Whither, ethics in medicine? Qoiin la»A I]oKri +"• W W'>+V>eT| - - - /VE>U3S55' Digitized by the Internet Archive in 2016 ‘ https://archive.org/details/whitherethicsinmOOquin Whither, Ethics in Medicine? By JOHN F. QUINLAN, M.D. San Francisco, California ( Reprinted with permission from “The Linacre Quarterly**) New York, N. Y. THE PAULIST PRESS 401 West 59th Street Deacfdifier* Whither, Ethics in Medicine? TTISTORY runs as the growth of a man, slowly, persistently, imperceptibly. Its course can be appraised through the run of ages as a man's in in- fancy, youth, adolescence, maturity. It runs with all its parts. Let us examine the course of medicine. From the dawn of its scientific era the sociolog- ical ramifications of Medicine were well appreciated ; so well appreciated that the applicant to practice was required to subscribe to a formula of conduct before being admitted to apprenticeship . 1 * 2 And sanction for this subscription was had in recourse to the deity with a prayer of benediction for com- pliance and a curse for its transgression. He called upon the deity as the witnesses for his earnestness ; for his piety and devotion to his teachers; for his honorableness in practice specifically withholding himself from the malpractice of abortion; for the uprightness of his life; for the secrecy of informa- tion entrusted to him in the performance of his duties ; for his deference to the more skillful in times of difficulty. But all this is by way of tradition. The earliest recorded version of a Hippocratic oath is the cruci- form Christian Oath of the tenth or eleventh cen- tury. 2 Its only essential difference from the so- called Pagan Oath is that the Witness for the Chris- tian is the Trinity. The bodies of the oaths are otherwise similar in their brevity of form, and sub- stance. From these features we may judge that 3 4 WHITHER, ETHICS IN MEDICINE? much was left, because it could be on account of a common Faith or Religion, to the conscience of the individual. But it is not so with us. The religious upheaval of the sixteenth century wrested from Christendom its unity of Belief, the common ground upon which all matters of ethics must be judged. For, as Ches- terton says, speaking of standards: “If I would measure the distance between the earth and the moon my reed must not be in a pot.” And what has been the result? Out of deference to the amoral and unbelieving segments among us, our principles have degenerated into mere codes which require frequent recodifications, amplifica- tions, deletions, to allow for the changing conven- tions of the times. In its own short history Ameri- can medicine has modified its principles of ethics several times. It has become so wanting in logic and the meaning of terms that “Principles” is sub- stituted for “Code” with the ease and flaccidity of an alcoholic’s gesture. Its Principles of Medical Ethics is but a sad prototype for any book on eti- quette. The Christian Age gave man much. Though it was ignorant of Science (as we know it) it showed him the meaning of life, demonstrated its purposive- ness and intelligibility, and rediscovered for him the principles upon which it could be directed to its end. While these principles were yet virile as the inspira- tion of man’s activity, Sydenham could say : 3 “Who- ever takes up medicine should seriously consider the following points, firstly, that he must one day WHITHER, ETHICS IN MEDICINE? 5 render to the Supreme Judge an account of the lives of those sick men who have been entrusted to his care. Secondly, that such skill and science as, by the blessing of Almighty God, he has attained, are to be specially directed towards the honor of his Maker and the welfare of his fellow creatures : since it is a base thing for the great gifts of Heaven to become the servants of avarice and ambition. Thirdly he must remember that it is no mean or ig- noble animal that he deals with. Lastly he must remember that he himself hath no exemption from the common lot, but that he is bound by the same laws of mortality and liable to the same ailments and afflictions with his fellows. For these and like reasons let him strive to render to the distressed with the greater care, with the kindlier spirit, and with the stronger fellow feeling.” More than three hundred years have passed since Sydenham’s day. The principles by which his con- duct was motivated, the heritage of a more Chris- tian age, have become diluted with the sophistries of the Industrial Age in which we live. They no longer move man’s life or regulate his conduct. The modern physician has his own code, appraises his own actions, and is accountable only to himself — except he fall afoul of the law. He is in the service of Humanity and Humanity cannot exact an account of what he does. He has become so engrossed in Humanity that he is forgetting his patients are hu- man ; forgetting that man is body-soul and not body alone. And what is the result? Having lost sight of 6 WHITHER, ETHICS IN MEDICINE? fundamental principles we have had recourse to conventional rules or codes to which we can give but nominal assent. Where there is no common con- viction there can be no conformity. And, in our bewilderment, we cry out for a “guild,” forgetful again of the one thing that gave the guilds suste- nance and made them practicable. An instance of our present state of confusion is the cry that goes up for the general practitioner. We have forgotten the service for which our pro- fession has been renowned and have thought pri- marily of remuneration. That is the primary rea- son for the glut in specialism. In consequence we have had to emphasize our service to the public. We have done it so well that our astute politicians would make us truly the public’s servants. And, now that the remuneration of specialism is rapidly lessening, and specialists are widening the fields of their activity, and realizing the thing called “exten- uating circumstances” and making allowances for it, the little fellow over the drug store is coming into his own again and is having a halo placed over his head. In his comment upon the Majority Opinion con- cerning the Study of the Cost of Medical Care, Cushing 4 well illustrated our present dilemma as regards the dearth of general practitioners in his parable of the knife-maker. He wails the loss of the family doctor who was the family adviser as well. He pleads for more men to engage in general prac- tice because the nation needs more old-time family physicians. WHITHER, ETHICS IN MEDICINE? 