Dear Doctor Jay: My check for $14.45 accompanies this letter. I have taken two deductions from the $15 for which you billed me. The first one, thirty cents, is the 2 per cent for current payment customary in commercial transactions; business ethics, I gather, now govern our relationship. I will explain the remaining twenty-five cents in a moment.
I fully understand why you have been forced to raise your fee for house calls from $10 to $15, though I am not able to adjust my own professional fees so readily to the rise in living costs. I am still being paid for the Easy Chair just what I was getting in June 1946 when I wrote a piece attacking the anti-vivisectionists for which you and about a thousand other medical men wrote me letters of approval. (Many of them phrased so similarly as to suggest that someone had sent out word to give me a hand.) Still, though my income is not large enough to enable me to pay for my children’s education this year without dipping into savings, I realize that it is large enough to put me, statistically, in the topmost 5 per cent of Americans. I am therefore glad to send you the $15, less deductions, as payment for your treatment of my son’s cold plus my share of your treatment of others who cannot afford your full fee or perhaps any of it. The 95 percent of my fellow-countrymen who are less able than I to afford medical treatment thrust themselves on my attention. I will help American medicine take care of them — as long as I can.
I do not know how long that will be. This month the hospital to whose staff you belong asked me to contribute to its endowment drive. The last time it did so I sent what was for me a thumping big check, much larger than I could really afford. I would be glad to contribute now, all the more glad because of the magnificent care I received during the three weeks I spent there last April. But this year I cannot afford to give the hospital a dime. One reason, besides taxes and the inflation, is that the cost of those three weeks, the fee of the surgeon who operated on me, and the loss of income while I was convalescing used up all my margin. The chairman of the drive tells me that it is going to fall far short of its goal; many people on whom it could once depend for contributions can no longer afford them. He, you, and I all know how grave a danger this is to the hospital, to your profession, and to the public. Who is going to pay the hospital’s deficits and who is going to support its medical research now that we of the middle class no longer can? I understand your trade association, the AMA, to say that though it cannot answer that question it will not permit the government to pay for them.
I thank you for the publicity matter which you inclosed with your statement. I am especially glad to have the copy of Dr. Elmer L. Henderson’s inaugural address, “Medical Progress versus Political Medicine.” I understand that in sending me this material you were helping in the crusade which Messrs. Whitaker & Baxter outlined for you in “A Simplified Blueprint of the Campaign against Compulsory Health Insurance.” You must, they tell you there, “do double duty until this issue is resolved.” You must, they say, “help in treating the ills of the body politic.” But I must tell you that as part of the body politic I do not think you are qualified either to diagnose or to treat such illnesses, and I know that advertising agencies will make any diagnosis asked for on a fee-for-service basis.
Your proprietary advertising reached me opportunely. I was following the ads which you were running in the Boston newspapers. I found them dishonest, and they further annoyed me by the copywriter’s assumption that I am a fool. But they harmonized well with the ads on the opposite page, which were trying to sell me water from a radium spring that is guaranteed to cure everything from impotence to cancer. They set out to rouse the same fears to the same ends. Your radio commercials interested me too. Little dramatic sketches presented you as the old family doctor, with the nobility and self-sacrifice which copywriters now have you wearing like a streetwalker’s smile, and assured me that you were guarding my health (without fee, the implication was) and simultaneously protecting me from political enslavement. I observed that as soon as you signed off, another little drama came on. There was a woman who was very, very tired. She was so exhausted and suffered so much from backache that she could not greet her husband with the loving eagerness which alone could save their marriage. It turned out that she needed the dollar economy-size of a cathartic which acts painlessly, and I rejoiced that the advertising agencies were saving freedom, monogamy, and peristalsis in the same half-hour.
You and a tobacco company will relieve throat irritation; you and Seneca Snake Oil will get rid of gallstones. Your advertising has already cost you a very great deal of the prestige which the advertising agency told you would put your campaign over. And it has radically changed the relationship between you and me. Your ads speak of the trust between physician and patient, so noble it says here, so sacred, so certain to be destroyed by what the propaganda calls socialism. But I do not like any kind of solicitation that trades on prestige or on such fears and hopes as illness necessarily involves, and I will not tolerate political solicitation in a relationship of trust. Solicitors who call at my house must use the back door.
