BLACKWELL FAMILY ELIZABETH BLACKWELL Article "Medicine And Morality"MEDICINE AND MORALITY By Elizabeth Blackwell M. D. [Reprinted from The Modern Review, October, 1881.] London: W. Speaight & Sons, Printers, Fetter Lane. 1881. MEDICINE AND MORALITY. A SENSE of injustice will always be aroused by an indiscriminate attack upon any necessary portion of society. The Medical Profession is an essential part of the social state. Birth, sickness, and death are serious epochs of human life, when weakness and sorrow imperatively demand experienced care. If those who meet this essential want of human nature--Englishmen sharing the influences of English civilisation--could be justly accused as a class of corruption, treachery, or cruelty, it would, indeed, be a fact of direful import to our country. Having had the honour of belonging for thirty years to the Profession, I must protest against any wholesale denunciation of that Profession. Its defence, however, has been undertaken on the various counts of the indictment by able physicians, and no words of mine are needed for the purpose. It is a principle, however, which should always be adopted in seeking truth--to consider carefully and dispassionately the arguments and views of opponents. It is not only wise, but necessary, to inquire into the grounds of that charge of "dangerous tendencies" in the Profession, not only made in the attack of a contributor to the April number of this Review, but held, to some extent, by a very large body of the general public. Such an inquiry is not in any way derogatory to the dignity of the Profession, or likely to lessen the confidence of the community. Quite the contrary effect would be produced by impartia discussion. Every profession has certain A--2 4 MEDICINE AND MORALITY. tendencies which it is well to guard against. Is there no truth in the charge made against the Legal Profession of a dangerous tendency "to make the worse appear the better cause"? Is there no danger in the Clerical Profession of an undue assumption of authority, or of making churchgoing the test of Christianity? It is not by placing the Medical Profession apart from all other occupations, and claiming an unnatural and impossible exemption from injurious tendencies that the true interests of the Profession will be served. It is by bravely considering the difficulties which the Profession will rise into increasingly honorable position. The great importance to the nation of the prevalence of a high standard of mortality in the body of the Medical Profession is evident from the confidential character of the services they are everywhere called on to perform. Very few are investigators or experimenters. The great majority become the trusted friend of the family in its time of greatest weakness and need. They are brought intimately into the innermost recesses of the home, trusted unreservedly by the father to guard wife and children, trusted by the mother to give care and counsel to her boys and girls which may influence their whole future lives, trusted by the whole family with a degree of reliance given to no other person outside the home circle. This exceptional position occupied by the great body of the Profession in the relation to every family in the kingdom, high and low, is an immense responsibility of which the importance cannot be exaggerated. It makes of the Medical Profession itself, in relation to the fulfilment of this great trust laid upon them in the family and in the community, that some of the MEDICINE AND MORALITY. 5 special difficulties that which stand in the way of its fulfilment are now noted. The first danger to be noticed is the character of medical study itself in relation to those who are called on to undertake it. Medical study deals chiefly with certain classes of physical facts, and with every variety of diseased humanity. At the early age (19) when it is most desirable that a youth should enter upon these studies, the passions are strong. the judgement is unformed, and the discipline of self-control, gained through the later experiences of life, is unattained. This eager, unbalanced life, removed generally from the special influences of home, is set down in the midst of the temptations of a large city, to occupy itself exclusively with the study of one class of facts-material facts-and with the constant observation of all kinds of disease. The indispensable foundation of all medical study-anatomy-when it fails yo create reverence for the instrument of life, tends to destroy reverence. The pitiful weaknesses and diseases of human nature are brought to the student's notice through the coarse, degraded, and unromantic sufferings of the poor. There are the people with whom he has to deal-broken-down sufferers, oppressed by the unavoidable evils of their state, irritable, often unreasonable, or brutal, vicious, and reckless. These two unavoidable conditions of the medical student's career-viz., the exclusive attention given to certain classes of physical fact, and the constant observation of diseased human beings under the most degraded and repellent forms, inevitably tent to give disproportionate importance to physical facts, and to convert the sick poor into mere subjects for medical study. No one who has gone through the drill of college and hospital can fail to recognise the danger which exists in these two directions. As the character is largely formed during the period of college life, and as these youths are being prepared for the respon-6 MEDICINE AND MORALITY. sible position of intimate family advisers, it is especially necessary that elevating influences be brought to bear upon the period