7 But, to engage in general practice and be a gen- eral practitioner, as Cushing implies, is not the same thing. The general practitioner was the fam- ily adviser and counselor. To be a counselor pre- supposes convictions; convictions follow from prin- ciples; and principles are established upon a phi- losophy of life. Ours seem to be naught but the transigence of Pragmatism. Until our profession is infused with an immutable philosophy it cannot expect to fill the need of the general practitioner. Let us go on ! The aspirant to medical practice during four long years is filled with the glory of Medicine, is steeped in its noble traditions, and ab- sorbs its high idealism. The while, he is exposed to the stress laid upon the economics of medicine and the propaganda for the inclusion of courses re- lated to it in the medical curriculum. He is taught indications for abortion which are limned with a gravity that leaves him impressed only with its questionable necessity. Then, in glorious proces- sion, in cap and gown, following the file of an awe- some professorate in the beautiful multicolored vel- vet capes of their various distinctions and schools, to the assembly hall to receive the reward of his labors. With cap in hand, shielding his heart and the precious parchment he has won, and head erect he intones, in silly solemnity, the pagan Hippocratic oath, swearing before gods that are not, for prin- ciples the existence of which he can only question but, nevertheless, impressing him with the idealism of his brothers of a former day. He engages in practice. He calls upon his elders, 8 WHITHER, ETHICS IN MEDICINE? sometimes his old teachers, in his difficulties only to find that problem and patient, as well as his meager sustenance are deftly maneuvered from his control into their own. And they have with them young men who are nurtured to continue and extend the pernicious practice. He hears of exorbitant fees and the exaction of fees before service is rendered. He observes their bitter jealousies; often, malicious slanders. He notices with what dexterity the laws regulating the practice of therapeutic abortion are circumvented. He observes with what noble con- sistency his colleagues in public life fight for hon- esty in the food and drug traffic and its advertising while, at the same time, they sponsor, on the radio, proprietary medicines whose only merit is a price several times that of an equivalent article not bear- ing the copyrighted name; a member of our es- teemed College of Surgeons founded to end the per- nicious practice of fee-splitting, conducting a pro- gram for Lysol. These men, as often as not, hold high places in academic circles and in the councils of our societies. There he has heard their effusions for better ethics. He wonders, and logically con- cludes: Ethics, for our saps and saplings! He falters in his adherence to professional ideal- ism and ethics. Often he fails ; the pressure against them has been too persuasive. But he is made of weak stuff and is unworthy of his high calling who would find excuse for failure in the example of these perfidious brothers. He is unworthy of the trust of the secrets of other men's tribulations and some- times their very lives. But how can he show that WHITHER, ETHICS IN MEDICINE ? 9 devotion to his teachers, that deference to the more skillful, when they prove themselves so unworthy of it? In these considerations I have shown how the lack of ethical principles has affected our conduct towards each other. In what follows, it is my pur- pose to show how it affects our conduct towards our patients, the peerage of medicine, and the common- weal. We are all teachers, some formally by choice, all by circumstance. Though we may not be professors of medicine we are all instructors in the fields of sociology. We teach in the classroom, at conven- tions, at the bedside, in the sancta of our offices, over teacups. What we advance and support in the name of Science will have more weight in molding Public Opinion than reams of polemics. Questions to the fore at present, upon which we should declare ourselves because of their medico-sociological im- portance are: sterilization of defectives; disposal of the incurably affected; abortion; and contraception. So far, from us there has been only an ominous si- lence; or, what is worse—officially—an attitude of unconcern or “scientific detachment,” as it is called in the J. A. M. A . 