(An earlier version of this paper was also published in the Christian Medical Dental Society Journal, Spring 1989, volume 20, number 1, pages 22-26.The opinions expressed are those of the author and do not necessarily reflect those of the institutions with which he is affiliated.)
David Schiedermayer, MD
Associate Professor of Medicine
Medical College of Wisconsin
Jack W. Provonsha Lectureship
School of Medicine Alumni Postgraduate Convention
Loma Linda University
February 6, 1993
It is an honor to he invited here to give the Jack Provonsha lecture in ethics and medicine. Dr. Provonsha was an example of the model family physician when he practiced here, and was also the model of the ethical Adventist. He lived and continues to live out his life by Adventist principles, and often the Church has looked to him for opinions on matters of medicine and ethics. This lecture honors his work and his ethical standards as a Christian physician.
One of the most important ethical issues a physician faces is the fundamental tension between altruism and greed. As we move into a period of health care reform, society is increasingly focused on cost containment in medicine. Increasingly we practice in a world of competition in HMOs, PPOs, IPAs, and OWAs (Other Weird Arrangements). Increasingly we are being forced to choose our bedfellows between government and big bureaucracy, and we are not so certain we like either one that well. To put it bluntly, we are worried. We are worried, in the words of Groucho Marx, that "the future ain't what it used to be."
My goal is to show you that our problems are not new; that physicians and societies have always struggled with the issue of altruism versus greed; and to point out that the answer to the question, "How much money should a physician make?" depends on our ethical framework for medicine as well as our culture's particular economic milieu. An historical review confirms that public scrutiny of physician's wages has been ongoing, and is not a new phenomenon.
My premise is that medicine is changing, but rather than succumbing to pessimism, as Christian healers we can use this time of turmoil to be light and salt and to challenge those in our profession who may have "a special love for gold."
Our Example: A Willing Healer
Jesus received no payment for His healings. As the passage in Mark 5 illustrates, other physicians of the time charged for their services: the patient had "spent all she had." During His first reported evening clinic in the gospel of Mark, we are told the people "brought to Jesus all the sick and demon-possessed. The whole town gathered at the door, and Jesus healed many who had various diseases" (Mark 1:32-34). A man with leprosy came to Him and said, "If you are willing, you can make me clean." Filled with compassion, Jesus reached out His hand and touched the man. "I am willing," He said, "Be clean!" Immediately the leprosy left the man and he was cured (Mark 1:40-42).
A few days later, when Jesus entered Capernaum, four men came to Him bringing a paralytic on a mat. Since they could not get him to Jesus because of the crowd, they made an opening in the roof above Jesus and lowered the mat with the paralyzed man on it. When Jesus saw their faith, He said to the paralytic, "Son, your sins are forgiven. I tell you, get up, take your mat and go home." The paralytic got up, took his mat, and walked out in full view of them all. This amazed everyone and they praised God, saying, "We have never seen anything like this!" (Mark 2:1-5,11-12). Dr. Luke's accounts are similar; after the healing of the paralytic, the people were filled with awe and said, "We have seen remarkable things today" (Luke 5:26).
Jesus, we know, "took our infirmities and carried our sorrows yet we considered Him stricken by God, smitten by Him, and afflicted." The dynamic of His healing ministry is outlined in the next verses in Isaiah: "But He was pierced for our transgressions, He was crushed for our iniquities; the punishment that brought us peace was upon Him, and by His wounds we are healed."
These passages and numerous other accounts of Jesus' healing emphasize again and again that the Son of God came at personal cost to seek and save the lost. He had palpable and tangible healing power which He used for the benefit of the sick and the demon-possessed, free of charge. He didn't need any classes on bedside manner; He was often moved by compassion or grief. His clinics were burgeoning.
The story of the woman who spent all she had on other physicians but was freely healed by Jesus emphasizes the charitable nature of Jesus' healing ministry as opposed to the usual, customary and reasonable charges of the time. Besides the finances of His own medical practice, the accounts of the rich fool, the rich man and Lazarus, and the rich young ruler emphasize Jesus' point: life does not consist in the abundance of possessions but in richness toward God.
