The Patient's Grievances Against the Doctor

On the raging battlefront between man and disease, there emerged man the doctor, devoting himself to the study of the arts of disease, attempting to prevent it, to cure it, or to lighten its burden. Three tasks have occupied the doctor ever since he came into being, fighting in man's ranks against the ranks of disease: warding off sickness, curing ailments, and easing the pain that is in them.

And man the patient has harbored, against man the doctor, a reproach since the beginning of these human wars against diseases of every kind. Just as the kinds of disease are many and the arts of their behavior strange, so too have the arts of man the doctor in fighting them multiplied: at one stage he was a sorcerer or a charlatan, then an experimenter without guidance, and after that a man of science — diagnostician, then healer, then preventer.

And the reproach of the patient — or of the man who is not a doctor — against man the doctor kept growing and developing along with the developments of the arts of medicine itself, down to this very day; the methods of disease have developed along with the development of the methods of medicine, and the reproach itself has developed until it too has become an art, or very nearly.

What, then, are the elements of this reproach — what are the patient's grievances against the doctor?

The doctor, wherever he is found, forms a minority unit in his surroundings, and the patient's reproach of the doctor is nothing but the reproach of the majority against the minority, or a contest between these two classes of mankind — that contest of many shapes, causes, and ends, which has continued since man existed and will continue until he passes away: a reproach or contest or struggle between giver and taker, or rich and poor, or learned and ignorant, or strong and weak, or oppressor and oppressed, or exploiter and exploited, or ruler and ruled, or the one in the right and the one in the wrong, or teacher and pupil, or lover and beloved, or male and female, or individual and society, or describer and described — or, if you will, mind and body, or science and faith, or life and death, or health and sickness... A duality in the nature of man, its fires raging as the one half challenges the other; and this continual, straining challenge is man himself: by it he exists, and by nothing else.

The patient's grievances against the doctor are but one chapter among the chapters of this eternal tug-of-war in the duality of human nature. Every one of man's ages has witnessed different manifestations of this reproach, until in this age of ours we are entitled to add, in this field, a front of war or of reproach between patient and doctor, alongside the war-front that exists in origin between man and disease.

Perhaps the arts of medicine have never multiplied in any age as they have multiplied in this one — and this not only on account of the advance of medical science and the growing entanglement of man's social life, but on account of the piling up of the various arts of the past one upon another, and their gathering, all of them, side by side with the newest arts... Thus we see today the sorcerer doctor, the empiric doctor, and the scientific doctor, curative or preventive, all at one time... each of them contending in the war against disease on the front of the man who is not a doctor — to ward off, to cure, or to ease pain. Three classes of doctors, with three aims; and today the grievances of the sick man, or the man who is not a doctor, pile up against all these classes and all these aims in a way that calls even for public reckoning...

It is no secret that reproach has its source in failure, in one form or another; and were it not for failure — in warding off, in curing, or in easing pain — there would be no cause or occasion for reproach at all. This failure arises either from a fundamental deficiency in the knowledge from which the doctor draws his art or his science, or from a personal deficiency in the doctor himself in his application of the principles of this knowledge to the sick man or the healthy one, or from a cause that has to do neither with knowledge, theoretical or applied, but with the material compensation paid to the doctor for his wielding the weapon of this knowledge in his fight on the front, with man, against disease. To demonstrate these various kinds of failure, some details must be recounted...

How many individuals among us, one wonders, have consulted doctor colleagues and gained no benefit from their prescriptions, then gone back to them a second time and a third,

and gone back to buying new medicines without obtaining any benefit, then gone off to consult others and still others, each time leaving the doctors' clinics either with requests for analyses and X-rays or with prescriptions upon prescriptions, and curses from one doctor upon another, while the symptoms grew worse instead of weaker — until they despaired of medicine and doctors, and decided, heeding the advice of neighbors and friends, to consult the practical doctors: the bonesetter, or the priest, or the sheikh, or the midwife, or the practical nurse, or so-and-so renowned for giving injections. These prescribe for them herbs, or cautery, or fasting... to no avail; so they go back to licensed doctors, only to leave their clinics with empty pockets and costly prescriptions, found only in Europe and America, or Russia, or found nowhere except at such-and-such a pharmacist's and no other, or found only with the doctor himself — but at an exorbitant price on account of its scarcity. In despair they are forced to pawn the jewelry, or sell the plot of land, or borrow a sum at interest, in order to try these modern medicines, powerful in their effect, God willing... Then before long the futility of these, too, becomes plain to them, despite the dearness of their price and the rarity of their supply, and so they give themselves over to the quacks — the astrologers and their like — who cauterize their bodies at the places of pain, or tie a thread in such-and-such a spot in the hope that an ailment may vanish from their bodies in some other spot... And thus each one of them will have begun with a simple ailment, which defied a doctor who misdiagnosed it, so that it grew intractable upon the patient's spirit and upon his pocket, and cost him the consultation of a second doctor and a third, and the price of successive analyses and prescriptions, after which he was forced to resort to unlicensed doctors, and from them to quacks — and all of it to no avail. The patient comes out of all this melee gravely ill, empty of pocket, amply stocked with medicines, and stripped of all confidence in medicine and doctors.