6 Sterilization The object of our ministrations is a human be- ing. For, if he be not human, we are not physicians but veterinarians. He is free. He has rights which are prior to the State. There is a law of nature written in the heart of man confirmed by religion, 10 WHITHER, ETHICS IN MEDICINE? and which forms a part of the basic philosophy of our American State: “All men are created equal. They are endowed by their Creator with certain in- alienable rights, that among these are Life, Liberty, and the Pursuit of Happiness. That to secure these rights Governments are instituted among men” These rights are inalienable; they may not be re- linquished though they can be forfeited; nor are they dispossessable. As the State, anticipating a crime, may not punish a man, much less may it pun- ish him in anticipation of an inconvenience. But, in view of its foreknowledge, it has the duty of pro- tecting the community against any possible attack. A frankly insane person cannot commit a crime, and, the State recognizing this, rightly segregates him from the rest, preventing him from abusing the faculties the proper use of which he is incapable of realizing. The idiot, the imbecile, and the feeble- minded, in a measure, are insane. To that ex- tent they are incapable of crime. The State has no authority over their persons; but it has the duty of securing for them the possession of their facul- ties while it safeguards the community from the in- conveniences which are the result of their irration- ality; poverty, squalor, social diseases, enfeebled off- spring. And, here we come to the consideration of heredity. It is a long jump from peas and rats and flies under absolutely controllable conditions to the gregarious human. Regardless. There are two kinds of heredity, the one, intrinsic, absolutely in- dependent of environment; the other extrinsic, con- WHITHER, ETHICS IN MEDICINE? 11 ditioned thereon. If I have a defect that is intrin- sically heritable it must have been a blossom on my genealogical tree; it is characterized by recessive- ness; if it is obvious it must have existed in the chromosomes of both my parents—and in the same order ; and the instances of its occurrence were more numerous the farther back my genealogy is traced. The obvious conclusions for this kind of defective heredity are : Since it has a tendency to perpetuate itself only in purity, its elimination can most ef- fectively be accelerated by mixed breeding. Al- binism remains dominant in a colony of Central American Indians because of inbreeding. It has been dissipated from a colony in western Canada by the infusion of unaffected stock. And polydac- tylism disappeared from a colony in Brittany by the same means. The same result 7 will follow in cases of hereditary blindness, otosclerosis, the abi- otrophys or any other intrinsically heritable dis- ease. The instances of the occurrence of this kind of heredity as a recessive characteristic are discover- able only through the offspring. Sterilization, be- cause of the complex and unpredictable character of hereditary transmissibility, and the unwholesome results for the community (to be discussed later), is but a futile gesture. The eastern seaboard Indians, seeing in what a maze the colonists were with the maize-seed they had given them, in stunted stock and sparse yield, advised them to put rotted fish in the soil when the seed was being planted. The rotten fish applied 12 WHITHER, ETHICS IN MEDICINE? when the seed was planted was responsible for a luxuriant growth and prolific yield; when applied after the stalks were half-grown it had to be used more generously and, as often as not, the yield was disappointing; when applied after the stalks were full-grown the results were fruitless. The quality and abundance of the corn was as much, if not more, dependent upon the character of the soil as it was upon the factors inherent in the seed. This is the type of conditioned heredity. The stock is man, the seed his character, the soil the conditions in which we live, and the rotten fish the irksome re- strictions with which civilization surrounds us that our best characters may be produced. And we are in a maze. Our eugenists and geneticists would have us destroy the seed by sterilization rather than apply the needed fertilizer. The present generation of Japanese, on the av- erage, is taller by one inch than the generations pre- ceding it. It has been brought about by the institu- tion of a Western dietary. Before a recent medical conference at the University of California a boy of nineteen was presented as a case of constitutional psychopathic personality. In the discussion it was stated, almost as an irrelevancy, that he had indul- gent parents, and that all his desires were acceded to from early infancy. A few years ago at the San Francisco State Teachers College, Behaviorism held forte; let the child express itself; it should not be hampered with restrictions; they tend to form only shut-in characters and to warp the personality. How soon its force was dissipated ! And now, from WHITHER, ETHICS IN MEDICINE? 13 the University of California, we hear over the radio, in a series of lectures on Education to Character, that the child must be taught to say “no.” Self- restraint as the cardinal principle in character for- mation is again being asserted and the biblical adage of sparing the rod and spoiling the child is being proven daily with increasing emphasis. We little realize that for years, long before the days of Jung and Freud, Catholic sociologists have been carrying on this work of character reclama- tion. The Sisters of the Good Shepherd and others have been taking girls before they were confirmed in their Behavioristic tendencies and, after years of patient and relentless guidance, have returned them to the community as useful citizens. Were many of them allowed to continue in the path of least re- sistance they would, no doubt, reach the stage that would entitle them to the label “constitutional psy- chopath.” The crime wave is assuming tidal proportions. We hear much of its causes and of committees in- vestigating them. In our confusion we cry out: “Something must be done.” It is only “something.” We do not know what. We remain unimpressed when it has been discovered that the teachers in our schools have been bought by big business or com- munistic groups, or subserve