Jesus may have received contributions from His followers, and He shared meals with them, but He was not troubled or anxious about money. These are His words to worried, covetous, greedy, gluttonous disciples like us:
"Therefore I tell you, do not worry about your life, what you will eat; or about your body, what you will wear. Life is more than food, and the body more than clothes. Consider the ravens: they do not sow or reap, they have no storeroom or barn; yet God feeds them. And how much more valuable you are than birds! Who of you by worrying can add a single hour to his life? Since you cannot do this very little thing, why do you worry about the rest? Consider how the lilies grow. They do not labor or spin. Yet I tell you, not even Solomon in all his splendor was dressed like one of these. If that is how God clothes the grass of the field, which is here today, and tomorrow is thrown into the fire, how much more will He clothe you, O you of little faith! And do not set your heart on what you will eat or drink; do not worry about it. F or the pagan world runs after all such things, and your Father knows that you need them. But seek His kingdom, and these things will be given to you as well.
Do not he afraid little flock, for your Father has been pleased to give you the kingdom. Sell your possessions and give to the poor. Provide purses for yourselves that will not wear out, a treasure in heaven that will not he exhausted, where no thief comes near and no moth destroys. For where your treasure is, there your heart will be also" (Luke 12:22-34).
Jesus healed freely and instructed His disciples to do likewise: "Heal the sick, raise the dead, cleanse those who have leprosy, drive out demons. Freely you have received, freely give" (Matthew 10:8). He told us that the conflict between our love for God and our love for money is one of the most fundamental ethical tensions in our lives. Physicians have been insulated from this tension for the last several decades by the creation of third-party payers and the development of a remarkably generous medical system. Even those of us with a "special love for gold" have been happy. Current cost constraint measures and proposals for government intervention, however, force us to reconsider our motivations for practicing medicine. An historic review can help us better understand our modern dilemma.
Earning a Living: Wages through the Ages
Skull trephination is one of the first known medical procedures; a hole was chiseled through the skull, presumably for release of noxious humors or relief of headache. Prehistoric skulls show evidence of trephination, and even of healing at the site, so some of the patients survived the procedure. Nonetheless, for procedures with this degree of risk, I assume payment was at the time of service.
Early on, the profession of medicine struggled with the problem of fees. How could physicians consider themselves healers and at the same time earn a living? The Latin word for profession, profiteer, means to make a public statement or announcement of a special skill. The word "profession" is closely linked to the Christian concept of "vocation" or "calling," but the word "profit" is visible in the root word as well. Aristophanes and Sophocles debated whether medicine was a trade or a profession; Aristophanes contended that medicine was an art, but Sophocles asserted that the physician was merely a hired hand, a tradesman.1 The debate continues today.2
Socrates noted that money was important. "Unless pay is added to the art," he wrote, "there would be no benefit for the craftsman, and consequently he would be unwilling to go to the trouble of taking care of the trouble of others."3
The physician Galen was more cautious; "It is not possible to pursue the goal of medicine if one holds wealth more important than virtue, and learns the techne not to help people, but for material gain."4
Hippocrates, a wealthy physician of noble birth who eschewed fees, noted that since physicians save people from death, "...no fee, not even a large one, is adequate for the physician, but it is with God Almighty that his remuneration rests_and what he may receive should be reckoned as a gift, a present."5
Hippocrates, however, also realized that some doctors needled to charge a fee, and he said in his Precepts that the doctor should be kindhearted and willing to accommodate his fee to the patient's circumstance.6
Over the last two millennia, physicians have struggled with the issue of remuneration. Ibn al-Tilmidh, a Christian physician in Baghdad, would not accept any gift unless the patient was a caliph or sultan.7
In Renaissance Venice, physicians and surgeons enjoyed modest to high incomes; the largest recorded salary per year_thirteen lire di grossi_was received by surgeon Master Gualtieri in 1348.8
An Irish physician, Dr. Thomas Arthur (1593-74) wrote in his diary in 1619, "The amount of my fees for this year is 74 pounds 8 shillings, for which and for other gifts conferred upon me, unworthy, I return boundless thanks to the Almighty God, who has thus deigned to bless the beginning of my medical practice; and I beg of Him to vouchsafe, to direct, govern, and sanctify the rest of my actions, to the praise and glory of His Name, through Christ our Lord, Amen."9
Among Arthur's first entries for 1620 are:
"I went to Dublin to Mr. George Sexton (Gonorrhoea laborantem) who, being thoroughly cured, gave me a horse of the value of 13 pounds gold. I then went to the lady of Arthur Chicester...the treasurer of this kingdom...in Ulster...labouring under dropsy...and forewarning her of her death within a few days after my prognosis, I attended upon [her]; he gave me 15 pounds. I went to Margaret Walsh, the daughter of Cormac O'Hara, who was pregnant, and became convalescent without injury to herself or the child_1 pound; Sir Randel M'Saurley...sent for me to Dunluce, and gave me 1 pound.
