Charlatans and Shamans

As a socialist and Darwinian, George Bernard Shaw probed the ethics of health care in ways that were revolutionary in 1906 and remain remarkable today. If Shaw returned to earth to survey U.S. health care circa 2001, he would be entitled to tell us, “One hundred years ago I predicted the mess you are in today. If you had paid attention to The Doctor’s Dilemma, you would have done things better!”

In The Doctor’s Dilemma and its Preface, Shaw demonstrates what happens when we ask a capitalist economy to minister to our fear of mortality. In Shaw’s view the situation is simple. We are frail beings who fear death and the slings and arrows of illness. We turn to other equally frail human beings – doctors – for treatment when we are sick, and for a sense of safety. In the Preface, Shaw advised that we should “make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words ‘Remember that I too am mortal.'” Today, contrary to Shaw’s advice, we have turned doctors into totems of capitalism. For the past five years, the health care industry has accounted for one seventh of the U.S. economy.

In The Doctor’s Dilemma, Shaw actually confronts us with three distinct dilemmas. The action of the play revolves around what high school students refer to as “lifeboat ethics,” the question of who should come first when there isn’t enough to go around. The Preface delineates a second quandary – no matter how we pay our doctors, we inevitably create destructive conflicts of interest. Finally, Shaw dramatizes the clash between intellectual integrity and the fear of death. Integrity requires us to face facts. Fear prefers the consolation of fantasy.

In ethics classes today, students debate which swimmer to save when there is only one place left on the lifeboat, but Shaw was the first to see that in health care the lifeboat problem is not just a classroom exercise. Dr. Colenso Ridgeon has a limited supply of his new antitoxin, which appears to cure tuberculosis. Should he use it to save his worthy but dull colleague Dr. Blenkinsop or Louis Dubedat, the brilliant artist with a penchant for womanizing and thievery? He has to choose. But how?

Sir Colenso takes for granted that the choice should be determined by moral worthiness. He and his colleagues meet Louis and examine his drawings at the Star and Garter Inn at Richmond, where they have gathered to celebrate Sir Colenso’s knighthood, awarded for the tuberculosis cure. Initially the excellence of the drawings makes Ridgeon determined to save Dubedat. But when he learns more about Dubedat’s skullduggery, Ridgeon turns the artist over to the good-hearted but incompetent Sir Ralph Bloomfield Bonington, an action that is tantamount to killing him.

The Doctor’s Dilemma shows us the arbitrariness of rationing by moral worth, since our judgment is clouded by such motives as Sir Colenso’s attraction to Dubedat’s wife Jennifer. When kidney dialysis was first developed in Seattle in the 1960s, we used a similar method – a panel was established, popularly known as the “God squad,” that ranked potential recipients according to the panel’s assessment of merit. Since then medical ethics has come to agree with Shaw that rationing decisions should not be made by individual doctors or “God squads” on the basis of morality alone.

In The Doctor’s Dilemma, Shaw does not try to tell us how to ration health care, but he forces us to reflect on this difficult problem once the play is over. The dramatist would be sardonic about our contemporary pretense that rationing is an unethical and unnecessary practice. He would say something like, “Anyone who looks in doorways around Harvard Square on a cold night and claims that rationing doesn’t occur is a fool or a liar! You are rationing health care every day. You can’t avoid it. Figure out how to do it fairly!”

With regard to the dilemma created by the way physicians are paid, Shaw recognized that any system of incentives creates potential distortions. His analysis of the hazards of compensating physicians on a fee-for-service basis is pithy: “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.” In addition to creating a deficiency of attached legs, when we pay doctors, laboratories, hospitals, ambulance staff and other health-care practitioners on a fee-for-service basis, we inevitably contribute to the nation’s ever increasing health care costs.

In reaction to the dangers Shaw identified, many payment schemes now encourage doctors to do less by giving them a lump sum to care for patients, independent of how much or how little treatment they provide. It is easy to imagine Shaw’s reaction to the new system: “In 1906 we rewarded surgeons for cutting off good legs. In 2001 you reward them for leaving on gangrenous feet. The only thing political humanity has learned in one hundred years is how to create foolish dilemmas in new ways!”

Shaw’s solution to the payment dilemma, which he describes at length in his Preface, was to create salaried physicians whose role was the promotion of public health, not solely the treatment of illness. He saw health as a communal good, best promoted by collective action. He would have viewed the worldwide trend towards emphasizing individual health care over public health and the use of markets over collective action as a catastrophic step backwards.

Shaw’s analysis is most subtle when he dramatizes Dr. Ridgeon and his circle of amiable humbugs struggling to cope with their patients’ need for comfort, and the limits of what can and cannot be achieved by medicine. The play makes wonderful comedy of the doctors’ eagerness to reassure the fetching Mrs. Dubedat by professing their ability to cure her consumptive husband. Jennifer’s idealization of Sir Colenso and his colleagues arises from her fear of loss, which is part of being mortal, but Sir Colenso dangerously confuses her desperate hope with romantic love.

Why does Shaw call this highly comic play a tragedy? I believe the tragic element resides in the way each character unavoidably contributes to the follies of the medical system. Early on, wise old Sir Patrick Cullen, the most experienced physician of the pack, tells Sir Colenso, “When you know as much as I know of the ignorance and superstition of the patients, you’ll wonder that we are half as good as we are.” Sir Colenso, in distress, replies, “We’re not a profession: we’re a conspiracy.” Sir Patrick is unfazed. He recognizes that frail mortals need the solace provide by shamans, and not just in medicine: “All professions are conspiracies against the laity.” The “curious aching” Sir Colenso complains about is not simply the midlife loneliness that predisposes him to fall in love with Mrs. Dubedat, but a symptom of his dilemma; should he act as a consoling shaman, or a brutally honest scientist?

In Shaw’s era, questioning the authority of the medical profession came close to blasphemy. In this way, The Doctor’s Dilemma was revolutionary. In the intervening years, however, questioning authority has moved from revolutionary act to tired cliché. In 2001 we no longer worship doctors as omnipotent shamans, but define them in economic terms as “providers.” Patients are no longer helpless petitioners but active consumers. Shaw would see this as replacing one form of folly with another. Ultimately, the dilemma of how we should assuage our fears of mortality remains as vexing today as it did at the first performance of The Doctor’s Dilemma.

Dr. James Sabin is Clinical Professor of Psychiatry at Harvard Medical School and director of the ethics program at Harvard Pilgrim Health Care.