other selfish projects. Their interest is not the child or its welfare which, in the end, is the welfare of the State. How timely it is that out of the city that might be called the “nation’s shooting gallery” should rise the Catholic Youth Organization, a movement whose purpose it 14 WHITHER, ETHICS IN MEDICINE? is, under competent religious guidance and leader- ship, to direct the mind of youth into channels which will lead to the formation of wholesome characters. In a few years we may look for the trough to appear in the tidal wave of crime through the instrumen- tality of just such organizations. Insanity is on the increase. Some authorities claim the increase is out of proportion to the in- crease in population. Psychiatrists tell us that it is due, in great measure, to the complex civilization in which we live, to the strain incidental to making a living. Temperaments which would bear up well in a simpler environment crack under the strain in our own. Schizophrenia is given as an illustration. Doesn’t it strike you that much of life’s complexity is needless? Why this obeisance to wealth, to posi- tion, to learning? These futile goals which men have set for which they goad themselves beyond their endurance are, in greatest measure, responsi- ble for this rupture. Euthanasia Human life is sacred. Its inviolability is en- graven in the heart of man and is confirmed in the Commandment of the Decalogue: “Thou shalt not kill.” The fathers of our country thought so highly of it that they named it first of the gifts of man’s Creator for which they were ready to sacrifice their lives. We are its custodians. We are not free to abuse it. The physician who is a Christian, recog- nizing this law and its confirmation in the Fifth Commandment, is deterred from any inclination to WHITHER, ETHICS IN MEDICINE? 15 stifle it no matter what course expediency may dic- tate. However, many of our fraternity are not so minded. With them the sentimental novelist has his way. Their imaginations are so possessed that their reason is clouded and the normal relationship of man-to-man is lost sight of. Under a mask of sym- pathy and compassion for the enfeebled aged—the crippled old father, the paralytic old mother—the duty of filial piety is discarded, and Nirvana, in the form of painless death by poisoning, is substituted. Some of these exponents of a New Medicine, inse- cure in the possession of the license which shields their ignoble acts, or sheepishly aware of an “an- tiquated code” which they cannot ignore, content themselves with proffering the fatal hemlock. Eu- phemism has the day. Under the guise of Eutha- nasia murder is committed or the stage is set for the suicide. Is there nothing for us in the selfless devotion of father and mother, of sister and brother, or the dis- interested service of religious to what modern man may call “these animated gangling hulks”? By what then does civilization advance? Osier answers for us : 8 “The spirit of Love only received its incarna- tion with the ever memorable reply to the ever memorable question—Who is thy neighbor?—a re- ply which has changed the attitude of the world.” But if we should not have these incurables where would Medicine be? Yesterday's impossibilities are Today's realities ; Today's problems are Tomorrow's discoveries. There is a meaning in Life. There is 16 WHITHER, ETHICS IN MEDICINE? a plan in the universe. Who am I that I should con- stitute myself competent to judge the part that you should play, and how, and how long you should play it? We are here to heal or assuage suffering hu- manity not to snuff it out. “I will give no poison” applies as well to us as it did to the pagan or the medieval Christian. Abortion There is another phase of this materialistic phi- losophy by which man is degraded to the level of the beast and which accounts for the levity with which man’s life is taken. A unity of identity is recognized in the seed in the pod, the seed in the sod, the tender sprout, and the flowering vine. And, yet with human nature we would make distinctions ; we will not see a unity running through the un- formed embryo, the foetus, and the infant. Though it would be abhorrent to us to take an infant’s life we do not falter in the commission of a foeticide. The therapeutic abortionist differs little from the radical eugenist. Both stand on the untenable ground of expediency. Make of this what you will ; it is the reply of Dr. W. J. Robinson 9 in the J. A. M. A. to the review of his book, The Law Against Abortion, in an earlier issue: “Your re- viewer places foeticide, infanticide, and homicide on exactly the same level. . . . when I initiated the propaganda for birth control thirty years ago, the same thing exactly was said about the prevention of conception that is now being said about abortion. . . . Perhaps twenty-five years from now the views WHITHER, ETHICS IN MEDICINE? 17 on abortion, in certain cases, will also undergo a radical change. . . . ” The obstetrician who would do an abortion, in a sober moment, uninfluenced by the stress of circum- stance will, more often than not, admit that the course is little changed by abortion in the cases in which it is considered indicated. Yet, in these par- ticular circumstances, because of the tense atmos- phere—the tearful cry of the patient for help, the anguished pleading of husband and family, and his own welling compassion for the patient’s sorry lot —because he lacks that disposition of soul which Osier so highly prized as the possession of the true physician — equanimity — and because he cannot realize the courage that is required of him in “standing by,” he falteringly advises abortion or foetcide. But many of our fraternity are not swayed by argument from natural ethics. Statistics is their god