In America, physicians were becoming established in the 1630s. The doctors charged in pounds of tobacco. One particularly scroogish physician was named John Stringer. According to court records of a county in Virginia, his average medical bill equaled a year's wages for a laborer.
In 1639 Virginia had to pass legislation to limit fees, commenting on the helpless position of the poor when ill. In that same year, Stringer's bill to a married couple, Roger and Ann Moy, was paid by one William Burdette in exchange for seven years of service. Stringer literally enslaved his patients to receive payment. In 1644 the Moys disappear from the county records, and it is not known whether they obtained early release or died. Dr. Stringer's progress, however, is well documented in the courts, for he often sued patients to get payment. In 1642 he treated two patients with the plague for one week: both died. He sued the estate of one of these patients for 500 pounds of tobacco for the week's work, about eight months wages. He sued the other for his clothes.10
Not all physicians were like Stringer, of course. The good Dr. Isaac Senter (1753-1799), a surgeon in Rhode Island, received $8 for a delivery, $20 for a thigh amputation and $14 for inoculating a man and his wife for smallpox (which would necessitate daily house calls for a week while they recovered from their mild attacks). Senter paid $1 a day to a man to build a fence, and $1.50 a day to a man working on his house. He bought a live hog weighing 122 pounds for $5. A shirt cost $1.50. His son went to Rhode Island College (now Brown) for $100 per year.11
The Spade Guinea: a Professional Fee
A review of these and other historical documents reveal that for several hundred years physicians made the equivalent of about one gold pound (or one guinea) per visit. The Oxford English dictionary still defines a "guinea" as the unit for a professional fee, and this coin continued to he the unit of consultation on Britain's fashionable Harley Street even after decimalization of the coinage in 1971.12
Although expressed in dollar equivalents, the guinea was the standard fee in America as well. In Isaac Senter's time a guinea was worth about $4, so he charged the standard two guineas for a delivery. Dr. Arthur's usual house call fee was one pound; he received more, however, from the grateful patient "cured" of gonorrhea, and from the wealthy husband of the woman with dropsy. How much money should physicians make? Several points are worth noting. First, they should earn the equivalent of a gold guinea as their base office fee! A guinea (adjusting for inflation) is worth about $46.50 today. Thus, a patient visit should he worth about $50; office fees of modern physicians are not far from this figure, although of course surgical fees and delivery fees are much higher, reflecting the increased technology available in this area; and in rural areas they are lower. My friend Bob Orr tells the fascinating story of how one old-time Vermont physician set his fees. Back when stamps were four cents each, the physician charged four dollars for an office call. Now he charges $29 for an office call. This adjusts for inflation! Bob tells me the system worked pretty well over the years!
Second, historical data about physician income in numerous cultures reveals that physicians in general have earned about four times as much as day laborers, although the ratio varies between two and ten-fold.13,14
Third, the debate over physician's income is an old one; the modern controversy is just a resurgence of the ongoing controversy. An 1856 textbook noted, Every impartial observer, in contemplating the rapid augmentation of the fees of physicians of the past thirty years, must be struck with astonishment at the magnitude of the imposition, and the oppressive amount of their extractions. If they [the doctors] go on thirty more years at the rate they have for the thirty past, the whole community will be little better than the slaves of the medical faculty...We are far from wishing to see medical fees reduced down to the mere compensation of an ordinary day laborer_far from it. But we desire to see them so modified that it may not require the wages of a laborer for a quarter of a year to pay the physician for one day's [hospitalization].15
Fourth, the personal choice between economic interest and altruism has also existed throughout history. Philosophers and physicians have addressed this issue in an attempt to balance the doctor's need to earn a living and the need of the poor for care.
Fifth, whatever their finances, Christian physicians can give thanks. Dr. Thomas Arthur, the obscure Irish physician whom we already mentioned, gives us an important historical example "...for which and other gifts conferred upon me, unworthy, I return boundless thanks..." Arthur goes on, in his accounting statement of one of his first years in practice, to ask God to direct, govern, and sanctify his actions.
