One of the best-known indictments of the medical profession – which though over 100 years old still applies today – is found in the preface to George Bernard Shaw’s 1906 play, “[The Doctor’s Dilemma](https://en.wikipedia.org/wiki/The_Doctor%27s_Dilemma_(play).”
Shaw (1856-1950), an Irish playwright and critic, sought to dramatize the tensions in medicine between making money and serving the best interests of patients.
Shaw focuses his attack on the fact that doctors are generally paid for the care they provide, such as prescribing medicines and performing surgeries. He believes that this places doctors in an irresolvable conflict of interest:
That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity… . I cannot knock my shins severely without forcing on some surgeon the difficult question, “Could I not make a better use of a pocketful of guineas than this man is making of his leg?”
The financial incentives for doctors to do something they can bill for, Shaw asserts, are so strong that they will forever be “performing unnecessary operations and manufacturing and prolonging lucrative illnesses.” They are abetted in this, he says, by the great need of patients and families to have something done for them:
You have a wildly urgent feeling that something must be done; and the doctor does something. Sometimes what he does kills the patient; but you do not know that; and the doctor assures you that all that human skill could do has been done.
Shaw is not singling out the doctor as lower than other tradesmen and professionals. “I do not blame him: I would do the same myself,” he says. He attributes the abuse of the patient’s trust to the way in which doctors and other health professionals are compensated. In fact, his indictment extends to all professions – law, clergy, teaching, art, business and so on – all of which he brands “conspiracies against the laity.”
A prescription for profit
Sadly, a number of well-publicized cases tend to support Shaw’s argument. Two doctors, an oncologist in the Detroit area and a spine surgeon in Cincinnati, have recently been indicted for misdiagnosing and overtreating patients in schemes to generate millions of dollars that often made their patients only sicker.
Even the nation’s largest medical association, the AMA, was embroiled in scandal 20 years ago when it attempted to profit by endorsing products of appliance manufacturer Sunbeam that it never tested.
An observer could be forgiven for concluding that the problems Shaw describes are still with us.
Helping patients comes first
Yet I personally know many doctors who put the interests of patients far ahead of their own pocketbooks. Most of the young medical students I work with every year sincerely want to provide their patients with the very best care, irrespective of profit. And this dedication is not confined to physicians.
In fact, some of the most admirable people I know are found in places Shaw would regard as highly unlikely, including the pharmaceutical and medical device industries, where the profit motive seems to reign unchallenged.
Consider the case of Bill Cook (1931-2011), founder of the world’s largest privately held medical device manufacturer. In connection with a scholarly project last year, I interviewed a number of Cook’s colleagues, family and friends.
In 1963, Cook and his wife Gayle started their business in the second bedroom of a two-bedroom apartment in Bloomington, Indiana, with an initial investment of US$1,500. They manufactured and sold wire guides, catheters and other devices that enable doctors to diagnose and treat diseases without surgery, using x-ray guidance. Cook recognized early on that such techniques would revolutionize medicine, and he wanted to play a role in making it happen. Today the Cook fortune amounts to $5.9 billion.
But it would be a grave mistake to say that they did it for the money. For the first several decades, Cook’s business ran without a budget. Bill Cook declared over and over again that “the patient is the ultimate standard of whether you are doing the right thing,” His goal was not to make money, but “to come to work every day excited by a problem, get busy working on a solution, and make a difference in the life of a patient.”
One day an employee told Cook that the company could not begin developing a new device because the profit margin was not there. He responded, “What you just said to me, I don’t want to hear it again. What matters is this – will it help patients?”
More interested in making a difference
The Cook story also includes a doctor. Charles Dotter, M.D., longtime department chair at the University of Oregon, is often called the “father of interventional medicine.” It was Dotter who was featured in a 1964 Life magazine story touting medicine’s revolutionary new ability to open up narrowed arteries, in which he is pictured using devices made by Cook. In many cases, it was Dotter’s new ideas that led to new Cook products. Dotter was the first doctor to whom Cook offered a royalty, but he always refused – he too was not interested in making money but in making a difference.
Such aspirations may seem quixotic in today’s money-saturated health care environment, but Cook clearly believed in them, and they served as the moral bedrock for a company that has enjoyed over 50 years of continuous growth in products, employees and profits.
To those who might dismiss Cook’s approach as a facade, it is important to point out how the Cooks used their money. Instead of buying extravagant cars and houses, for many years Bill Cook drove an old Pontiac, and despite has vast fortune, he died in the same three-bedroom house that he and his wife purchased in 1967.
The Cooks were not interested in drawing money out of their business to support a lavish lifestyle. Instead they wanted to reinvest profits back into the company to keep it growing and making even bigger contributions to patients’ lives. In stark contrast to Shaw’s unflattering portrait of the denizens of health care, Bill Cook stands as an exemplar who never looked at patients as a way to make money. Instead, like Dotter, he saw money as a means to improve the lives of patients.
Recent reports of doctor misconduct and betrayals of patient trust make it clear that Shaw’s critique is still relevant. The temptation to put money before people is an ever-present one, and health care professionals need to be regularly reminded of it.
But it is a temptation to which many do not succumb. The Cook story provides an important reminder that, even at a time when money exerts unprecedented sway in health care, the moral compasses of the best doctors still point true north – to the welfare of patients.