so we must make him speak. The most frequent indications for abortion are convenience, pernicious vomiting, nephritis, eclampsia, heart disease, and tuberculosis. The toxemias of pregnancy include hyperemesis gravidarum, eclampsia, and nephritic toxemia. Straus and McDonald state : 10 “As yet not one of the toxins allegedly responsible for the anemias of pregnancy, the polyneuritis of pregnancy, for hy- peremesis gravidarum, or for eclampsia has been identified, isolated, or recovered in any form.” Their presence, though not of other abnormal sub- stances, in eclampsia and other severe toxemias, is 18 WHITHER, ETHICS IN MEDICINE? rendered questionable by the work of Macht and Losee 11 on the blood of women affected with these conditions. They have found nothing in the serum of their bloods which is detrimental to the growth of seedlings of Lupinus Albus. Eden, 12 in a study of 2,005 cases of eclampsia, reports a death rate of 10.29% for Ireland, where conservatism reigns, and of 25.0% and 23.8% for Scotland and England, re- spectively, where intervention is the rule. Maternal Mortality in Eclampsia 2005 Cases Locality Cases % Mortality Edinburgh 148 25.0 Dublin 204 10.29 England, North of 804 24.43 Midland 302 25.10 London 547 21.90 Wilson 13 (1929), publishing observations of the Johns Hopkins Hospital, found for the period (1894-1912), including cases treated by early and forced evacuation, a maternal mortality of 24.8%. For the period (1912-1924) for cases treated by the conservative method, the mortality was 12.8%. Statistics from personal experiences in regard to the effectiveness of abortion staying the course of coincidental maternal diseases are extremely un- reliable. They are too often affected by the author’s attitude towards the subject we are considering — abortion. If he is by habit an interventionist his mortality rate will be low; if conservative, it will be hip*» WHITHER, ETHICS IN MEDICINE ? 19 Vollman 14 admits the total mortality for abor- tion is seven times greater than that of deliveries at term. In Berlin (1922-1924) there were 1,348 deaths for puerperal fever following abortion against 312 after births at term. In 1928 at the Rotunda in Dublin, for the extern service, the ma- ternal mortality was 0.5% in 1,979 cases. When the intern service was included the mortality was 0.32%. In California in 1928,15 there were 493 deaths attributable to puerperal causes. Abortion preceded 102 (50%) of 206 deaths from septicemia. It preceded the deaths of 134 women. Of these 15 (11%) were therapeutic and 70 (50%) were in- duced. And 164 had been “delivered of previable children.” These too are abortions, presumably therapeutic, as criminal or self-induced abortions are never designated as “deliveries of the previ- able.” Therapeutic abortion, therefore, presum- ably accounted for 37% of California's maternal mortality in 1928. In Marys Help Hospital, 16 in the last 2,616 cases, the mortality was 0.23%. The deaths from puerperal causes per 1,000 live births in the registration area in 1928 were 6.9, almost 0.7%. The comment in Mortality Statistics for 1928 17 is significant: Special attention is called to the fact that for both white and colored, rates from all puerperal causes and puerperal septicemia were, without exception, lower for the rural part of the birth registration area than for the urban: Urban Rural 5.4 11.2 White Colored 7.2 13.9 20 WHITHER, ETHICS IN MEDICINE? In Russia,18 in 1,815 cases therapeutically aborted for social reasons the mortality was 0.7%. The obvious conclusions to be drawn from these figures are: since abortions performed under “ideal” con- ditions (social reasons) are fraught with greater danger to the life of the abortee than delivery at term is to the normal parturient, it is unlikely that therapeutic abortion should diminish the hazard to the sick mother ; it is more likely to increase it. The death rate is lower under conditions which do not permit intervention — Ireland, Catholic hospitals, rural communities—than it is under those that do. Herein may lie an answer to our concern over the national maternal mortality. Disregarding these considerations the obstetri- cian differs from the physician in ordinary circum- stances of sickness in that he is concerned with the well-being of two persons. If he cannot help the one without jeopardizing the chances of the other he may help neither. He is not judge but physician. Women die at home and in the streets. Must we close the one and barricade the other against them? There are dangers imminent in every vocation; a certain per cent of them will be fatal. “I will not give treatment to women to cause abortion. ... I will use treatment to help the sick according to my ability of judgment” 1 * 2 applies as much to us as it did to the ancients, Pagan or Christian. Convenience. 19 How absurd ! Yet it is the most widespread cause for abortion. Society's tacit ac- knowledgment of the moral law that imposes mu- tual fidelity upon married couples and chastity upon WHITHER, ETHICS IN MEDICINE? 