The Doctor’s Dilemma – a century later

Bernard Shaw wrote The Doctor’s Dilemma in 1906. What dilemma was he interested in, and how relevant is it today?

Sir Colenso Ridgeon is a distinguished doctor who has discovered a cure for TB using opsonins. He finds himself obliged to choose between treating a worthy colleague who is the one doctor in the play who looks after the poor at the expense of his wallet, and a talented but amoral artist. The artist’s wife pleads for her husband and the doctor’s dilemma is heightened by his realisation that he is attracted to her and would like to marry her should her husband die.

Shaw does not explore the question of professional ethics raised by the romantic attachment. Nor does he resolve the rationing dilemma, presented in terms that were highly contrived even in 1906. He uses these two personalised dramatic conflicts - ‘The Doctor’s Dilemma’ – to construct a platform for expounding his views on contemporary medical practice – ‘The Doctors’ Dilemma’.

The play’s central message isn’t really rationing. True, in many countries doctors still have to look at individual patients and choose whom to save, but someone working in a refugee camp is unlikely to feel kinship with Colenso Ridgeon. Everywhere, difficult choices still have to be made about who can be treated. In this country these have usually been taken at a managerial level, but politicians are now devolving rationing to doctors, using us as human shields when there’s a row.

Shaw also introduces three of his personal hobbyhorses into the play: vegetarianism, vaccination and vivisection. But his central message is that private practice distorts healthcare and corrupts those who provide it.

First the hobbyhorses. The producers of the National Theatre’s recent production have cut out most of the passing references to them. To find out Shaw’s views, you have to go to the play’s preface. He discusses these issues at length – well, he bangs on through 80 pages, with none of the wit of his stage play. For Shaw, a proselytising vegetarian, the eating of meat is the slippery slope to vaccination. He feels that for doctors who are seduced into thinking that vaccination is effective (or are seduced into the financial rewards of administering it) it’s a small step to vivisection, and in Shaw’s mind vivisection leads directly to immoral professional practice.

How relevant are Shaw’s hobbyhorses today? Vegetarianism is now mainstream. Vivisection still provokes a minority to moral outrage, but animal testing, tightly controlled by law, is generally regarded, albeit sometimes reluctantly, as an essential research tool.

Vaccination against smallpox was well-established by 1906, but coverage was haphazard and there was a major outbreak in London in 1901, which may have fuelled Shaw’s prejudices. Immunology had made great strides in the years before the play was written, and Shaw knew about opsonins, discovered in 1903. Former Mary’s students may recall Almroth Wright Ward, named after the doctor on whom Shaw modelled Colenso Ridgeon. Another character makes his living administering a single form immunisation – one size fits all – on the grounds that they all stimulate the immune system. Which may have been a reasonable thesis in 1906. Although Shaw’s reservations are still quoted on some anti-vaccination sites, few doubt that smallpox would have been eliminated were it not for vaccination, and immunisation has become a public health measure rather than a source of income for doctors.

It is how doctors’ ethics are undermined by pecuniary interests that is the underlying theme of Shaw’s play. His doctors are professionally arrogant. We would not see ourselves in them. Our practice is grounded in evidence, applied with judicious empathy. Unlike Shaw’s doctors. Evidence-based medicine would have caught up with them. The surgeon in Shaw’s play who makes a handsome income removing patients’ nuciform sac (no, you weren’t asleep in that anatomy lesson – Shaw made it up) to remove the source of blood poisoning which he believes to be the source of all illness, would soon have the GMC on his tail. Or, I hope he would. But we doctors still have our hobbyhorses, and patients are still forced into specialists’ Procrustean beds. And even if doctors don’t invent new diseases, drug companies certainly do.

We don’t depend on selling quack treatments for our livelihoods. But evidence for many common treatments is still scanty. And GPs’ income is increasingly tied to performance through the QOF, so part of what we do is with an eye to our income as well as our patients’ interests. And it doesn’t take much poking by the government to stimulate self-righteous howls from the BMA.

But we do have the NHS. So Shaw’s vision of a public health service has been realised. He knew from his experience in local government just how bad was the health of ordinary people, and how little doctors and medical science contributed to improving it, and he argued strongly for a system of public health doctors. Five years after Shaw’s play was premiered, the government passed the National Insurance Act which was the forerunner of today’s NHS.

There is one of Shaw’s wealthy doctors whose stratagem still strikes a chord. His patients are comfortably off but not rich. Compared with his colleagues his charges are modest. His dodge is to advertise ‘Cure Guaranteed’. He knows he is risking trouble if the authorities notice, but they don’t and, as he knows and we know, most patients will get better with time and a little support. But these days I hope we know when a patient needs the modern equivalent of opsonins.

Judith Harvey

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