And how many persons among us have needed a medical certificate for employment, or travel, or marriage, and could obtain it only from doctors appointed by the companies or schools or institutions or governments — and find no one who trusts these certificates, because the reputation of doctors' attestations is like the reputation of the testimony of porters, or of drunkards: it has no truth, no value, and no ground whatever for reliance in time of need or in emergencies.... Whoever wishes obtains it, and in an unprofessional way... for a known sum.

Or is there not among our honored readers someone who knows stories upon stories of doctors banding together, to conceal one of their number's erroneous diagnosis, or in an attempt to do unjust harm to one of their number's reputation, or of brokerage among some of them for others, or for a group of pharmacists or laboratory owners, or of collusion on the part of some of them with cheap agents from outside the profession, who stand in the paths of the sick to snare the simple among them into the traps of the greedy, exploiting colleagues? I speak as a doctor, but I speak with the patient's tongue; and I know full well that defaming my profession before the people does no honor to my personal dignity, neither in the eyes of my colleagues, nor perhaps in the eyes of the people either, whom I am defending on this occasion. Public defamation is a method of criticism that is destructive and wrong, and wrong does not mend wrong.... But I know at the same time that the dignity of my profession in the eyes of the people can no longer be defended by a cover-up of closed ranks, for its stories are current among all the people, and the patients' reproach of our colleagues has no end.... whether on account of the deficiency in the science of medicine itself, or on account of the ignorance of some of them, as individuals, of that science, or on account of their fees, and the lengths to which they will go for the sake of the pocket's interest at the expense of the honor of the profession and the interest of the patient... I am confident that I am defaming no particular colleague here, for that is not permissible under any circumstances; and I divulge no secret when I say that the standing of the doctor in society at the present time is no longer what it once was — that standing at which fingers used to point, sacred, respected, insofar as it was a means of putting science at the service of the patient's benefit before the doctor's, so as to ward off disease or cure it or ease its pain. It has become, on the contrary, a mere trade for earning a living... The doctor rejoices at people's sickness, because he lives at the expense of their sickness; the doctor grows in wealth the more people grow in sickness, and the more his surroundings grow in epidemic. If this wealth were at the expense of the patient's wealth alone, the matter would be somewhat tolerable; but it is at the expense of his wealth and his health together, and at the expense of the wealth and health of the healthy whom the patient himself supports, at

the very same time... Is it not misery enough for the patient that he is stricken with disease, without there being added to this misery the misery of his being forced to pay the price of the disease — in diagnosis, in treatment, and in deprivation of work — especially in those diseases against which the individual patient cannot, by himself, protect himself, but for whose striking him the government, or the community, and the medical body itself, are all responsible?

Yes — we, the company of doctors, can no longer bear the patients' reproach that exposes us. At one time we devise free clinics as publicity for ourselves, not as a service to the patient; at another time we devise the novelties of medical insurance in its various kinds, whose pivot, for the most part, is the doctor's interest before the patient's... And what is the patient's fault, if the doctor spent years — so many of them — in acquiring his learning, and spent sums of money — so great the degree of their debts — before obtaining his diploma, and his family's demands have grown, that he should pay to this expensive, indebted doctor his health and his money together, as the price of consulting him? Our arguments, we doctors, against the patients are many: in our eyes they are ignorant, they do not follow advice as they should, they do not seek professional help until the ailment has grown grave and the time has passed, they do not value science at its true worth, nor the doctor, except when his fees are high, or his disparagement of his colleagues frequent, or his boasting over them loud; and so the doctor is forced, in deference to this mentality in his surroundings, to descend from his scientific and moral level to the level of self-interest, to earn his bread.

And let every citizen and every colleague know, on this occasion, that every system of medical practice — no matter whether it be the old system of individual practice, or the new one of group practice, with insurance or without insurance — does not keep the doctor from moral or scientific lapse; because the practice of medicine is, in the end, a scientific service and an ascetic, moral sacrifice, nothing more. Every doctor who will not accept this medical cross must withdraw from medicine, to make room for others to join together in carrying it — out of sheer delight, nothing more, in warding off ailment, curing sickness, and easing pain — and to trace, in this spirit, not the mercenary spirit, the designs of medical insurance, so as to secure the scientific benefit, good and complete, for the greatest number of those people most in need of it, and at the cheapest prices.

Yes, the patients' reproach has grown until it has all but toppled the pillar of the medical bloc; and we, the fraternity of doctors, cannot preserve our dignity by closing ranks or by syndicates, but only by stopping the people's reproach of us, and forestalling their grievances against our company — by each one of us counting himself responsible for the health of his surroundings, for his patient's awareness of the basic matters of health, for his government's awareness of its preventive duty; and responsible, at the same time, for the full perfection of his work, by persevering in study, keeping abreast of what is new, searching out the latest, and consecrating his science as a means for the patient as an end in himself — not counting his science and the patient together as a mere means to his fame and his livelihood.....

Yes: human medicine, in its loftiness, was a service; we must not degrade its dignity by making it a trade.

Dr. Zaken Shakhashiri
Secretary of the Lebanese Society for Public Health