My second deduction, the twenty-five cents, signifies that I will not help pay for the $25 assessment you sent to the AMA to run these ads and print these pamphlets. I will not help you finance distortion and demagoguery. In an envelope that has your name and degree on it you tell me by way of Dr. Henderson that “all infectious diseases have been brought under effective methods of prevention, control, and treatment.” I am to have no more colds, then, and my friend’s daughter need not have died of poliomyelitis last summer. Cure guaranteed, Dr. Henderson’s ad says in effect, and it was only through inadvertence that he did not mention the great increase in chronic diseases, especially among the elderly, and that he did not point out how our increased longevity makes more medical service necessary, not less. There is much further disingenuousness in his anthem of self-praise but let us pass over it. I am willing to grant him that on the whole “the history of American medicine is a vibrant, continuing story of human progress.” But when you follow him into a political agitation that is at once arrogant, insolent, and dishonest, someone has got to call you.
“It is,” the two of you say, “the administrative arm of our Government in Washington which has failed us in this generation — a Government which is sick with intellectual dishonesty, with avarice, with moral laxity, and with reckless excesses.” You say that to me when you send me his speech, Doctor. You sound like Mr. Vishinsky, and that eloquent rabble-rouser was surely pleased by your allusion to “the totalitarian plan which Washington directs and the people pay for.” You and Dr. Henderson are to be highlighted in your nobility against the government’s viciousness, and I am to rejoice that, all other moral heroisms having been defeated, yours will keep us free. And the conspiracy, though so powerful, is so small. You tell me that the people who do not stand on the AMA’s party line are “a comparatively small group of little men — little men whose lust for power is far out of proportion to their intellectual capacity, their spiritual understanding, their economic realism, or their political honesty.” Expert hysterical rabble-rousing, Doctor, and you add, “Their real objective is to gain control over all fields of human endeavor. Their real objective is to strip the American people of self-determination and self-government and make them a Socialist State in the pathetic pattern of the socially and economically bankrupt Nations of Europe which we, the American people, are seeking to rescue from poverty and oppression.” You go on to say that the issue is “whether we are to become a Socialist State, under the yoke of a Government bureaucracy, dominated by selfish, cynical men who believe the American people are no longer competent to care for themselves.” You and Dr. Henderson and his publicity adviser, from your advertising agency I suppose, appear to believe that the American people are no longer competent to think for themselves. But you make me wonder how competent you are.
Much might be said about this delirious rant, which would have landed Dr. Henderson before the un-American Activities Committee if it had been circulated by a group of excited college boys who had just heard of Marx. One thing is this: you and Dr. Henderson are saying what is not so. Another is this: Dr. Henderson acquires no immunity by wrapping the flag round the vested interest of the AMA’s bureaucracy and trustees. Your acquiescence in his claptrap withdraws you from my respect but I take it to be a consequence of the fact that you have not done much thinking about the subject he is misrepresenting. Medicine is your field, not economics, sociology, or government. You come innocent and virginal to social thinking. It is a fair bet that, like thousands of other physicians whose rage Dr. Henderson is whipping up, you have not even read the bills for compulsory payroll deductions for medical insurance which, after all, are what he is talking about. You probably do not know what the bills say, and you had to work so hard on biochemistry at college that you did not learn to detect the propaganda in such phrases as “socialized medicine,” “statism,” “socialism,” and “totalitarianism.” With what valorous stupidity you charge head down at those red rags — and all they are concealing is certain bills which would require some people to take out medical insurance. Bills that are an admittedly clumsy attempt to remedy an intolerable situation which your trade association refuses to face realistically and which, it makes clear, must be solved without its help.
You are a busy man, I know. You have not got time to find out for yourself, though every day you see some of the conditions that the bills are trying to alleviate. So you check your intelligence with the AMA, whose refusal to do anything grows more reactionary as conditions grow more alarming. And with your intelligence and your $25 in its pocket, the AMA systematically distorts the facts and misrepresents the conditions to you. You docilely swallow the cure-guaranteed elixir which your propagandists prescribe. And, docile to them, but truculent to me, you send me Dr. Henderson’s nonsense and forfeit your status. A friend of mine, a Vermonter, has a useful locution. He does not say, “Joe is a damned fool.” Knowing the mixed nature of the human being and the fallibility of human judgment, he says instead, “Joe puts me in mind of a damned fool.” What you put me in mind of, Doctor, is a sap.
