The Doctors Dilemma: Preface | Page 7

and a better
drained and ventilated house. It is kinder to give him a bottle of
something almost as cheap as water, and tell him to come again with

another eighteenpence if it does not cure him. When you have done that
over and over again every day for a week, how much scientific
conscience have you left? If you are weak-minded enough to cling
desperately to your eighteenpence as denoting a certain social
superiority to the sixpenny doctor, you will be miserably poor all your
life; whilst the sixpenny doctor, with his low prices and quick turnover
of patients, visibly makes much more than you do and kills no more
people.
A doctor's character can no more stand out against such conditions than
the lungs of his patients can stand out against bad ventilation. The only
way in which he can preserve his self- respect is by forgetting all he
ever learnt of science, and clinging to such help as he can give without
cost merely by being less ignorant and more accustomed to sick-beds
than his patients. Finally, he acquires a certain skill at nursing cases
under poverty-stricken domestic conditions, just as women who have
been trained as domestic servants in some huge institution with lifts,
vacuum cleaners, electric lighting, steam heating, and machinery that
turns the kitchen into a laboratory and engine house combined, manage,
when they are sent out into the world to drudge as general servants, to
pick up their business in a new way, learning the slatternly habits and
wretched makeshifts of homes where even bundles of kindling wood
are luxuries to be anxiously economized.
THE SUCCESSFUL DOCTOR
The doctor whose success blinds public opinion to medical poverty is
almost as completely demoralized. His promotion means that his
practice becomes more and more confined to the idle rich. The proper
advice for most of their ailments is typified in Abernethy's "Live on
sixpence a day and earn it." But here, as at the other end of the scale,
the right advice is neither agreeable nor practicable. And every
hypochondriacal rich lady or gentleman who can be persuaded that he
or she is a lifelong invalid means anything from fifty to five hundred
pounds a year for the doctor. Operations enable a surgeon to earn
similar sums in a couple of hours; and if the surgeon also keeps a
nursing home, he may make considerable profits at the same time by
running what is the most expensive kind of hotel. These gains are so
great that they undo much of the moral advantage which the absence of
grinding pecuniary anxiety gives the rich doctor over the poor one. It is

true that the temptation to prescribe a sham treatment because the real
treatment is too dear for either patient or doctor does not exist for the
rich doctor. He always has plenty of genuine cases which can afford
genuine treatment; and these provide him with enough sincere
scientific professional work to save him from the ignorance,
obsolescence, and atrophy of scientific conscience into which his
poorer colleagues sink. But on the other hand his expenses are
enormous. Even as a bachelor, he must, at London west end rates, make
over a thousand a year before he can afford even to insure his life. His
house, his servants, and his equipage (or autopage) must be on the scale
to which his patients are accustomed, though a couple of rooms with a
camp bed in one of them might satisfy his own requirements. Above all,
the income which provides for these outgoings stops the moment he
himself stops working. Unlike the man of business, whose managers,
clerks, warehousemen and laborers keep his business going whilst he is
in bed or in his club, the doctor cannot earn a farthing by deputy.
Though he is exceptionally exposed to infection, and has to face all
weathers at all hours of the night and day, often not enjoying a
complete night's rest for a week, the money stops coming in the
moment he stops going out; and therefore illness has special terrors for
him, and success no certain permanence. He dare not stop making hay
while the sun shines; for it may set at any time. Men do not resist
pressure of this intensity. When they come under it as doctors they pay
unnecessary visits; they write prescriptions that are as absurd as the rub
of chalk with which an Irish tailor once charmed away a wart from my
father's finger; they conspire with surgeons to promote operations; they
nurse the delusions of the malade imaginaire (who is always really ill
because, as there is no such thing as perfect health, nobody is ever
really well); they exploit human folly, vanity, and fear of death as
ruthlessly as their own health, strength,