Part 7

"As I sat writing this an evening or two ago, I jotted down the names of twenty-five families of my acquaintance in Los Angeles, taking them as fast as I thought of them. The list was composed entirely of professional and business men ranging in age from thirty-five to fifty. All had been married quite a number of years. The result of my memorandum was that in these twenty-five families there were but eighteen children. These families were wholly unselected, and are about the average Protestant American families outside the rank of laborers.

"What are the causes of this small proportion of children? Disease, preventives of conception, and abortion form the trinity of responsibility in this grave condition. It is true that the first cause (disease) results in many women being barren, but I believe that you will agree with me that the last two causes, preventives of conception and abortion, are the two chief causes.

"The A. P. A. might find food for thought by investigating the infrequency of criminal abortion in Catholic families in the United States. It is the Protestant or agnostic American who too often uses one of the preventives of conception." (Here the Doctor refers to a foot-note in which he says: "I write this opinion as a Protestant, and should be glad to learn that it is not well founded.") He continues: "If, through inadvertence, pregnancy should occur, then an abortion is in order. Disease and poverty and war and accident all work together to keep down the population, but we are overcoming these. Plagues and pestilences are rare. The number who die of starvation in California is very small, while war has played but a small part. Through the diffusion of the laws of sanitation, improved dietary, and advanced therapeutics, the longevity of man is increasing, but the American woman's aversion to child-bearing is blighting our civilization, and can be well named the twentieth-century curse. In this aversion the woman frequently echoes the wish of the husband.

"A large proportion of the American young women who marry do so with the determination that they will have no children. They are abetted in this notion by many elderly women. The cure for this terrible sentiment is education. The home, the press, the schoolroom, and the pulpit should be centres for reviving the ancient idea of the nobility of motherhood. The physician should not underestimate his influence.

"By constantly bearing in mind the danger of the present tendencies, he can do much to change the current. Let us hope that we shall again see the day when thoughtful motherhood shall be considered the highest function of womanhood, and to shirk this natural duty will be deemed a disgrace."

Gentlemen, it would be easy to prove that this testimony of Dr. Lindley is not that of an exceptional witness, or a piece of special pleading; but it is the acknowledged conviction of the medical profession generally, confirmed by the last United States Census, and in fact not questioned, to my knowledge, by any weighty authority. As early as 1857, Dr. H. B. Storer, an eminent physician of Boston, startled the community by publishing two books on this subject, entitled: "Criminal Abortion. Why not?--A Book for Every Woman"; "Is it I?--A Book for Every Man." Soon after, Rev. John Todd, a Protestant minister of Pittsfield, Massachusetts, published a work styled "Serpents in the Dove's Nest," all which works and a multitude of others tell the same tale of woe regarding the increase of child-destroying crimes in New England, chiefly among the old stock peculiarly called Americans. Dr. Nathan Allen, of Lowell, Massachusetts, in his treatises, "Changes in the New England Population" and "The New England Family," gives overwhelming testimony. "Harper's Magazine" (quoted by the "Catholic World" for April, 1869) remarks: "We are shocked at the destruction of human life on the banks of the Ganges, but here in the heart of Christendom fœticide and infanticide are extensively practised under the most aggravating circumstances." We Catholics are not personally interested in this matter; but the good of our fellow-men and chiefly our fellow-countrymen calls for the earnest exertion of us all to stop this dreadful evil. All the works I have referred to exempt Catholics from the blame pronounced; the "Harper's Magazine" article referred to expressly says: "It should be stated that believers in the Roman Catholic faith never resort to any such practices; the strictly Americans are almost alone guilty of such crimes." This matter is fully explained in a recent work called "Catholic and Protestant Countries Compared," by Rev. Alfred Young, C.P., ch. xxxii.

VII. Now, gentlemen, I am very much afraid that while physicians as a body abhor all such murders and openly condemn them, many do not show much repugnance to allow, and even sometimes to suggest, such onanistic intercourse among married people as shall prevent the possibility of conception. For instance, if it happens that a young mother suffers much in her first confinement, at once the suggestion is made that a second parturition may prove fatal. From that moment regular intercourse is dreaded. Either onanism is habitually practised, or the husband becomes a frequent visitor to dens of infamy, where to where to save his wife's health, he encourages a traffic that leads multitudes of wretched girls to a premature and miserable death. Every one despises those outcasts of society; but are not the men who patronize them just as guilty? Probably enough, if the imprudent suggestion about dangers of a second child-bearing had not been made by the Doctor, the young wife might have become the happy mother of a numerous family of healthy children. For we must trust in Divine Providence. If a husband and wife do their conscientious duty, there is a God that provides for them and their family more liberally than for the birds of the air and the lilies of the field. And if He should so dispose that the worst should befall, well, such temporal clangers and sufferings as attend child-bearing are the lot of woman-kind, just as the dangers and hardships of the battlefield, the mine, the factory, the forest, and the prairie are the lot of the men.