You had better stop acting like a sap. Our constitutionally elected government, which has to do something about an increasingly alarming social situation that the AMA refuses to deal with at all except on its own long-obsolete terms — do you really think it is what Dr. Henderson says it is? You had better think again, fast and hard. And this pamphlet called “Old Doc Truman’s Pink Pills.” Have you read it, Doctor? Take the passage that begins on page 27. It equates the Democrats, the party which a majority of our citizens have maintained in power, with Communists, and in doing so it makes some of the most scabrous and feculent statements I have ever seen in print. Its distributors have learned a little caution, but not much, from the public outrage that followed the notorious “Dear Christian Colleague” letter which one of your propaganda organizations sent out. As it describes the plot of various committees and learned foundations to deliver medicine and the United States over to Stalin, it insistently repeats Jewish names. It never quite says right out that the Democrat-Communist plot is a Jewish plot but it is so written as to make many a reader believe that it is. Thus it arrives at a standard technique of totalitarianism: anti-Semitism. Do you accept responsibility for this? You will be held responsible. I got the pamphlet from the office of your State medical society and the girl there said that it was for distribution to patients. You paid the $25 assessment. The noble old family friend has corrupted the relationship of trust with anti-Semitism. I know that you, personally, do not approve of this, but there it is. Thousands of your colleagues do not, either, and still there it is. Take a tumble to yourself.
And take a tumble to your leaders. Dr. Henderson says that in three more years ninety million people will be enrolled in voluntary health-insurance plans and that “when that number has been reached, the problem will be largely resolved.” Even if his wild guess should prove accurate, and even if all those voluntary plans should prove adequate, will the problem be “largely resolved”? Dr. Henderson will be satisfied if the remaining 40 per cent of the population are without insurance — will you be satisfied? And are you sure that the AMA will support the voluntary plans which it is now praising? For years it opposed voluntary health insurance as violently as it now opposes payroll deductions. Twenty-six state medical societies, I make it, have sponsored legislation which limits such plans to those that are controlled wholly by physicians. That is, plans in which neither the public nor the subscriber has effective power. Many medical societies have threatened disciplinary action — up to measures which would make practice impossible — against any of their members who participate in any other kind of plan. Some have been convicted of conspiracy in restraint of trade — which is a crime, Doctor — and others are under indictment for such interference with voluntary prepayment plans. The AMA has fought hard against comprehensive prepayment plans. It has tried to kill those that have succeeded. On the showing so far, is it honest about voluntary insurance or is it throwing dust in my eyes and yours?
Like lot of physicians, a lot of us laymen are fed to the teeth with the AMA’s methods. With its persistently negative approach to everything. With its unvarying misrepresentation of the efforts other countries are making to solve the problem. With its “crusade” and its “battle” and its vilification of the government, the public, and its own members who speak out. With its uniformly misleading attack on “government medicine.” Everyone in the military services is under a system of “government medicine”; so is everyone in a veterans’ hospital or receiving out-patient treatment from one. The Public Health Service is “government medicine.” Several thousand of your colleagues who have had the best training available are practicing “government medicine.” Are they venal, inferior, and suppressed?
One of your ads listed “damage to research” among the ills certain to follow “government domination of the people’s medical affairs under compulsory health insurance.” What about that? The hospital which asked me for a contribution is carrying out fundamentally important researches that are being paid for by the government. They are entirely in the hospital’s hands. How have they been damaged? As a member of a committee of the National Research Council, you regularly go to Washington to appraise projects in medical research for which the government is to pay. Your committee is composed exclusively of medical men who are not in the government service. You decide. whether a project is valuable and how much ought to be spent on it; the project then passes to representatives of the government just long enough for them to allocate the money for it; it then passes entirely out of their hands and the government has no more to do with it till private medicine has finished the job. . . . Why do you submit to a patent misrepresentation? Why do you try to deceive me?