of medical study. The medical student, above all others, should be guarded against a narrow materialism, and against the feeling of impatience or contempt for the sufferings of the poor, and he should be imperatively required to bring the self-control and pure associations of true manhood into his confidential post of adviser of women and of youth. To recognise a danger is the first step towards overcoming it. All that is here noted is the danger that may attend medical study itself, making the necessity therefore imperative that any injurious tendency in studies, or in the conditions under which they are pursued, be guarded against by the inculcation of a high morality in medical education. Some of the principles of this morality will be referred to below. Another feature of professional life that must be noted concerns the later portion of the medical career when the engrossing cares of practical life have begun. This feature is the tendency which must always exist amongst the hard-working members of a very arduous profession, to accept without due examination the opinions of some distinguished authority on all matters which have not come under their own immediate notice. This is a very natural course arising from inability to give the time, thought, and observation necessary to the formation of independent opinion. Where any individual has proved his ability in one direction, and come to be regarded as an authority, there is an inevitable disposition to trust him in other directions. This disposition is strengthened by the influence which the Press exerts in our day. Every one is inclined to believe the statements of his newspaper; and any clever writer enthusiastically interested in upholding some particular doctrine or practice, and setting himself resolutely to "write it up" MEDICINE AND MORALITY. 7 in a number of journals, may be very sure of exercising wide influence, even if his views will not bear the scrutiny of wide and impartial investigation. Now, the great body of the Profession, often overburdened with the engrossing responsibilities of their daily occupation, although they may have little time to glance at a daily paper, necessarily make time to go through their medical journal, which is conveniently at hand in a corner of the carriage or in a coat-pocket. It is true that, in all questions which involve no moral issues-questions such as the qualities of a drug, or the symptoms of a disease, our proper course is to accept the testimony of competent observers. But whenever a question has a distinctly moral as well as material aspect, and when this distinction, clearly marked, has caused division of opinion, the case is altogether changed. There is then great danger in being guided by any advocate, however distinguished. The careful and impartial examination of all sides of a question, each one for himself is then absolutely necessary. Every physician knows the numerous sources of error which may lead an able advocate to wrong conclusions. The difficult art of statistics, which is no simple arrangement of numbers, but often requires very elaborate calculations, may lend itself to error; the neglect of some facts, or the undue prominence of others, the comparison of dissimilar conditions, or observations made on too small a scale or for too short a period-all these various conditions must be considered as sources of possible error. In every question which involves a moral problem, no man who is Christian as well as physician dare accept the conclusion of another mind. No matter how distinguished the position of individuals may be who advocate measures of disputable morality, the responsible, trusted family physician is bound to make an entirely impartial and independent investigation before sanctioning the disputed theory of the practical measure.8 MEDICINE AND MORALITY. In forming this necessary independent judgment, the guidance of fixed moral principles is of the utmost monument. Facts may be collected to support any theory, however absurd, or forced into the service of unwise practical measures. A war of details is interminable, for each side can draw upon endless sources of contrary facts to support the warfare. But a sound principle at once reduces confusion to order and leads to the victory of truth. The ethical principles, for example, Do to others as you would have others do to you; or, Never do a conscious wrong to attain a desirable end, are guiding principles of practical action, which will reduce innumerable perplexing facts to order. There are certain guiding principles which it especially concerns the Medical Profession to recognise clearly. The first principle is this, that "there are just limits to scientific investigation." The assertion that knowledge is its own independent justification, regardless of its uses or influence, and that consequently there are no limitations to the means that may be employed in acquiring it, cannot be accepted by the moral physician. Conscience, the recognition of the duties as well as rights of superior intelligence-in short, the broadest principles which our present civilisation has reached, pronounce a clear and positive judgment on this point. The religious investigator necessarily places limits on the justifiable methods of scientific investigation; the materialist investigator need place none. The second principle, which it is essential for our Profession to recognise, is the distinction which must always exist between individual and social rights. In the necessary compact which individuals make with each other when they consent to avail themselves of the advantages of society, certain restraints are willingly accepted as essential to the structure of society itself, restraints without which it could not exist. In this compact, however, individual rights are also guarded with justifiable care, the growth of MEDICINE AND MORALITY. 