The man who shirks his duty to family or country is a coward; women, as a rule, are brave enough in their own line of duty, and patiently submit to God's sentence pronounced in Paradise, "I will multiply thy sorrows and thy conceptions, in sorrow shalt thou bring forth children" (Gen. iii. 16), just as they have to submit to the words immediately following: "Thou shalt be under thy husband's power, and he shall have dominion over thee."

Certainly, the husband of a delicate woman ought to spare her strength and restrain his passion, but not at the sacrifice of morality; and Doctors ought to be very careful not to cause false or exaggerated alarms, and thus make themselves to some extent responsible for untold moral evils. They should remember that, as a rule, the raising of a family is the principal purpose of a married life. The happiness and virtue of the parties concerned depend chiefly on the faithful performance of this duty. How sad is the lot of those--and they are many--who undertook in early years of married life to prescribe a narrow limit to the number of their children; they had one or two, and they would have no more, and for this purpose criminally thwarted the purposes of nature. Then comes death and snatches away their solitary consolation: and they spend their old age childless and loveless, in mutual upbraidings and unavailing regrets.

How different is the lot of those aged couples--and they were many of yore, and are yet in various nations--who are like patriarchs amid their crowds of children and grandchildren and great-grandchildren, dwelling in mutual love and as if in a moral paradise where all domestic virtues bloom!

VIII. True, such families are usually the outcome of moderately early marriages; and many Doctors nowadays disapprove of such unions as an evil. A moral evil they certainly are not; and the physical evils sometimes attending them must, I think, be traceable to a variety of causes; for such evils are certainly not inseparable from early marriages. As to their moral advantages, Mr. Wm. E. H. Lecky, in his "History of European Morals," writes of the Irish people in particular: "The nearly universal custom of early marriages among the Irish peasantry has alone rendered possible that high standard of female chastity, that intense and jealous sensitiveness respecting female honor, for which, among many failings and some vices, the Irish race have long been pre-eminent in Europe" (v. i. p. 146). And that he does not confine his statement to female chastity is evident from what he adds farther on: "There is no fact in Irish history more singular than the complete and, I believe, unparalleled absence among the Irish priesthood of those moral scandals which in every Continental country occasionally prove the danger of vows of celibacy. The unsuspected purity of the Irish priesthood in this respect is the more remarkable, because, the government of the country being Protestant, there is no special inquisitorial legislation to insure it, because of the almost unbounded influence of the clergy over their parishioners, and also because, if any just cause of suspicion existed, in the fierce sectarianism of Irish public opinion it would assuredly be magnified. Considerations of climate are quite inadequate to explain this fact; but the chief cause is, I think, sufficiently obvious. The habit of marrying at the first development of the passions has produced among the Irish peasantry, from whom the priests for the most part spring, an extremely strong feeling of the iniquity of irregular sexual indulgence, which retains its power even over those who are bound to perpetual celibacy" (p. 147). No one will say, I believe, that the custom of early marriages in Ireland has any injurious effects on the health of either parents or children. Nor need it necessarily have such effects on those of our American young men and women who lead regular lives and are not enfeebled by unnatural vices or demoralized by dainty food and luxurious manners.

A wise physician has many proper ways of providing for the health and strength of both parents and children without advocating practices which are a snare for innocence. Let him insist with all his patients on the cultivation of healthful habits for the family and the individual; wholesome and not over-delicate food; moderation in eating and drinking; regular and manly exercise, especially in the open air; early hours for retiring and rising. But, above all--and this is directly to our present purpose--let him show the greatest regard for the laws of morality, the main support of individual and social happiness. His views upon such matters, manifested alike in his conduct and his conversation, but especially in his management of cases involving the application of moral principles, will go far to influence the community in which he moves. His task is to be a blessing to his fellow-men, a source of happiness and security to individuals and to society.

LECTURE VI.

THE PHYSICIAN'S PROFESSIONAL RIGHTS AND DUTIES.

