The doctor's competence, care and fees

A doctor who holds himself out as ready to undertake the care of the sick must have competent knowledge of his profession and must exercise his office at least with ordinary care and diligence; otherwise he will sin against justice and charity in exposing himself to the risk of seriously injuring his neighbour. Unless he is bound by some special agreement he is not ordinarily obliged to undertake any particular case, for there are usually others who are willing and able to give the necessary assistance to the sick. Even in time of pestilence he will not commit sin if he leave the neighbourhood, unless he is bound to remain by some special contract. Of course, one who acted thus would show a mean spirit, and would be justly reprobated.

He should not make exorbitant charges for his services, nor multiply visits uselessly and thus increase his fees, nor call in other doctors without necessity. On the other hand, even at his own serious inconvenience, he should visit a patient whose case he has undertaken when called as far as is reasonable, and he should be ready to call in other doctors for consultation when necessary or when he is asked to do so. He is sometimes bound by the general law of charity to give his assistance gratis to the poor who cannot afford to pay the usual fees.

I. The chief rights conferred on him by the state are these:

1. Protection against all improper interference with his professional ministrations.
2. Protection for his professional career by the exclusion of unauthorized practitioners.
3. Immunity from responsibility for evil consequences that may result without his fault from his medical or surgical treatment of patients.
4. Enforcement of his right to receive due compensation for his professional services.

These rights are not granted him arbitrarily by the state; they are founded in natural justice, but made definite and enforced by human legislation. Take, for an example, his right to receive due compensation for his services. This right was not recognized by the old Roman law in the case of advocates and physicians, nor by the common law of England until the passing of the Medical Act in 1858. Surgeons and apothecaries could receive remuneration for their services, but not physicians. These were presumed to attend their patients for an honorarium or honorary, that is, a present given as a token of honor.

Certainly, if Doctors by common agreement waived their right to all compensation, or agreed to be satisfied with any gift the patient might choose to bestow, they would be entitled to honor for their generosity; but they are not obliged to such conduct on the principles of natural justice. For by nature all men are equal, and therefore one is not obliged, under ordinary circumstances, to work for the good of another. If he renders a service to a neighbor, equity or equality requires that the neighbor shall do a proportionate good to him in return. Thus the equality of men is the basis of their right to compensation for services rendered. The physician’s right to his fee is therefore a natural right, and on his patient rests the natural duty of paying it. Not to pay the Doctor’s bill is as unjust as any other manner of stealing.

As to the amount of compensation to which the Doctor is justly entitled, Ewell’s “Medical Jurisprudence” remarks: “By the law of this country, all branches of the profession may recover at law a reasonable compensation for their services, the amount of which, unless settled by law, is a question for the jury; in settling which the eminence of the practitioner, the delicacy and difficulty of the operation or of the case, as well as the time and care expended, are to be considered. There is no limitation by the common law as to the amount of such fees, provided the charges are reasonable. The existence of an epidemic does not, however, authorize the charge of an exorbitant fee.

“A medical man can also recover for the services rendered by his assistants or students, even though the assistant is unregistered; it is not necessary that there should be any agreed specified price, but he will be allowed what is usual or reasonable.

“It is not the part of the physician’s business, ordinarily, to supply the patient with drugs; if he does so he has a right to compensation therefor. If the agreement is “No cure, no pay,” he cannot, however, even recover for medicines supplied, if the cure is not effected. His right to recover for professional services does not depend upon his effecting a cure, or upon his service being successful, unless there is a special agreement to that effect; but it does depend upon the skill, diligence, and attention bestowed” (pp. 3 and 4).

Further details on this point belong more properly to the lecturer on Medical Law. We are now concerned with the principles underlying special legislation. The main principle regulating all compensation is that there shall be a sort of equality between the services rendered and the fee paid for them. Ignorant people sometimes find fault with the amount charged as a Doctor’s fee. There may, of course, be abuses by excess; but men have no right to complain that a Doctor will ask as much for a brief visit as a common laborer can earn in a day. This need not seem unfair if it be remembered that the physician had to prepare, during many years of primary, intermediate, and professional studies, before he could acquire the knowledge necessary to write a brief prescription. Besides, it may be that his few minutes’ visit is the only one that day; and yet he has a right to live in decent comfort on his profession together with those who depend on him for support.

We must, however, remember, on the other hand, that excessive fees are nothing else than theft; for theft consists in getting possession of another’s property without just title. The following rules of Dr. Ewell are sensible and fair:

“The number of visits required must depend upon the circumstances of each particular case, and the physician is regarded by the law as the best and proper judge of the necessity of frequent visits; and, in the absence of proof to the contrary, it will be presumed that all professional visits made were deemed necessary and were properly made.