9 society equally demanding the free development of the individual. One fundamental right never yielded by the individual is the possession and use of his own personal faculties. This self-possession is so clearly seen to be essential to human growth, that every species of personal slavery is inevitably abolished with the advance of truth. The line is clearly marked between the preservation of society and respect for the individual. If a man injures his neighbour, he may be restrained exercised by society must be limited to the restraint necessary to secure his neighbour's safety. Society has no right to take away the independent possession of the man's own personal faculties. Again, the recognition of equal justice-that grand triumph of the Common Law, that indispensable foundation of every high and progressive society-is the most precious sanctuary of English liberty. The dispensation of even-handed justice, without regard to riches or poverty, to station, sex, or colour, is our most sacred inhertiance, appealing to all that is noble in the English heart. Of this triumph of law over ignorance, passion, and brute force, our advisers in sickness and suffering, our family counsellors -the Medical Profession-should be the powerful and faithful guardians. It is the crowning glory of law, that it especially defends the poor, lowly, and helpless. It recognises the divine element in the most obscure phase of humanity. It is the privilege of the possessors of the healing art, whose especial business calls them to sustain humanity in its most helpless condition, to be the chosen knights of equal justice to those who most need such championship. The three principles now referred to are of especial value as guiding the morality of the Medical Profession, and ensuring its highest influence in the lecture-room, the hospital, and the community generally. Their authoritative character will at once be seen by applying them to various10 MEDICINE AND MORALITY. important questions of the present day-problems which can only be solved by the guidance of true principles. The great object proposed by the Medical Profession is a most noble one, viz., to raise the standard of national health. No praise is too high to give to this great and beneficent work, which is the especial medical glory of our day, and in which the Profession in Great Britain have proved themselves leaders. This work, so well begun by the pioneers of preventative medicine-Southwood Smith, Sutherland, Nightingale, and many others whose names stand high in the list of human benefactors-is carried on with increasing zeal by a younger generation. It is essential that the light of sound principle guide this zeal. In carrying on the grand work of improving national health, extirpating loathsome disease, discovering and removing the causes of disease, the distinction must be carefully drawn between the object to be accomplished and the means by which it shall be attained. The object is a grand one; the method of accomplishing it must be equally so, i.e., it must be guided by moral principle. It is impossible to dodge physical or moral law. A great end cannot be gained by ignoble or immoral means. Unforeseen obstacles arise in such an attempt, and the object is perverted by the vicious methods employed to gain it. Thus, observation and experiment on the lower animals entrusted to our care, by those who are thoroughly qualified to conduct experiments, constitute, within certain limits, a justifiable method of gaining truth. Observation and experiment on human beings are equally justifiable, within certain limits. In the former case the limit is torture. In the latter it is the welfare of the individual observed. The power of life and death over the lower animals is entrusted to our higher intelligence-intelligence which is human, because guided by conscience. But the conscience of human beings will always lead them MEDICINE AND MORALITY. 11 to inflict the most painless possible death. Torture under no circumstances, for no purpose whatsoever, should be voluntarily inflicted on the animals made subject to our higher responsibility. This ethical limitation of scientific investigation in regard to experiments on animals has been emphatically recognised by your able writer, who indignantly condemns the unjustifiable practices resorted to at Alfort-practices resulting from the false doctrine that there are no limits to be placed on scientific investigation. Again, the present system of vaccination can only be regarded as a temporary method of meeting grave evils. That it is a preservative from the most fearful ravages of small-pox is well proved. But it is also an undoubted fact that other forms of disease have sometimes been communicated by vaccinations. The conscientious physician who has to look at both sides of the question decides unhesitatingly in favour of the practice, and recommends it to his patients. But preventative medicine always seeks to remove the causes of disease. It can never rest satisfied with the universal diffusion of a mild form of disease as its final method of preventing a severe disease. Investigation must proceed until the causes of disease can be eradicated. This true aim of investigation has been reached with brilliant results in the case of typhoid fever. The most careful, persistent, and intelligent research has furnished us with the causes of typhoid; the causes