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EDITORIALS 1307
ond vice-president; and Major Brittain F. Payne, third vice-president, and Dr. Charles D. Blassingame, member of the Council. Lawrence T. Post.
BRITISH DISCUSSION OF SOCIALIZED MEDICINE
For some months past the columns of the British Medical Journal, the organ of the British Medical Association, have carried an abundance of discussion of the "White Paper," the document which offered for open debate an outline of the British Government's proposals for a gen-. eral system of socialized medicine.
The views expressed are many. More frequently they are unfavorable to, or at least severely critical of, the British Government's proposals. But, in leading articles, reports of speeches, and, above all, in that open correspondence which is so striking a feature of British journalism, all shades of opinion are represented.
In the columns of a periodical officially representing the British Medical Association it is refreshing to find a number of letters expressing frank and occasionally rather bitter criticism of that medical organization. The Association, through its Council, while condemning the Government scheme in certain principles and details, has shown a disposition to offer constructive criticism for improvement in the proposals. In this connection it is important to remember that the British Government has announced its firm policy to adopt a general scheme of medical-socialization, but issued the White Paper as an avowed basis for free public and professional discussion before the actual introduction of a parliamentary bill.
Very blunt is the attitude of the gentleman who speaks of the "apostasy of the B.M.A.," but a speaker who has leanings in the other direction finds it necessary to
suggest that many of the letters "contain much individual prejudice, and are written as though their opinions and statements were self-evident facts."
Dr. H. Guy Dain, Chairman of Council of the B.M.A., speaking before the profession at Bristol, calls attention to the wide contrasts between those physicians who would take no part whatever in a government service, however organized, and those of the other extreme who believe that the best service would be by whole-time salaried officers; and between those who argue that the state service should be for everybody in the country, "irrespective of means, age, sex, or occupation," and those who believe in limitation to a certain income level. Dain points out that private practice is beginning to reappear even in Russia, and that in Norway, notwithstanding a system of state hospitals, voluntary hospitals have entered the field. Whatever arrangement is made, Dain suggests, it must provide for the freedom of the patient to go where he desires for his doctoring and to pay for it if he wishes to do so.
We find one writer stating that the general British public has welcomed the scheme; and another declaring that one hundred percent of his office patients have voted against it.
One correspondent writes at some length to draw a parallel between the attitude taken by the British Medical Association in 1911, when Mr. Lloyd George introduced his National Insurance Bill, and the situation today. It is suggested that the British Medical Association then fought what at first appeared to be a losing battle but in the end worked out not so badly for the profession. This writer quotes a British gibe to the effect that "The National Insurance Act gave the doctors their motor cars." In 1911, while the National Insurance Bill was being fought in Parliament, the British
1308 EDITORIALS
Medical Association "obtained the signatures of twenty-seven thousand doctors to a pledge that they would not accept service under the Bill except on terms in accordance with the Association's policy, and that they would not enter into any contract except through a local medical committee representative of the local profession." Today, says the same writer, the British profession has the advantage of considering a preliminary scheme instead of fighting a bill already introduced into Parliament.
Surgeon Vice-Admiral Sheldon Dudley, Medical Director-General of the Navy, delivering the Harveian Lecture before the Harveian Society of London, pointed out that the oldest and most comprehensive medical services were those of the Navy and Army. Speaking as to the possible effect of a set salary upon the quality of the physician's work, Admiral Dudley said that in the British Navy there were very few medical officers who did as little work as possible, and he argued that "on the whole, self-respect, the desire to do well in the eyes of the herd, a natural sympathy with sick people, and a praiseworthy desire for promotion would outweigh the alleged stultifying effect of a fixed salary." He suggested the experience of the Navy showed that "a patient-doctor relationship of the best type was possible on a salaried basis of remuneration and without free choice."
British municipal hospitals have come in for a good deal of abuse as contrasted with the voluntary hospitals. Yet the accommodations provided in the voluntary hospitals are far from adequate, as demonstrated by the fact that there is usually a long waiting list of applicants for admission.