“There must not be too many consultations. The physician called in for consultation or to perform an operation may recover his fees from the patient, notwithstanding that the attending physician summoned him for his own benefit, and had arranged with the patient that he himself would pay.” (This, of course, does not mean that the practitioner has a right thus to shift the burden of pay from his own shoulders.) “Where a medical man has attended as a friend, he cannot charge for his visit. Where a tariff of fees has been prepared and agreed to by the physicians of any locality, they are bound by it legally as far as the public are concerned (that is to say, they cannot charge more than the tariff rates), and morally as far as they themselves are concerned” (p. 5).

In these rules Dr. Ewell regards chiefly what conduct the courts of justice will sustain. It is evident that the Doctor is never entitled to run up his bill without any benefit to his patient; where there is no service rendered at all, there can be no claim to compensation. Still it is not necessary that actual benefit has resulted to the patient; it suffices for the claim to the fee that measures have been taken with a view to such benefit. Even when no physical advantage can reasonably be hoped for from the visit, the consolation it affords the patient and his friends may render those who are to bear the expense fully willing that it should be often repeated and, of course, charged on the bill. Provided care be taken that they understand the situation, no injustice is done them. “Scienti et consentienti non fit injuria” is a good moral maxim.

1. He must acquire and maintain sufficient knowledge of his profession for all such cases as are likely to come in his way. No Doctor has the right to attempt the management of a case of which he has not at least ordinary knowledge. In matters of special difficulty, he is obliged to use special prudence or ask for special consultation. The courts justly hold him responsible for any serious injury resulting from gross ignorance; in such cases they will condemn him for malpractice. I would here remark that, in an age in which the science of medicine is making such rapid progress, every Doctor is in duty bound to keep up with the improvements made in general practice, and in his own specialty if he has one.

2. A second duty is that of proper diligence in treating every single case. Many a patient suffers injury to health or even loses his life in consequence of a Doctor’s neglect. Gross negligence is an offence that makes him punishable by the court, if it results in serious injury. But even if such injury cannot be juridically proved, or has been accidentally averted, the moral wrong remains and is to be settled with the all-seeing Judge. Still, in ordinary ailments, no one is obliged to take more than ordinary trouble.

378. State of the question. - To physicians and surgeons there has been committed the office of protecting life and bodily health. Whence a) from justice they can be held to bodily care as from their proper office or from contract; - yet on the occasion of the exercise of this office, b) from charity they can be held to caring for the spiritual or temporal good of the sick, or also c) they can unjustly injure and damage in temporal things, namely by reason of expenses or harm. Concerning these things one must now speak specifically.

379. As regards bodily care, three principles must be attended to by physicians:

I. That they have sufficient skill in their art, at least ordinary skill, namely, for the cases which usually occur among them; otherwise they expose themselves to the danger of inflicting irreparable damage on the sick or wounded, and for that cause they can be obligated to restitution. From justice those are held to having knowledge and skill who have obligated themselves by a prior contract; but others are held not to exercise their art without sufficient skill, unless in a case of urgent necessity, when another is lacking.

Hence 1) physicians who wish to fulfill their office faithfully should not cease to apply themselves to study, because medical science and surgical art progress much.

2. In more difficult cases, if they doubt concerning their own skill, they ought to call in a more skilled physician, taking care that the sick person or his family consent to this; indeed even at their own expense, if it were necessary and he himself were ignorant of matters to be known by ordinary knowledge.

3. Those who lack sufficient knowledge are bound under grave obligation to acquire it, and meanwhile to abstain as far as possible from the exercise of the art, or to invoke the counsel of one more learned.

II. That they employ diligence proportionate to the gravity of the matter which is committed to their care. A physician who has been hired from contract or from a stipend accepted or promised is held from justice; otherwise he can be held from charity, even under grave obligation, in a case of grave necessity, if another is lacking and he himself can help without grave inconvenience; but if he undertakes the care, he is now held from justice, as from a contract tacitly entered into. And indeed:

1. He who has been hired by contract or stipend a) must hurry morally as soon as possible at any hour of day or night, even with grave inconvenience to himself, unless he certainly knows that from delay no damage will follow for the sick person; b) even in time of contagious disease he cannot desert the sick person.

2. He who has undertaken care of the sick person without a prior contract, a) is held to help the sick person in the better and more certain way in which morally he can; b) nor can he desert him, even if the disease becomes contagious, unless another is found who will take care of him.

3. He who, in employing ordinary diligence proportionate to the gravity of the matter, is notably negligent, sins against justice and is held concerning damages.

III. That they not use illicit means for procuring health. From justice safer remedies are to be employed, namely certain ones if they can be had; otherwise those which are more probably less dangerous and harmful, and more and more quickly profitable.

Hence 1) it is illicit, secure means having been left aside, to try uncertain ones.

2. When certain means are lacking, doubtful ones can be employed, provided that they are harmless; and they must be employed if the safety of the sick person is despaired of.

3. Indeed, when other means are lacking, remedies doubtfully harmful but probably profitable can be employed, if the safety of the sick person is despaired of; otherwise, lest death be accelerated, the matter is to be committed to nature, which by no means rarely lifts itself up. In these cases, namely, there must be proportion between the harm which is feared and the good which is hoped for; but even then a dangerous or extraordinary remedy generally is not to be employed without the consent of the sick person, at least presumed.