can be removed with certainty; and we may confidently look forward to the disappearance of typhoid fever in all districts governed in accordance with known sanitary laws. But the method adopted in vaccination or inoculation is of a very different character. It does not teach how to remove the causes of particular diseases, but only how to mitigate their effects; and, for this reason, no experiments or practices of such a nature can be final. To inoculate and re-inoculate sheep for rot or other formidable diseases which kill our domestic animals by tens of thousands, should12 MEDICINE AND MORALITY. only be considered as a possibly useful experiment in the present imperfect state of discovery. The effects which might be produced on the quality of thoroughly inoculated mutton as human food are still unknown. The sound instincts of people generally would certainly lead them to prefer the healthy mutton grown upon dry and breezy uplands, to that which has been inoculated with various formidable diseases in view of their prevention. Vaccination for the prevention of small-pox being then placed in its true position as a useful temporary expedient the practice may be justly adopted as an ordinary usage. As, however, it cannot be considered as a final preventative agent, since it does not eradicate the causes of disease, and as, moreover, injurious results are known occasionally to ensue to the subject of vaccination, it ought not to be inflicted by force on those who conscientiously object to it. The fundamental principle of natural right, the control of one's own person, sets the limit between wise social precaution and tyranny. A suitable fine to prevent the non-adoption of a useful precautionary measure, through mere carelessness, might be justly inflicted; but society has no right, by repeated fines and imprisonments, to try and crush out conscientious objection and inflict medical treatment on the body of any human being against his will. Any attempt to eradicate the diseases which afflict men and women alike by treating, in a small number of women only, the effects, not the causes, of the diseases, is a false method of dealing with disease, and must necessarily be futile. It involves a double scientific error. But when the cause of suffering is mutual vice, such an attempt involves something far more serious than a mistaken scientific method-viz., a moral blunder. The insidious and far-reaching effects of moral error are of vital importance to the future of any nation. Vice and disease are positive evils to be considered and MEDICINE AND MORALITY. 13 resolutely checked with a view to their final extirpation. There are right and wise ways of doing this, but such methods cannot be discussed here. It is only necessary now to point out clearly the dangerous departure from accepted principles of right, which must ensure the repeal of the Contagious Diseases Acts in a free and just nation, - a nation whose practical ability will also ensure the introduction of necessary, but wise and just legislation when those injurious Acts are repealed. The several references comprised in the foregoing remarks may explain to some extent the painful doubt which certainly exists in many minds in relation to the high morality of the Medical Profession. This doubt is not justified in relation to the great body of the Profession. The dangerous tendencies of various legislative Acts have not been brought home to the careful consideration of the general Profession -the hard-working, fully-occupied practitioners of medicine. They are an honoured and trusted portion of our English nation, sharing the intelligence and the love of justice which distinguish the nation. When the attention of this great body of the Profession is fully aroused to the broad bearing of the questions at issue, then only will they become responsible for the maintenance of any injurious medical legislation. The Profession generally will certainly never allow the fundamental basis of right and wrong to be overturned, but will strongly maintain the principles of our civilisation. From the sound and independent judgment of the Profession when slowly but fully aroused, we may look with confidence to a righteous decision on the vital questions at issue. I hope it may not appear out of place, in conclusion (as the attitude of the Profession to female students of medicine has been referred to), to offer sincere and grateful testimony to the generous aid which I have always met with in the Profession during a long and arduous pursuit of medical14 MEDICINE AND MORALITY. knowledge. From the year 1845, when a distinguished physician accepted me as his private pupil, and placed his library and best advice freely at my disposal, such generous support has never been wanting. The college class of more than 120 young men who invited my attendance, nobly redeemed the pledge of friendly aid they forwarded to me. The class of 1850-1 at St. Bartholomew's Hospital, with whom I sat in the lecture-room, and whom I joined in the clinical visits of the hospital, displayed the same true manliness. Time would fail me to relate all the acts of generous kindness received by myself, and a few years later by my sister, from the heads of the Profession in Great Britain and in France. Less favourable experience could, of course, be furnished; but the facts I have now stated are facts, generous and encouraging, and only a part of those I would gladly record. Surely it is the truest wisdom, and whilst we note errors and warn against dangers, to judge any class of human beings by their noblest actions and their highest tendencies! Elizabeth Blackwell, M.D.