THE PLACE OF THE HOSPITAL IN A CIVILIZED COMMUNITY
Authors: L. E. Shaw
Journal: BMJ (1911)

All around us we see the clearest indications that great dissatisfaction exists with regard to the means at present available in this country to meet the requirements of considerable sections of the community who are in need of medical assistance. This dissatisfaction is expressed with almost equal strength on behalf of the public, large numbers of whom are said to fail to obtain the help they ought to have, and on behalf of the medical profession, many of whom are stated to be overworked and underpaid. The two-sided nature of the complaint may perhaps be regarded as a hopeful sign by those who have faith in the possibility of ultimate improve ment. The wrongs of a small class, such as a section of the medical profession, would be difficult to right if the community as a whole was unable to recognize that wider interests were involved, nor would the public easily secure the reforms which it regarded as desirable in its own behalf if it were faced with the apathy or resistance of an entirely satisfied profession. Whether the prospects are hopeful or not for a speedy and thorough removal of these unsatisfactory conditions, there are sure signs of impending changes m many directions. The great interest aroused all over the country by the reports of the Poor Law Commission and by the attempts of the authors of its two main sections to secure public sympathy with their particular views, is already compelling many changes such as can be effected by departmental regulation, and must shortly result in extensive legislative action. The present Government's promised scheme for insurance against sickness and invalidity will profoundly alter the conditions under which vast numbers of the working classes will find themselves when in need of medical aid. If one may judge from previous experience, the probability is that in accordance with the spirit of our people, such changes as are made will be effected in this or that direction as urgent necessity demands, or as some point of little resistance allows, with no very clear idea of fitting Hhe various items into an effective and harmonious whole. This prospect makes it all the more desirable that sections of the community who have special knowledge and experi ence of various departments of work connected with health questions should lose no time in evolving for themselves a clear conception both of the general problem before the nation and of the relation of this general problem to its component parts, and of these several parts to each other. The medical profession must not only make up its mind as to the direction in which it desires reform to be guided in order that its own independence and power for good work shall be maintained, but it must take steps to make clear to the public the practicability and sanity of its proposals. Many sides of this broad question are now under the consideration of the British Medical Association and are dealt with in the exhaustive report recently issued to Divisions on the organization of medical attendance on the provident or insurance principle. To-day I propose to consider the small part only of the question indicated by the title of our discussion? The Place of the Hospital in a Civilized Community. If we desire to reach an agreement on this question we must clearly not differ very widely as to our general views of the aims of our civiliza tion and the functions of a hospital. I do not think I ?hall have much difficulty in securing your acquiescence in four propositions with regard to the hopes and duties of a modern civilized community which are relevant to our present inquiry. Proposition I. That no commwnity can regard itself as civilized which does not recognize a com?non duty to render [ medical assistance to those of its members whose condition of health makes such assistance necessary and whose  economic position does not enable them to secure it. I To agree with this proposition we need not be prompted ? by identical motives. To some the chief motive will be sympathy with suffering, to others the prevention of race degeneracy, and to others again the maintenance of the economic fitness of the present workers of the nation. With such a variety of motives impelling us there is little fear that this proposition will be unacceptable save to an insignificant number of quite peculiar individuals. Proposition II. That it is undesirable for any civilized community, as at present organized, to provide without cost medical assistance for all its members regardless of their economic position. The words  as at present organized  are introduced in order to enable this proposition to be acceptable to any of our friends with advanced collectivist views. I would ask such to recognize that we are dealing with things as they are, and not as they may be in the distant future. Proposition III. That every civilized community should encourage its members to make provision by some method of mutual insurance against those insurable risks which without such assistance they are unable to meet. As a general principle this is not likely to be denied to-day. There are few, if any, who agree with the view of the considerable number of our forefathers who regarded life insurance as an immoral means of cheating Provi dence. To accept this principle does not commit us to approval of Pluvius policies for holiday makers or other extravagances of insurance not far removed from gambling, nor does it indicate sympathy with the proposal that the State should actively take part in the business of insur ance. 0 I ask your acquiescence merely in this general principle, and shall of course later apply it to the concrete and reasonable example of the provision by methods of mutual insurance against the costs of medical assistance. Proposition IV. That in every civilized community specialization of effort is essential to effective performance. This proposition will be recognized as having a strict relation to my subject. Please note that this does not say the greater the specialization the more effective the per formance. The great principle that one can have too much of a good thing applies in civilized communities as well as in those not yet weaned from cannibalism. We in the medical profession are not likely to fail to recognize the possible evils of excessive specialism. For the pur poses of my argument I find it necessary to emphasize the fact that specialization means not only that certain indi viduals or institutions are recognized by the community as being set apart to do certain things, but that they are also recognized as being set apart not to do other things. To use a dentist to shoe horses is as great a neglect of our principle as to use a blacksmith to pull out teeth. The dentist maybe able to shoe a horse and shoe it well. From the point of view of the community, however, it is an extravagant disregard of an important principle. It is a principle which must be considered in defining the proper work of an institution as well as of an individual. Later I shall hope to show that this principle is disregarded in our modern method of using hospitals, and to indicate the necessity of paying strict attention to it if we are to succeed in assigning a proper place to these institutions. I must now ask you to allow me to leave these four propositions for a time and to submit to you certain con siderations with regard to the fundamental ideas under lying the true functions of a hospital. It must at the outset be recognized that there are several distinct aspects of hospital work, none of which can be neglected if we are properly to understand how best to use and develop these institutions. These various aspects may be briefly defined as the charitable, the economic, and the scientific. So closely intertwined have these different functions become that it is difficult to isolate them from each other. But I wish to emphasize what I believe to be the fact?that even if we could imagine a civilized community from which all poverty and need of charity were eliminated, so that every one could obtain by adequate payment all that he required in the way of medical assistance, a hospital would still be as necessary an institution as a road or a train or a school. No intelligent community would be