4. It is illicit to test a new remedy, even one that will profit others, with probable danger to health or life, not even with the consent of the sick person: for he is not lord of his life, nor are evils to be done so that goods may come to others. Unless perhaps there were only the danger of a lighter damage which could easily be repaired, and the consent of the sick person were added.

5. A physician must altogether abstain from illicit remedies and operations, of which kind are the direct procurement of abortion even to save the mother, - remedies of sterility even for preventing dangerous childbirth, - craniotomy, - the use of morphine, opium, cocaine, etc., in that way and degree in which these harm the body or mind, - imprudent or harmful use of hypnotism, - a dangerous operation done without a proportionately grave reason. In so great a proclivity as exists today rashly to perform whatever surgical operations and to employ doubtful and harmful remedies, especially in hospitals of the poor or of infants, physicians easily offend against justice, so that they are held to repairing damages.¹

¹ Noldin, Th. M. II, d. 744.

6. Finally, a physician sins gravely who, without true necessity or manifest utility, inspects or touches the genital organs, especially of women, because he abuses his office; he also sins more gravely who gives to the sick counsels which are directly opposed to the law of chastity, such as of performing onanism, pollution, fornication.

380. As regards the spiritual or temporal good of the sick: By natural law and by the grave precept of charity, the physician is held, either by himself or through another, to warn a sick person in danger of death concerning the sacraments to be received at an opportune time and concerning temporal affairs to be arranged, at least if the warning is necessary: for from charity he is held to remove grave evil from his neighbor, if he can without grave inconvenience.

Hence 1) if others could not or would not warn the sick person, or if the sick person would not believe them warning him concerning the danger, the physician himself by himself is held to warn him.

2. Yet he would be excused from warning if he knew with moral certainty that the sick person was in the state of grace and already had arranged temporal affairs, or was so hardened in impiety that even warned he would not wish to be converted: this can only very rarely be affirmed with certainty.

3. The physician also ought to warn the family, so that provision may be made more safely for the spiritual and temporal good of the dying person.

Formerly by ecclesiastical law, namely by decree of Lateran Council IV (1215), afterwards again confirmed by Pius V (8 Mar. 1566), it was prescribed to physicians that they should not undertake the care of one dangerously lying sick unless by warning him concerning confession to be made, and, if he had not confessed within three days, they should abstain from visiting. Yet the law was never received everywhere, and where it was received, it is now abrogated.

381. As regards expenses: From justice the physician is held to beware of useless expenses and of excessive stipends to be demanded.

A stipend, according to justice, must not only be sufficient so that according to his condition the physician who exercises his art and gives his powers for the greater part to medical care can live; but it can be rather great, as is clear from the importance and utility of those things concerning which he has care, from the breadth of the knowledge and skill required which is acquired only by longer study and great expenses, from the great responsibility at the same time and the dangers to which he is sometimes exposed. But the stipend can be increased when an accidental circumstance is given: a) by reason of greater distance, longer time, multiplied visitation, or special care or operation; b) by reason of more excellent or extraordinary skill, which is not usually acquired except by increased studies and expenses; c) by reason of special danger, to which, in a more difficult case, the reputation of the physician is exposed.

But in determining the stipend, a double measure can be attended to of itself: for either the common estimation can establish it proportionately to services furnished according to those things which we have handed down here; or also it could have it not as compensation according to equality, but as a contribution to the honorable support of the physician, so that for the same care less would be paid by persons of lesser condition, more proportionately by those who are of better condition. Now even according to this measure a stipend is justly established, provided, however, that a price excessive is not demanded from the rich, nor the salary according to the other measure defined by an association of physicians or by common estimation: for no one is judged to wish to grant a price greater than is customary.

Hence 1) the physician sins who for the sake of gain institutes useless visits or prescribes superfluous remedies, unless the sick person desires it or it is necessary for procuring health by such suggestion; who without necessity calls in other physicians or prolongs treatment longer; who performs useless or too dangerous operations for the sake of gain; or demands too great a stipend.

2. A physician cannot demand a stipend greater than ordinary, with the circumstances of places and persons considered. But if extraordinary services are sought from him, such as a difficult surgical operation which supposes singular skill, he cannot demand whatever price according to his pleasure, but that which, with account taken of labor, difficulty, etc., has proportion with the stipend which the most skilled are accustomed to demand.

3. From charity he ought to care gratis for the poor constituted in necessity, namely, in extreme necessity even with grave inconvenience; in grave necessity without grave inconvenience; in common necessity, if he conveniently can, at least when others are lacking.

It is better that a physician abstain from all means little worthy or less right, which smell of cupidity, and easily furnish occasion for abuse.²

² He who desires more on these arguments should consult Salsmans, Geneeskundige Plichtenleer, deontologie medica, in which various practical cases are considered.