioner gets rid of him. And the danger is that no one else takes ·it over. There is virtually no possibility of so-called assessing treatment. Actually, the practitioner loses contact with the patient as loon as the latter is delivered into the hos pital or· even to the specialist. In the hospitals, in every scheme, the patient's free choice of doctor is suspended. He may call in the family doctor at .his own expense, but even then. the latter has no power to "interfere." The patient is being treated and operated on by specialists who may know no more about him than his perfunctory case·history, if any is .available. In the place of a systematic, beginning-to-end, medical guiding and controlling, the compulsorysystem'semphasis Is an special ized performances.

COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 106 They serve to exhibit results not only of medical but also of great publicity value. But they do not substitute for medical care proper. To make things worse, the more these"special services are being provided the more difficult it becomes to obtain them. Where they are being made available totally free of charge and, therefore, politically most effective, the patient has to wait. In June, 1949, when this writer surveyed the situ ation in London, it took four weeks and more to get a tooth extracted, six weeks for a barium meal X-ray, two to four months' wait for a hospital bed, up to six months for eye glasses, and so forth. ·But all were available on short notice if paid for in cash. The number of incidents reported involving serious damage to people who had to wait too long was growing. At the same time, sorely needed hospital wards had to be closed due to the lack of nurses, and ward patients even had to per form menial services.

ANTINOMIES Govemmentalization revolutionizes OF MEDICAL medicine to the disadvantage of proAUTHORITARIANISM fessional standards-of medical results. They depend to a large extent on.the trusteeship relation between doctor and patient. That relationship is being uprooted. For one thing, medical secrecy ceases wherever controls are instituted, as they must be sooner or later. Even in the French system, the caisse bureaucracy can decipher the doctor's diagnosis by reading between the lines of his prescriptions. Elsewhere, especially also in Britain, he has to discloseevery detail to the officialswho are not bound by oath to the patient. Confidence in the doctor is not en hanced by this innovation nor by the fact that physicians engaged or retained by the bureaucracy may reverse the prac titioner's judgment. On top of it all, the practitioner tends to lose his independ ence vis-a-visthe patient. Being economically weak, he cannot afford losing clientele. He often cannot afford to contradict the patient, especially in matters in which the latter's material interests-such as keeping out of work-are affected.

Then, there is the burning question of who is "sick" from the technical point of view of the schemes. They all are inclined to consider sickness as a matter of objective symptoms. No proven symptom, no certifiable sicknessis the German panels' 107] ''DBJl'QMANIZING'' MEDICINE device. Otherwise, anyone could come and ask·for benefits. A bureaucratic set-up could not operate rationany-.· without corruption-. if it had. to .leave such important decisions.to "ar bitrary" judgment. But even the laym~nknows that subjective symptoms,although in no wise recognizable by instruments and chemistry, may be diagnostically most significant. Wh.at then ~ shouldthedoctor.do who is bound by oath to serve the patient and by· contract to obey the rules of the panel-and who wants to earn money, too? As a bureaucratic set-up, medical compulsion operates on the implied assumption that diseasesare objective, wen-defined phenomena, and that prefabricated techniques to cure· them are at the profession's disposal. In reality, not only have most diseases psychological implications, but even many purely physiological problems are highly .controversial. Medical judgment must be subjective to a substantial degree. It does not take conspiracy between patient and doctor to move the latter toward generous allowances to the benefit of the former.

By professional standards, as well as under the incentive of his own interests, the physician is likely to give way to the· de mands for paid vacations, for more than essential medications, for rests in hospitals and sanatoria, for special treatments the patient urges. Giving way to all claims.and signing a certifi cate are, of course, the easiest escape from tesponsibility. As a matter of fact, the mechanism of compulsion compels the practitioner to fulfill the patients' request to the limit, whether rational or not, which is one way the former mitigates the ill effects of his diluted practice on the latter. Since the doctoring is likely to be· superficial, putting it mildly, due to lack of time and incentive, the compensation of the patient· in the form of gratuities-at the scheme's expense-is the doc tor's moral and material relief. Indeed, the trouble with com pulsory medicine is not entirely that it gives free rein to doctors who do not take their responsibilityseriouslyand are satisfied with "quick" diagnoses and simplified medications on the purely instrumental and chemical level. It is the conscientious docto,r who is in danger of· being driven into mechanizing. his professional work. He cannot declare a patient health" and risk the consequences of error when he has no time to·diagnose properly. The safe thing is to· accept, so far as possible, the scheme patient's own diagnosis or to make a "temporary" one, COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 108 and to expedite him further, hoping for the best, as experienced panel practitioners of several countries assured this writer. The patient, of course, is the one who takes the ultimate punishment.