The advertising, propaganda, and vilification which the AMA conducts is steadily, and now seriously, undermining your professional standing and prestige. The public very much needs both. The traditional system of medical practice has burst its seams; it is now inadequate and outworn. We are going to have something different. No matter what your propagandists say, it is certain to be not a single system but multiple and mixed. And there is no chance whatever that the AMA will get what it demands — no chance that the mixed system will be developed and administered solely by doctors. This is a public matter, a community and national matter. It requires innumerable skills which medical men simply have not got, and it must be under the unremitting scrutiny of representatives of the public with power to act. Medical knowledge is only one of many kinds of knowledge that are required for social action.
But you and your colleagues can shape the future of American medicine if you will accept the responsibility. If you study the problem and act to solve it, not to prevent its being solved. If you turn back the AMA’s headlong opposition to every change not approved by the extremely small group of men who enforce its reactionary policy on its whole membership. (Is there no lust for power on the top level of the AMA? And how much of this policy is designed to secure to a very few men the largest possible incomes while the average income of medical men is smaller than it would be if people could afford to pay their doctors’ bills?) If you stop acting like a sap, then you can count on shaping the solution. But time passes, the problem grows more desperate all the time, and a solution will be worked out somehow — with, without, or in spite of you. It had better be with your help.
Desperate social problems have to be solved, Doctor; they are solved as needs must, if it comes to that. Even if we accept Dr. Henderson’s figures, 40 per cent of the population will have no insurance protection against medical expense. Of his 60 per cent, only a part will have adequate insurance. Ward service in the hospital that is trying to raise funds now costs $10 a day, the cheapest room $18 a day. Last week in the out-patient department I saw a patient getting a prescription filled at a drug window. It called for six capsules of aureomycin a day for ten days. The hospital was selling him the capsules at cost, forty cents apiece, $24. If his job paid him $40 a week, he could not afford them. In that case the hospital would give them to him, but the hospital had to pay $24 for them — and it can no longer get its deficits paid by contribution. Yet aureomycin is cheap compared to certain other remedies which medical research — in part supported by government appropriation-has developed. How could he afford ACTH, or the hospital afford it for him?
There are other considerations too. You know that, in spite of what your advertising says, the only places where American medicine can fully live up to its possibilities are the teaching hospitals. You know that elsewhere it is not doing as well as it wants to and must. You know that there are many areas inadequately provided with doctors, hospitals, and the proper equipment for tests, treatment, and research. You know that some doctors are not well enough trained — with the cost of training climbing before your eyes — and that some hospitals are not good enough — with the cost of making them better steadily mounting.
You know too that thousands of physicians disapprove of the AMA policy, are alarmed by it, and want to substitute for it one which will enable the profession to grapple successfully with all these problems. And you know that the hard facts of a rapidly changing world are forcing thousands of other physicians into activities — contract practice is one of them — which the AMA condemns. You know that many thousands of your colleagues agree with Dr. James Howard Means, who is not a Communist, who I think is not a Democrat either, but who is Chief of Medicine at a great hospital and Professor of Clinical Medicine at a great medical school. “A learned profession has sunk, or been dragged, in its political sphere, to a distressingly low level,” Dr. Means wrote, and he went on, “What organized medicine needs . . . is a new and more enlightened leadership.”
That puts it up to you, Doctor. For the campaign of what the AMA calls “public education” run by an advertising agency, you had better substitute one of self-education. You had better adopt the scientific attitude and find out what the facts are and what, besides propaganda, can be done about them. You might begin by reminding Dr. Henderson of his oath: “I shall strive constantly to maintain the ethics of the medical profession and to promote the public health and welfare.” The public does not consider misrepresentation ethical. The AMA is not promoting public health and welfare by intimidating its members, trying to frighten laymen, lapsing into anti-Semitism, and accusing a government which has also sworn to promote the public welfare, of conspiring with Communists to stamp out freedom in the United States. You can hold your leadership to proper ends, Doctor, or you can repudiate it. You have that option. But if you are to retain the public respect that has been yours or if you are to do your part in guiding the future of medicine in the United States, you have no other choice.