21 the unwed is responsible for the great trek to the abortionists. The desire of self-expression and in- dependence, greater participation in social activi- ties, education and the quest of wealth send the legitimately pregnant to them. And the regular practitioner finds sufficient reason in squalor, pov- erty, and sizable families as though all of us should and could be cast in one mold. Fortunately for us, but unhappily for Russia, we do not need to speculate upon the results of such an unwholesome policy. “Russian experiences with legalized abortion as reflected in the First All- Ukranian Congress of Gynecologists and Obstetri- cians meeting in Kiev from May 23-28, 1927, do not seem to have refuted or challenged by more recent reports emanating from the same sources,” reads an editorial in the J. A. M. A.18 “The unbiased and ob- jectively scientific attitude of the congress towards the question seems apparent,” it states, and con- tinues to enumerate a number of these experiences : 13.5% of adnexal complications in 1,242 abortions; uterine perforations in 0.04% of cases of which 75% recovered with conservative treatment; 0.7% mor- tality in 1,815 cases, the principle being infection; the incidence of general sepsis four times, and of adnexal inflammation two times as frequent after repeated abortion than after one ; as a result of the replacement of normal mucosa by scar tissue oligo- menorrhea in 74%, amenorrhaea 10%, secondary sterility 5.4% and habitual abortion; from the ef- fects of the sudden loss of decidual secretions on the ovaries and uterus disturbed follicular forma- 22 WHITHER, ETHICS IN MEDICINE? tion, cystic degeneration, perenchymatous atrophy, thickening of the tunica albuginea, uterine atrophy and hyperplasia; the incidence of tubal pregnancy 1.3% in 3,790 cases following abortion; of the ef- fects upon succeeding pregnancies 32% post-partum fever as of 9.5% in them not previously aborted, prolongation of labor, increased incidence of pla- centa praevia and necessity of manual removal be- cause of retention of placenta, post-partum hemorr- hage five to six times, subinvolution three times, and stillbirths; from the interference with the at- tainment of complete sexual characteristics caused by the first pregnancy psychic disturbances—depres- sion, hysteria, frigidity, dyspareunia, and discord; and some of the conclusions arrived at by men of the Congress : “Chronic inflammation of the uterus and adnexa, as well as abortions without end, is the herit- age of those years.” “There is no disease of the female in the causation of which abortion does not play an important role.” “When we report 140,000 abortions a year we report just that many women on the road to invalidism.” Already our English colleagues are widely spon- soring social reasons for abortion. And, lest we ap- pear too sanguine, let us revert to Dr. Robinson's letter: “May I remind your readers that when I initiated the propaganda for birth control thirty years ago the same thing exactly was said about the prevention of conception that is now being said about abortion. . . . Perhaps twenty-five years from now the views on abortion, in certain cases, will un- dergo a radical change. . . . And if a modification WHITHER, ETHICS IN MEDICINE ? 23 of the abortion law is desired it is necessary to en- list the co-operation of the intelligent laity.” There is a move on to relax the laws against abortion. The intelligent laity is being comman- deered to sponsor the movement. And twenty-five years is given to effect the change. Is it not likely that those regular practitioners who advance social indications and would perform an abortion for them are unwittingly the dupes of a deliberate social “re- form”? The intelligent laity!—the general popu- lace—whose average intelligence is but fourteen years, is to decide the issue in a matter most tech- nically involved and about which it will ever be most abysmally ignorant. Must the tidal wave be upon us before we will realize that water is wet and that we are in for a drenching? It is not difficult to foresee the results of this movement should it be allowed to get under way: marriage will be meaningless; the State will totter because home and family will cease to be; and the lot of womankind will beggar description. Will we lie supinely by while these purblind agita- tors take the reins and drive America through these hellish experiences ? Russia has experienced all this and Communism has had to compromise.20 Must we make compromises to it? Confraception Whatever else may be said of the leaders in the birth control movement, stupidity is not one of their characteristics. They know the sophisticated popu- lar mind and what needs to be done to engage its 24 WHITHER, ETHICS IN MEDICINE? support. When they discovered that “contracep- tion” had begun to sound a discordant note they deftly replaced it with “prevenception” as the pur- pose of their movement. The lax public conscience is rendered insensible by euphemisms. And, just as “euthanasia” is the euphemism for medical murder or suicide, “abortion” for foeticide, so are “birth con- trol”, “contraception”, and “prevenception” for sex perversion. The sexual organs subserve the functions of pro- creation and pleasure. They exist wholly in neither sex, the one being but the complement of the other. The functions are not essential to the well-being of either and they may be rightly disposed only through the mutual agreement of lawful marriage. Though procreation is their primary function it may be subordinated to the function of pleasure in a natu- ral way without doing violence to nature. But when a mechanical or chemical contrivance is interposed between the sexes the act becomes an unnatural one and is therefore perverted. Stripped of its euphem- istic dress the practice of contraception is synchron- ized bisexual masturbation. Prevalence is no indi- cation of normality: it is rather an index of our social depravity. Dismissing the moral and aesthetic objections to the birth control movement with these few remarks, let us concern ourselves with some of the sociologi- cal aspects. There is dinned in our ears and flashed before our eyes in all the pages of history the one solid foundation of all human advancement, of civiliza- WHITHER, ETHICS IN MEDICINE? 