WHAT ABOUT The more medical science· progresses, the THE PATIENT? more conscious it becomes of the tremendous complexities of what is called "sickness." That the treatment of patients on the pattern of factory pro duction cannot fulfill scientific requirements should be ob vious. (Note that 'in nationalized accident insurance, in which substantial compensation is at stake, thorough-going and re peated medical examinations are mandatory, while they tend to be the exception in compulsory health care of every denom ination.) The few minutes the average scheme doctor can spare for the average patient cannot do justice to the psycho logical implications of the case, to say nothing of such ultra modern requirements as the proper consideration of the lat ter's occupational and family backgrounds and his hereditary circumstances, or even to weigh properly his frequent "exag gerations, under-statements and distortions."5 Nor is the question one of curative medicine alone. The family doctor's role in providing preventive medicine hardly can be exaggerated. Quick diagnoses, usually without case history, and even with the best of specialized clinical treat ment, may produce curative results but never can substitute for the long-run counsel and guidance of the practitioner in avoid ing or minimizing illness.6 Comparatively poor medicine but rich subsidies tend to be the net result of governmentalized health care. In fact, it "cares" for a minority, one privileged by its own insistence or by sheer accident, rather than for the health of the masses. It leaves a large sector of those in real need often without a rea sonable minimum of medical protection. The cases of actual damage done by neglect or through lack of facilities never could be counted. Such cases may occur in a free medical . economy, too, and to an unknown extent; but there the facilities are not overstrained to any similar degree; remedy is possible, disregarding exceptional situa tions.

109 ] HDEHUMAN1ZINO" MEDICINl! Under. compulsion the medical services tend to· be progres sively dehumanized, to use·the descriptive term coined by an eminent. student (and advocate!) of social.security, .Monsieur Georges de Lagarde. Small wonder that the doctors' dissatis faction bursts into the open in all countries concerned. To quote one characteristic emotional outburst: "95 per cent of all patients entering a doctor's surgery (office)," wrote an English practitioner in 1943, under the comparatively restrained Lloyd George system, "demand some form. of certificate. The pri mary.function of a general practitioner is no longer medicine, either preventive or curative, but· merely the. writing out of certificates. And his most important concern is that the cer tificate .shall be a safe one, that is, one that will satisfy the patient, satisfy his own tattered conscience and ... keep him out of the clutches of the General Medical Council."7 And he is overloaded with forms myriad and formidable. Lately, the number of British "forms" has multiplied further.

QUANTITY vs. Scheme administrations and their .following QUALITY. OF argue that we should be patient and let the SERVICE system develop its potentialities. Of course, the same admonishment-for patience-. may be invoked in favor. of the free medical market, too. But the objective student is faced with an even more serious question, the discussion of which is blurred usually by emo tions. Is it not preferable to provide the "needy" (who need to be defined) with some medical service, be it t>ne that is .ad mittedly far from satisfactory, rather than to let them drift "helplessly" (whatever that means)? Undoubtedly, the com pulsory systems imply that in terms of doctors-per-minute, of drugs-per-ounce, of appliances-per-piece, of teeth-pulled-per person, etc. more is being put· at the public's disposal than would have been offered in the same country and at the same time if all those services had to be acquired at· their market prices. If so,comparison of a free'vs. a compulsory medical market should result in favor of the latter-· in purely quantita tive terms. If it were possible to measure those services by re ducing them to multiples of a homogeneous unit of energy, let us call it an "erg med.," the compulsory systems should be COMPULSORY MEDICAL CARE AND THE WELFARE STATE r110 found producing a much larger number of such units per capita than the free systems do under the same or similar circumstances.

But it is equally certain that the unit of service procurable and actually procured under a free system must be of higher quality. The evidence is overwhelming. For one thing, a doctor who sees 20 or 30 patients a day is likely to do better with each of them than one who sees 80 or 100. That leaves us in a quan dary: What kind of medicine do we consider desirable-<>ne that produces the maximum number of per capita ergs med., or the other that gives the highest quality of service under the given conditions of the respective country? What I am trying to say is that not all is light on the one side and darkness on the other. The free medical market may pro duce marvels, but they mayor may not be accessible to the "submarginal" patient. Governmentalization is supposed to take care of that. On the other hand, the quantitative progress achieved in compulsory systems should be weighed in the light of the qualitative deterioration that accompanies it. Such weighing can take place, however, only in the spirit of cold blooded realistic discussion, not in the atmosphere of political oratory under which the controversy labors in virtually every country. To promise adequate health care, as the proponents of compulsion do, means to use the words in an irresponsible careless fashion. AIl they can promise honestly and knowingly is some care for every one, including those who (allegedly) would have none or too little, but accompanied by a qualitative lowering of the level of medical service for the vast majority.

MEDICO-However, it should be remembered that SOCIOLOGICAL even the quantitative gain may turn out to ARGUMENTS be illusory if the demand for medical services expands faster than the supply of com petent doctors and nurses,of hospital beds and equipment, etc., can be increased. But that is exactly what happens when the attempt is made to satisfy the demand at a greatly reduced cost or at no cost to the recipient. Then, new submarginal patients emerge: patients who cannot get what they are entitled to, in the place of those who could not pay for what they needed. That still leaves another medico-sociological argument in favor of governmentalization: the argument that at least it 111 ] "DEHUMANIZING" MEDICINE awakens the public's interest in, and hope for, health care. It does that, provided the interest and the hope are not checked by sharp "deductibles," discriminatory,; physical controls and thedisappointirig lack of promised facilities. Even so, the im portance of making ,the public conscious of its own need for medical care should not be deprecated. The inducement of- • fered might lead to the early discovery of incipient diseases, diabetes and tubercul6sis in particular. In this, respect, the compulsory systems may have an accomplishment'to their his torical credit. But so have the free clinics, which under free systems always have been available to the poverty-stricken patient. At any rate, the same result might be attained, if somewhat more slowly, at much less cost to society.