Gentlemen, so far I have explained the duties which the physician has in common with all other men, and which arise directly from the natural law independently of any civil legislation. The natural law requires the Doctor to respect the life of the unborn child, thus forbidding craniotomy and abortion. It also obliges him to protect his patients from the baneful effects of venereal excesses. Over these matters human law has no control, except that it may and ought to punish such overt acts as violate the rights of individuals, or seriously endanger the public welfare.

We shall now consider the physician's natural rights and duties in regard to matters which civil and criminal legislation justly undertake to regulate. One of the chief functions of civil authority is to provide for the observance of contracts. Now, the physician in his professional services acts under a double contract, a contract with the state and a contract with his individual patients. By accepting his diploma of M.D. from the college faculty, and indirectly from the civil authority, he makes at least an implicit contract with the state, by which he receives certain rights conditioned on his performance of certain duties. In offering his services to the public, he also makes an implicit contract with his patients by which he obliges himself to render them his professional services with ordinary skill and diligence on condition of receiving from them the usual compensation.

I. The chief rights conferred on him by the state are these:

1. Protection against all improper interference with his professional ministrations.

2. Protection for his professional career by the exclusion of unauthorized practitioners.

3. Immunity from responsibility for evil consequences that may result without his fault from his medical or surgical treatment of patients.

4. Enforcement of his right to receive due compensation for his professional services.

These rights are not granted him arbitrarily by the state; they are founded in natural justice, but made definite and enforced by human legislation. Take, for an example, his right to receive due compensation for his services. This right was not recognized by the old Roman law in the case of advocates and physicians, nor by the common law of England until the passing of the Medical Act in 1858. Surgeons and apothecaries could receive remuneration for their services, but not physicians. These were presumed to attend their patients for an _honorarium_ or honorary, that is, a present given as a token of honor.

Certainly, if Doctors by common agreement waived their right to all compensation, or agreed to be satisfied with any gift the patient might choose to bestow, they would be entitled to honor for their generosity; but they are not obliged to such conduct on the principles of natural justice. For by nature all men are equal, and therefore one is not obliged, under ordinary circumstances, to work for the good of another. If he renders a service to a neighbor, equity or equality requires that the neighbor shall do a proportionate good to him in return. Thus the equality of men is the basis of their right to compensation for services rendered. The physician's right to his fee is therefore a natural right, and on his patient rests the natural duty of paying it. Not to pay the Doctor's bill is as unjust as any other manner of stealing.

As to the amount of compensation to which the Doctor is justly entitled, Ewell's "Medical Jurisprudence" remarks: "By the law of this country, all branches of the profession may recover at law a reasonable compensation for their services, the amount of which, unless settled by law, is a question for the jury; in settling which the eminence of the practitioner, the delicacy and difficulty of the operation or of the case, as well as the time and care expended, are to be considered. There is no limitation by the common law as to the amount of such fees, provided the charges are reasonable. The existence of an epidemic does not, however, authorize the charge of an exorbitant fee.

"A medical man can also recover for the services rendered by his assistants or students, even though the assistant is unregistered; it is not necessary that there should be any agreed specified price, but he will be allowed what is usual or reasonable.

"It is not the part of the physician's business, ordinarily, to supply the patient with drugs; if he does so he has a right to compensation therefor. If the agreement is "No cure, no pay," he cannot, however, even recover for medicines supplied, if the cure is not effected. His right to recover for professional services does not depend upon his effecting a cure, or upon his service being successful, unless there is a special agreement to that effect; but it does depend upon the skill, diligence, and attention bestowed" (pp. 3 and 4).

Further details on this point belong more properly to the lecturer on Medical Law. We are now concerned with the principles underlying special legislation. The main principle regulating all compensation is that there shall be a sort of equality between the services rendered and the fee paid for them. Ignorant people sometimes find fault with the amount charged as a Doctor's fee. There may, of course, be abuses by excess; but men have no right to complain that a Doctor will ask as much for a brief visit as a common laborer can earn in a day. This need not seem unfair if it be remembered that the physician had to prepare, during many years of primary, intermediate, and professional studies, before he could acquire the knowledge necessary to write a brief prescription. Besides, it may be that his few minutes' visit is the only one that day; and yet he has a right to live in decent comfort on his profession together with those who depend on him for support.

We must, however, remember, on the other hand, that excessive fees are nothing else than theft; for theft consists in getting possession of another's property without just title. The following rules of Dr. Ewell are sensible and fair:

"The number of visits required must depend upon the circumstances of each particular case, and the physician is regarded by the law as the best and proper judge of the necessity of frequent visits; and, in the absence of proof to the contrary, it will be presumed that all professional visits made were deemed necessary and were properly made.