25 tion itself—Sacrifice! As it is with the nations so it is with individuals; personal interests, the sen- sual appetite, must be curbed. Children are reared in the self-sacrificing devotion of parents; the com- munity in the beneficence of the talented towards the less gifted; the nation secured in peace by the protection of the rights of the unprivileged. Char- acter is built only through self-restraint or self-con- trol. The purposes of the propaganda of the contra- ceptionists are twofold: to inform the public of the benefits of eugenic childbearing and the harm of too frequent pregnancies. But, as most of it has con- cerned itself with the description of contraceptive devices and the detailed manner of their use, the mails have been officially closed to it. Actually, that is not so; matters of contraceptive import are still distributed under the guise of “incidentals of femi- nine hygiene.” And here we may ask how is Eu- genics furthered by the indiscriminate publicity and sale of materials whose purposes are anti-genic? The denial of the mails to the contraceptionist has so hindered the progress of their movement that they have resorted to direct contact and open adver- tising in journals and stores. And, as the adult population is not responding with sufficient alacrity they are cultivating the juveniles—with more im- mediate success. And, quite incidentally, the most conspicuous displays, in some parts of the country, have been in the proximity of the high schools. And the rumor is widespread, and not unfounded, that there is an increased incidence of juvenile preg- 26 WHITHER, ETHICS IN MEDICINE? nancy and unwed maternity. It has been my own observation in this matter that, even through the depression, there has been a gradual increase in its incidence. Unwed Maternity 21 Age 1 Years | 1928 | 1929 | 1930 | 1931 | 1932 | 1933 21 and over 1 24 | 20 1 22 | 22 1 24 | 23 Under 21 1 36 | 12 1 22 | 23 1 15 1 32 Total 1 60 | 32 1 44 | 45 1 39 | 55 And as the numbers increase the spread is more dense in the earlier years. Juvenile Maternity 21 Ages 1 Years | 1928 i 1929 1 1930 | 1931 1 1932 1 1933 14 1 o i 0 i 2 1 0 1 0 ] 0 15 1 2 1 1 1 1 | 1 1 2 1 3 16 1 5 i 1 i 4 1 3 1 1 3 17 1 5 i 6 1 4 | 3 1 6 1 6 18 1 7 1 2 1 2 | 4 1 3 1 6 19 1 io i 1 i 5 1 6 1 1 1 5 20 1 7 i 1 i 4 1 6 1 2 1 9 Total I 36 JL 12 I 22 | 23 I 15 1 32 The juvenile is impetuous, in many respects un- reasonable and, much more than his age-sobered elder, inclined to the gratification of his sensual na- ture. Fear of disease will not deter him, nor, in most cases, will it persuade him to be cautious or to take precautions. An epidemic of social diseases, profligacy, and bastardy lies in the wake of this movement. And, with one exception—bastardy—what ap- WHITHER, ETHICS IN MEDICINE? 27 plies to Contraception, applies more emphatically to Sterilization. Our English brethren who have studied the problem in relation to mental deficiency report : 22 “Sterilization does not improve the men- tal condition and it does not lessen sexual activity. The unstable and antisocial defective remains un- stable and antisocial. The thief remains a thief. The erotic girl or youth will still need institutional care. The impossibility of procreation will not save them from being a social menace. ,, In the face of these conclusions the J. A. M. A. proposes that we who possess the only dependable information and knowledge of public health, shall content ourselves with standing by in an attitude of “scientific detach- ment” while these misinformed zealots enjoy a feast of human mutilations. “The medical profession can perhaps serve its purpose best by assessing the biologic and social results” 6 of the carnage. Is it any wonder that organized Medicine has lost pres- tige when, in the face of its own convictions,23 it succumbs to fantastic schemes of social betterment, following rather than leading the blind in the mat- ter of social health legislation ! The incidence of cancer is increasing and cancer of the uterus is participating in the increase. In- juries incidental to child-birth are given as a rea- son. Yet the women of the past bore many more children than those of the present day and they did not have the benefits of modern surgery. They knew little of the methods of contraception. Is it not more likely that contraception in the form of chemicals may be the responsible factor? 28 WHITHER, ETHICS IN MEDICINE? Gynecologists are concerned with the health of the female organism. Often, for social reasons alone, they institute measures to obviate the possi- bility of pregnancy. They do but cut into their co- ordinated activities as obstetricians. There were 600,000 fewer births in 1933 than in 1921 ; 600,000 fewer still in 1937 than in 1933. It is not difficult to see the ramifying results of this shortsighted pol- icy as it affects Medicine in all its spheres. Drug Topics , an organ of the pharmaceutical trade, sponsors the movement because it means $208,000,000.00 annually to the business. It is not farsighted enough to see still further when the re- duction in the birth rate will affect materially, and more deeply, the sale of other merchandise. The future of the drug trade is sacrificed for immediate profits. Nations 25 are interested in their population and of those of rival countries. France, where contra- ception is most widely practiced, and where its re- sults are most conspicuous, suspiciously eyes Ger- many whose man-power is more than 3 to her 2, and bellows for “guarantees of security”. Germany, which has taken up the movements of sterilization and birth control, in like manner watches Italy, whose birth rate and total births outnumber its own though the total population is less. And we are showing signs of concern because of the decrease here. We know that nothing can stop the ingenuity of man ; that security is to the strong ; that a falling Jbirth rate an omen of economic stagnation. Yet, WHITHER, ETHICS IN MEDICINE? 