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THE STATE AND THE MEDICAL
Ar intervals during the last quarter of a century, Committees of the Houses of the Legislature and specially appointed Commissions have occupied themselves with the affairs of the medical profession. Much evidence has been taken, much wrangling has gone on over the reports of these bodies; and sometimes much trouble has been taken to get measures based upon all this work through Parliament, but very little has been achieved.
The Bill introduced last session was no? more fortunate than sundry predecessors. I suppose that it is not right to rejoice in the misfortunes of anything, even a Bill ; but I confess that this event afforded me lively satisfaction, for I was a member of the Royal Commission on the report of which the Bill was founded, and I did my best to oppose and nullify the most important proposal of that report.
That the question must be taken up again and finally dealt with by the Legislature before long cannot be doubted; but, in the meanwhile, there is time for reflection, and I think that the non-medical public would be wise if they paid a little attention to a subject which is really of considerable importance to them.
The first question which a plain man is disposed to ask himself is, Why should the State interfere with the profession of medicine any more than it does, say, with the profession of engineering? Anybody who pleases may call himself an engineer, and may practise as such. The State confers no title upon engineers, and does not profess to tell the public that one man is a qualified engineer and that another is not so.
The answers which are given to the question are various, and most of them, I think, are bad. A large number of persons seem to be of opinion that the State is bound to take care of the general public, no less than to see that it is protected against incompetent persons, quacks and medical impostors in general. I do not take that view of the case. I think it is very much wholesomer for the public to take care of itself in this as in most other matters; and, although I am not such a fanatic for the liberty of the subject as to plead that interfering with the way in which a man may choose to be killed or cured is a violation of that liberty, yet I do think that it is far better to let everybody do as he likes. Whether that be so or not, I am perfectly certain that, as a matter of practice, it is impossible to prohibit the practice of medicine by people who have no special qualification for it. Consider the terrible consequences of attempting to prohibit practice by a very large class of persons who are certainly not technically qualified—I am far from saying a word as to whether they are otherwise qualified or not. The number of Ladies Bountifulgrandmothers, aunts, and mothers-in-law-whose chief delight lies in the administration of the subordinate provinces of domestic medicine, is past computation, and one shudders to think of what might happen if their energies were turned from this innocuous, if not beneficent channel, by the strong arm of the law. But the thing is impracticable.
Another reason for intervention is propounded, I am sorry to say, by some, though not many, members of the medical profession, and is simply an expression of that trades-unionism which tends to infest professions no less than trades.
The general practitioner whose medical training has cost him a good deal of time and money, trying to make both ends meet on a poor practice, finds that many potential patients, whose small fees would be welcome, as the little that helps, prefer to go and get their shilling's worth of doctor's stuff' and advice from the chemist and druggist round the corner, who has not paid sixpence for his medical training, because he has never had any. The general practitioner thinks this is very hard upon him and ought to be stopped. It is perhaps natural that he should think so, though it would be very difficult for him to justify his opinion on any ground of public policy. But the question is really not worth discussion, as it is obvious that it would be utterly impracticable to stop such practice over the counter' even if it were desirable to do so.
Is a man who has a sudden attack of pain in tooth or stomach not to be permitted to go to the nearest druggist's shop and ask for something that will relieve him? The notion is preposterous. But if this is to be legal, the whole principle of the permissibility of counter practice is granted.
In my judgment, the intervention of the State in the affairs of the medical profession is to be justified, not upon any pretence of protecting the public, and still less upon that of protecting the medical profession, but simply and solely upon the ground that the State employs medical men for certain purposes, and, as employers, has a right to define the conditions on which it will accept service. It is for the interest of the community that no person shall die without there being some official recognition of the cause of his death. It is a matter of the highest importance to the community that, in civil and criminal cases, the law shall be able to have recourse to persons whose evidence may be taken as that of experts; and it wil not be doubted that the State bas a right to dictate the conditions under which it will appoint persons to the vast number of naval, military, and civil medical offices held directly or indirectly under the Government. Here, and here only, it appears to me, lies the justification for the intervention of the State in medical affairs. It says, or should say, in my judgment, to the public, “Practise medicine if you likego to be practised upon by anybody;' and to the medical practitioner, ‘Have a qualification, or do not have a qualification if people don't mind it; but if the State is to receive your certificate of death, if the State is to take your evidence as that of an expert; if the State is to give you any kind of civil, or military, or naval appointment, then we call upon you to comply with our conditions, and to produce evidence that you are, in our sense of the word, qualified. Without that we will not place you in that position. As a matter of fact, that is the relation of the State to the medical profession in this country. For my part, I think it an extremely healthy relation; and it is one that I should be very sorry to see altered, except in so far that it would certainly be better if greater facilities were given for the swift and sharp punishment of those who profess to have the State qualification when, in fact, they do not possess it. They are simply cheats and swindlers, like other people who profess to be what they are not, and should be punished as such.