One of the most interesting products of the British controversy as to the Government's proposals takes the form of a vote by medical students upon a number of
questions submitted to them by the British Medical Students' Association. About one fourth of the total number of students replied. Forty-nine percent of them thought that the quality of the country's medical service would be enhanced by the proposed National Health Service, thirty-six percent thought it would suffer, fourteen percent "did not know." Seventy-two percent thought that complete medical services, including hospital and specialized services, ought to be available to everyone free of charge. Eighty-nine percent approved of the principle of health centers. Fifty-three favored payment by a small basic salary plus capitation fees. Sixty-three percent made a statement that it would not be possible for them to set up in practice without incurring a debt. Fifty-one percent reacted on the whole favorably to the Government's White Paper, forty percent unfavorably, and seven percent "did not know." Incidentally it may be mentioned that of those whose fathers were physicians fifty-two percent reacted unfavorably to the document and only thirty-eight percent were definitely favorable.
From medical students a similar vote would rather likely be obtained in the United States, since those who have not yet attained the position of special privilege associated with established practice are still preoccuped with the problem of buttering their daily bread. A British physician "under forty" suggests that the White Paper offers the young doctor two important advantages which should not be forgotten in discussing the future health services; namely, the opportunity to undertake general practice unburdened by financial considerations, and the existence of many more openings for the doctor who wishes to specialize.
What part does ophthalmology play in this general discussion of the British Government's proposals? Plans for an oph-
BOOK NOTICES 1309
thalmic service have brought up the question whether refraction shall be carried on entirely by ophthalmic physicians or shall enlist the cooperation of sight-testing opticians. One writer points out that against seven thousand opticians at present officially recognized as qualified to undertake National Health Insurance work, there are throughout the country only about one thousand ophthalmic medical practitioners, a part of whose time is taken up with other eye work. These figures were the basis of a recent recommendation by the Ophthalmic Group Committtee's draft scheme for a National Eye Service, which suggested that it would be necessary to call in the aid of optician refractionists who would work under the supervision of medically qualified specialists. The suggestion that in a few years time a sufficient number of physicians could be trained to do the refraction work is derided by the correspondent on the ground that "men are not going to take the six years medical course, then specialize in ophthalmology, and spend the rest of their lives doing refractions." The correspondent would establish eye clinics each "staffed by a medical eye specialist, who will have under him two or more optician refractionists," with sometimes the help of a nurse, clerical assistants, and possibly an orthoptist. The ophthalmic specialist would do only "difficult refractions or those requiring a cycloplegic." The writer assumes that in the course of years most sight-testing opticians will either "decide to go over to the dispensing side of the business or be absorbed as refractionists in the eye clinics." Some readers will admire ( !) the faith of this correspondent in the ability of the subordinate refractionist to determine which refractions are difficult and which will require the use of a cycloplegic.
If a system of socialized medicine is adopted in the United States, very thorny will be this problem of who shall do re
fraction in the public clinics or wherever it may be done out of the funds provided under the law. W. H. Crisp.
BOOK NOTICES I WANTED TO SEE. By Borghild
Dahl, with a Foreword by William L. Benedict, M.D. New York, The Mac-millan Co., 1944. Price $2.00. Some two years ago Dartmouth College
published a book, "Motivation and visual factors," based upon an intensive study of a large goup of college students. The conclusion of the authors, in brief, is that visual handicaps as such can be considered only in relation to the entire personality, specifically to the motivating drives of the individual. The motivation seems to be the dominant factor in any successful or unsuccessful adjustment to the presence of visual anomalies.
No stronger corroboration of the soundness of this conclusion can be found anywhere than in the personal narrative of Miss Dahl, in her volume, "I wanted to see." Here is a woman who from her earliest childhood was totally blind in one eye, had vision of only 4/60 in the other eye, and yet by sheer will and tenacity of purpose managed to get almost everything she strove for, and she aimed high. She would have done wonderfully if she had managed merely to get through grammar school. But Miss Dahl completed a regular high school course, a full college and university course, with the Bachelor and* Master of Arts degrees, became a successful high school teacher, anl later a college professor. She also managed to win a fellowship from the American Scandinavian Foundation, which, acclaiming her as a distinguished student in sociology, sent her for a year's study to Norway. And this is not all. We could go on discoursing on her extracurricular accomplishments ; for example, being chosen