29 we blindly foster every movement that encourages it. But how does all this come about? Why is the common weal sacrificed to selfish interest? We have lost sight of fundamental principles because expedi- ency is the philosophy of our schools. Publicity and the fame that attaches to it rather than intrinsic merit are the bases of professional position and ad- vancement. Context means little. Faced by an audience of his colleagues, Prof. Thimblewit treads cautiously, presenting his own work in the name of “one.” How often have you been driven to dis- traction while listening to him speaking, let us say, on Technique: “One must choose one’s subject to one’s liking and subject it to the test of experiment. One must gather the results and arrange them so as to prove the premise with which one started the study. And, lest one overlook a pertinent detail in the unused or discarded evidence that might be con- sidered relevant by one’s critics one must draw one’s conclusions circumspectly.” There is money in Science. And the cringing press cares nil for verities if, by distortion or am- biguity, the matters of Science can be made in- telligible to the masses. And Thimblewit panders to it in anonymity : 26 “While it is true that half- wits beget half-wits and criminals beget criminals and for that reason should be made sterile the ‘black sheep’ who break the hearts of respectable parents are no longer thought to be the reincarnations of some long dead criminal ancestors.” And how weirdly and sensationally Dr. Cornish’s experiments 30 WHITHER, ETHICS IN MEDICINE ? were presented! And what sorrow and gloom fol- lowed in the wake of the news-hawk who “covered” the meeting of pathologists at which the spectacular results following the use of an adrenal extract were reported ! We have passed through many phases since the dawn of our country but none so sharply as the change in our philosophy. Washington, living in an agrarian era, retired to private life admonishing the people : “Of all the dispositions and habits, which lead to political prosperity, religion and morality are indispensable supports. In vain would that man claim the tribute of patriotism, who should labor to subvert these great pillars of human happiness, these firmest props of the duties of men and citizens.” We had heard during the past decade in which the Industrial Era reached the zenith of its physical and intellectual power, that: the old religion was dead ; the old morality was out-moded ; religion must conform to the times. And we lived it in ruthless disregard of our fellow-man, crying out with Cain : “I am not my brother’s keeper.” We have seen that philosophy extolled as rugged individualism. Roosevelt came into office beholding the ruins of this rugged individualism. His first public act as a national figure, his last as a private citizen, was to kneel before God in the Church of his persuasion to ask Him for the strength and wisdom to lead his nation aright. He has said that the money changers must be driven from the temples of finance. And he keeps on reiterating that there must be a reign of social justice. Does that sound as though the old WHITHER, ETHICS IN MEDICINE? 31 morality is dead ; or that the bells which peal out the old Faith are moss-covered or broken? The princi- ples of ethics have not changed in all the Ages past ; and they are equally valid today! BIBLIOGRAPHY 1 Leake, C. D.: Percival’s Medical Ethics; Williams and Wilkins, 1927. 2 Jones, W. H. 8: The Doctor’s Oath. 3 Sydenham, Thomas: Preface to First Edition of Med- ical Observations— ; Northwestern University Press, 1931. 4 Cushing, Harvey: Medicine at the Crossroads; J. A. M. A., 100:1567-1575, May 20, 1933. 6 Editorial : Human Sterilization in Germany and United States; J. A. M. A., 102:1501-1502, May 5, 1934. 7 These among others are the subject of the German pro- gram: Congenital Weakmindedness, Schizophrenia, Manic Depressive Insanity, Epilepsy, Chorea Minor, Grave Bodily Malformations, Hereditary Alcoholism. 8 Osler, William: Aequanimitas, Doctor and Nurse, p. 18; P. Blakiston & Sons, 1922. 9 Robinson, W. J.: Letter, J. A. M. A., 102:391; Feb. 2, 1934. 10 Straus, M. B., and McDonald, W. J.: Polyneuritis of Pregnancy; Dietary Deficiency Disorder; J. A. M. A., 100: 1320; April 29, 1933. 11 Macht, D. I., and Losee, Joseph R.: Phytopharmaco- logical Study of Eclampsia; Johns Hopkins Hosp. Bui., 46: 216. 12 Eden, T. W.: Eclampsia; J. Ohs. & Gyn. of British Em- pire, 29:386-401; 1922. Maternal Mortality and Child- bearing, Lancet, 2:998-1004, Nov. 11, 1922. 18 Cited in Clement, G.: Thou Shalt Not Kill, p. 106; Peter Reilly Co., 1930. 14 Cited in Clement, G.: Thou Shalt Not Kill, p. 77. 32 WHITHER, ETHICS IN MEDICINE ? 15 An Analysis of Maternal Mortality in California : Cali- fornia State Department of Public Health, Weekly Bulletin , Vol. XII, No. 30. 16 Personal Review, years 1928 to 1933, inclusive. Mater- nity Records, Mary’s Help Hospital. 17 Mortality Statistics, 1928, p. 14 ; United States Depart- ment of Commerce. 18 Editorial : Russian Experiences with Legalized Abor- tion; J. A. M. A., 100:341; February 4, 1933. 19 Karlin : Abortions Performed for Social Indications ; J. A. M. A., abs., 100:1212; April 15, 1933. 20 Literary Digest, March 10, 1934. 21 Personal experience with the co-operation of other mem- bers of the staff of Mary’s Help Hospital. 22 Editorial on Sterilization of Defectives ; British M. J., 1:156; Jan. 27, 1934. Departmental Committee Report; Brit- ish M. J., 1:161. 23 Editorial: Problems of Human Sterilization; J. A. M. A., 102:1609; May 12, 1934. 24 Drug Topics, Feb. 5, 1934. 25 O’Malley, A. : Ethics of Medical Homicide and Mu- tilation; Deven-Adair, 1919. 26 Why Clergymen’s Daughters Went Wrong, Science Ex- plains; American Weekly; April 8, 1934. 51 ,