What lies ahead for American physicians? According to Eli Ginzberg, a respected medical economist, the supply of physicians will continue to increase, and unless total spending for health care accelerates or physicians can redirect the flow of hospital funds to themselves, physician incomes will be reduced, probably appreciably. Hospitals will merge and close, and staff appointments will become more difficult to obtain. Due to competition from other modes of health care, visits to physicians will decline. Congress will continue to freeze physicians' fees and institute other means to eliminate the usual, customary and reasonable fee determination. Recent medical school graduates will opt for corporate employment. "Even if some of the warnings prose to be unwarranted," Ginzberg writes, "the outlook for physicians has definitely taken a marked turn for the worse."16
We can view the words of medical futurists with alarm if we wish. We can retire. We can tell our children to avoid medicine as a career, and we can grumble and complain about our salaries (although since we earn about four times as much as the average American, we can expect little sympathy!). We can argue that our particular specialty should make more money than some other specialty (the old-fashioned word far this particular maneuver is coveting).
I am convinced that Christian physicians can do better than this. We do need to discuss these issues together; we should he concerned about the clinical and personal impact of the current medical economic upheaval. We need to be sensitive to those physicians who experience financial difficulty. But we also need to remember that despite doom and gloom predictions, there is historical evidence that physicians will continue to earn their guinea per visit and make from two to ten times as much as the average worker. Adjustments in our lifestyles may be necessary, but we can encourage each other instead of discouraging each other. We can even he thankful (remember Dr. Arthur's end-of-year audit) for what God has given us.
Because we follow the example of a willing healer, we can work as unto the Lord. Even if physicians' salaries drop fairly dramatically, we have a model of medicine which transcends any economic models. What a critical time for Christian young people to be entering medicine! We need to stop discouraging them! God can use them, here or elsewhere in the world! Medicine needs them!
Some doctors have an interest in pearls and a special love for gold. The current state of medicine will make them unhappy. Some doctors, like Dr. John Stringer, charge patients until they have spent all they have. Some doctors refuse to take care of the poor. But others balance altruism and greed, balance the need to serve with the need to survive, balance spiritual service with self-interest. It is my hope and prayer for you and me that we might, like Dr. Jack Provonsha, do more than just serve ourselves, that in the end we might be counted as the merciful servants of our God and of our patients.
1. F. Kudlein, "Medicine as a 'liberal art' and the question of the physician's income," Journal of the History of Medicine, October 1976: 448-459.
2. L. King, "Medicine_trade or profession?" Journal of the American Medical Association, 253 (1985): 2709-10. 3. Plato's Republic, 346D
4. Galen, "Quod optimus medicus," (n.34), p.4 line 13ff. 5. H. H. Biersterfeldt, "Some opinions on the physician's remuneration in medieval Islam," Bulletin of the History of Medicine, 58 (1984): 16-27.
6. I. Muller, "the professional ethics of the Greek physician," Bulletin of the History of Medicine, 30 (1956): 391-419.
7. Biersterfeldt, p.19.
8. G. Ruggiero, "The status of physicians and surgeons in Renaissance Venice", Journal of the History of Medicine, April 1981: 168-84.
9. J. Fleetwood, "Some lesser known Irish physicians," address to the Osler Club of London, May 1981.
10. R. S. Klein, "Medical expenses and the poor in Virginia: Roger and Ann Moy indentured to John Stringer." Journal of the History of Medicine and Allied Sciences, 30 (1975): 260-267.
11. T. Perry Jr., "Surgery in a rural area: 1638-1868," The American Journal of Surgery, 129 (1975): 347-355.
12. N. Asherson, "The age of John Hunter's golden guineas (1973-93)." Annals of the Royal College of Surgeons in England, 64 (1982): 262-265.
13. J. Lane, "A provincial surgeon and his obstetric practice: Thomas W. Jones of Henley-in-Arden, 1764-1846," Medical History, 31 (1986): 333-48.
14. J. I. Waring, "A Pendleton doctor's old account book," Journal of South Carolina Medical Association, October 1967: 363-364.
15. R. S. Agnes, "Physician's fees, 1856-2056," New England Journal of Medicine, 290 (1974): 751-2.
16. E. Ginzberg, "What lies ahead for American physicians: one economist's views," Journal of the American Medical Association, 253 (1985): 2848-9