"There must not be too many consultations. The physician called in for consultation or to perform an operation may recover his fees from the patient, notwithstanding that the attending physician summoned him for his own benefit, and had arranged with the patient that he himself would pay." (This, of course, does not mean that the practitioner has a right thus to shift the burden of pay from his own shoulders.) "Where a medical man has attended as a friend, he cannot charge for his visit. Where a tariff of fees has been prepared and agreed to by the physicians of any locality, they are bound by it legally as far as the public are concerned (that is to say, they cannot charge more than the tariff rates), and morally as far as they themselves are concerned" (p. 5).

In these rules Dr. Ewell regards chiefly what conduct the courts of justice will sustain. It is evident that the Doctor is never entitled to run up his bill without any benefit to his patient; where there is no service rendered at all, there can be no claim to compensation. Still it is not necessary that actual benefit has resulted to the patient; it suffices for the claim to the fee that measures have been taken with a view to such benefit. Even when no physical advantage can reasonably be hoped for from the visit, the consolation it affords the patient and his friends may render those who are to bear the expense fully willing that it should be often repeated and, of course, charged on the bill. Provided care be taken that they understand the situation, no injustice is done them. "_Scienti et consentienti non fit injuria_" is a good moral maxim.

II. We have said that the rights conferred on the physician by the state are conditioned on his performing certain duties. He owes the same duties to his patients in virtue of the contract, explicit or implicit, that he makes with them by taking the case in hand. Under ordinary circumstances, neither the state nor the patients can oblige him to exercise his profession at all; but, if once he has taken a case in hand, he can be justly held not to abandon it till he has given his patient a fair opportunity of providing another attendant; even the fear of contagion cannot release him from that serious obligation.

The duties arising from the physician's twofold contract, with the state and with his patients, are chiefly as follows:

1. He must acquire and maintain sufficient knowledge of his profession for all such cases as are likely to come in his way. No Doctor has the right to attempt the management of a case of which he has not at least ordinary knowledge. In matters of special difficulty, he is obliged to use special prudence or ask for special consultation. The courts justly hold him responsible for any serious injury resulting from gross ignorance; in such cases they will condemn him for malpractice. I would here remark that, in an age in which the science of medicine is making such rapid progress, every Doctor is in duty bound to keep up with the improvements made in general practice, and in his own specialty if he has one.

2. A second duty is that of proper diligence in treating every single case. Many a patient suffers injury to health or even loses his life in consequence of a Doctor's neglect. Gross negligence is an offence that makes him punishable by the court, if it results in serious injury. But even if such injury cannot be juridically proved, or has been accidentally averted, the moral wrong remains and is to be settled with the all-seeing Judge. Still, in ordinary ailments, no one is obliged to take more than ordinary trouble.

3. A third duty of the physician is to use only safe means in medical and surgical practice. He has no right to expose his patient to needless danger. What is to be thought of the use of such remedies as will either kill or cure? They cannot be used as long as safer remedies are available and capable of effecting a cure; for neither Doctor nor patient has a right to expose a human life to unnecessary risk. But when no safer remedies are going to effect a cure, then prudence itself dictates the employment of the only means to success. In such a case, however, the patient, or his parents or guardian, should, as a rule, be informed of the impending danger, so that they may give or refuse their consent if they please. For, next to God, the right to that life belongs to them rather than to the physician. The same duty of consulting their wishes exists when not life but the possible loss of a limb is at stake, or the bearing of uncommon sufferings. Moralists teach that a man is not obliged in conscience to submit to an extraordinarily painful or revolting operation even to save his life. Certainly, when the natural law leaves him at liberty, the physician cannot compel him to submit to his dictation; all he can do is to obtain his consent by moral persuasion.

4. As a consequence from the Doctor's duty to use only safe means it follows that he cannot experiment on his patients by the use of treatment of which he does not know the full power for good or evil. Nor is he excused from responsibility in this matter by the fact that the experiment thus made on one patient may be very useful to many others. His contract is with the one now under treatment, who is not willing, as a rule to be experimented upon for the benefit of others. And even if the patient should be willing, the Doctor cannot lawfully expose him to grievous danger unless it be the only hope of preserving his life. This follows from the principle explained before, that human life belongs chiefly to God and not to man exclusively.