But supposing we are agreed about the justification of State intervention in medical affairs, new questions arise as to the manner in which that intervention should take place and the extent to which it should go, on which the divergence of opinion is even greater than it is on the general question of intervention.
It is now, I am sorry to say, something over forty years since I began my medical studies, and, at that time, the state of affairs was extremely singular. I should think it hardly possible that it could have obtained anywhere but in such a country as England, which cherishes a fine old crusted abuse as much as it does its port wine. At that time, there were twenty-one licensing bodies—that is to say, bodies whose certificate was received by the State as eviderice that the persons who possessed that certificate were medical experts. How these bodies came to possess these powers is a very curious chapter in history, on which it would be out of place to enlarge. They were partly universities, partly medical guilds and corporations, partly the Archbishop of Canterbury. There was no central authority, there was nothing to prevent any one of those licensing authorities from granting a license to any one upon any conditions it thought fit. The examination might be a sham, the curriculum might be a sham, the certificate might be bought and sold like anything in a shop; or, on the other hand, the examination might be
fairly good and the diploma correspondingly valuable; but there was
It is difficult to imagine, at present, such a state of things, still more difficult to depict the consequences of it, because they would appear like a gross and malignant caricature; but it may be said that there was never a system, or want of system, which was better calculated to ruin the students who came under it, or to degrade the profession as a whole. My memory goes back to a time when models from whom the Bob Sawyer of thc Pickwick Papers might have been drawn were anything but rare.
Shortly before my student days, however, the dawn of a better state of things in England began to be visible, largely in consequence of the establishment of the University of London, and the comparatively very high standard which that body placed before its medical graduates. I say comparatively high standard, for the requirements of the University in those days, and even during the twelve years, at a later period, when I was one of the examiners of the medical faculty, were such as would not now be thought more than respectable, and indeed were in many respects very imperfect. But, relating to the means of learning, the standard was high, and none but the more able and ambitious students dreamed of attempting to obtain the degrees of the University of London. Nevertheless, the fact that many men of this stamp did succeed in obtaining their degrees, led others to follow in their steps, and slowly but surely reacted upon the standard of teaching in the better medical schools.
Then came the Medical Act of 1858. That Act introduced two great improvements : one of them was the institution of what is called the Medical Register,' upon which the names of all persons recognised by the State as medical practitioners are entered; and the other was the es-ablishment of the Medical Council, which is a kind of Medical Parliament, composed of representatives of the licensing bodies and of leading men in the medical profession nominated by the Crown. The powers given by the Legislature to the Medical Council were found, practically, to be very limited; but I think that no fair observer of its work will doubt that this much attacked body has exerted no small influence in bringing about the
great change for the better which has been effected in the training of men for the medical profession in recent years.
Another source of improvement must be recognised in the Scottish Universities, and especially in the medical faculty of the University of Edinburgh. The medical education and examinations of this body were for many years the best of their kind in these islands, and I doubt if, at the present moment, the three kingdoms can show a better school of medicine than that of Edinburgh. The vast number of medical students who frequent that University is sufficient evidence of the opinion of those most interested on this subject.
Owing to these and some other influences, and to the revolution which has taken place, in the course of the last twenty years, in our conceptions of the proper method of teaching physical science, the training of the medical student in a good school, and the examination test applied by the great majority of the present licensing bodies (reduced now to nineteen in consequence of the retirement of the Archbishop and the fusion of one of the other licensing bodies with another) are totally different from what they were even at a comparatively recent period.
I was agreeably astonished, upon one of my sons commencing his medical career the other day, when I contrasted the carefully-watched courses of theoretical and practical instruction which he is expected to follow with regularity and industry, and the number and nature of the examinations which he will have to pass before he can receive his license, not only with the monstrous laxity of my own student days, but even with the state of things which obtained when my term of office as examiner in the University of London expired some sixteen years ago.
I have no hesitation in expressing the opinion, which is fully borne out by the evidence taken before the late Royal Commission, that a large proportion of the existing licensing bodies grant their license on conditions which insure quite as high a standard as it is practicable or advisable to exact under present circumstances, and that they show every desire to keep pace with the improvements of the times. And I think there can be no doubt that the great majority have so much improved their ways, that their standard is far above that of the ordinary qualification of the best licensing bodies thirty years ago, and I cannot see what excuse there would be for meddling with them if it were not for two other defects which have to be remedied.
Unfortunately there remain two or three black sheep-licensing bodies which simply trade upon their privilege, and sell the cheapest wares they can for shame's sake supply to the bidder. Another defect in the existing system, even where the examination has been so greatly improved as to be good of its kind, is that there are certain licensing bodies which give a qualification for an acquaintance with either medicine or surgery alone, and which more or less ignore