unadvisable and impolitic tiling fortiori for medical officers, to bring, by any action of theirs, the question of fees before the public. There is a delicacy about the subject, which it is difficult, though by no means impossible, to explain, which is most It





for medical men, and


proper and

and should not therefore be violated with-


out strong cause. It is true that in England, and still more frequently in America, the question has been placed on the

legal right and referred to courts of justice, and such has occasionally been adopted in this country. Such proceedings do not always, we think, redound to the dignity of the profession ; and, while we should much prefer that they were not raised any where, we have a very strong opinion that in India and on the part of medical officers they are peculiarly unfortunate and unsavoury. Circumstances have occasionally arisen in this country, and in the nature of things must ever and anon arise, by which the question of remuneration for medical services has been brought to the front, and on such occasions we have considered it our duty to speak the voice of the profession on the subject. And now, when the matter has again been dragged into public prominence in Madras, though our decided inclination is to shirk the, to us, disagreeable discussion,' our attention has been so specially and pointedly drawn to it, that we feel that we should be wanting in our duty were we to refrain from recording our opinion on the merits of the case and stating the grounds thereof. The discussion in Madras has taken the form of a triangular dual, in which the combatants are the Madras Government doctors, the public, and the Madras Government?the newspapers and Medical Department performing the office of seconds. It appears that, for some reason best known to themselves, probably from a sense of unfixed or inadequate fees or both, the Madras doctors, or at any rate some of them, drew up a scale of contract and fee rates, by which they decided to guide their relations to the public as medical practitioners for the future. Somehow or other these proceedings got into the newspapers. Indeed, as the action in question concerned the public quite as much as the doctors, it is not very surprising that they should; and it was obviously in some way be made aware necessary that the public should of proceedings in which they were so closely interested. The matter seems to have attracted the notice of the Acting Governor, who took it up and referred it for inquiry to the SurgeonGeneral. The points on which the Acting Governor appears to have sought information were the truth of the newspaper rumour, the accuracy of the scale of charges as represented in the papers, and the propriety of the items iucluded in basis of a



300 this scale.


Balfour, before replying, consulted the Deputy Surgeon-General at the presidency, Dr. Van Someren, a gentleman who had himself held a prominent position as a Madras medical practitioner. The report furnished by the Surgeonset forth that, -while Dr. Balfour could not on his


information state that any common arrangement as to fee rates existed, Dr. Van Someren believed that the newsown





correct; the scale of fees published in the accepted as bond fide. He further

therefore be

papers stated that Dr. Van Someren considered the scale


one, and that it would bear rates


very fair with the

a very favorable comparison in the sister presidencies of Bengal and Bom-

Dr. Balfour himself

pronounced the scale reasonable ; was only intended to regulate emphatically the payments of such as were able to afford it, and that medical officers would, as they have always done, render their services to those who were not able to afford the fees specified in the scale," either gratuitously or with a generous consibay.

but asserted

that it


deration for their circumstances.

On this


formal Govern-

issued, ruling that the rates laid down in the were of fees scale "excessive," and that, "in all cases in which any refers for the orders of Government a question servant public ment order


between himself and neration to be


medical officer

will decide whether the ces

excessive or not."




to the proper




this subject

and, 3rd,




the conduct

2nd, proceedings of the


Government. It is


very difficult

thing to appraise

services, and peculiarly


the value of

of medical services.

professional quite im-

It is

possible to assign to them a fixed value, or treat them as a commodity ; still it cannot be denied that they possess some value, and it is absolutely essential for the mutual conveniences of employer and employed that that value should be approximately settled, and, when settled, generally known and accepted. As there is no method by which medical services can be weighed ormeasured or subjected to such exact definition that the thing can be formulated or embodied in exact laws or rules, the matter has come to depend on usage, and the sanction of the usage is a sort of social compact, which is best expressed as a mutual understanding between the doctors and the public. IIow the usage arose it is not our present object to enquire, but the usage is the only law regulating the matter, and, as society becomes more organised, such usage is apt to take the shape of a more or k-ss definite code of social law, which is generally unwritten and liable to be modified by a great variety of circumstances. We shall enumerate some of these. They are the gravity of the illness, the circumstances of the patient, the skill (and in many cases the popularity) of the practitioner, the amount of labour, attention and anxiety bestowed by him, the feelings of the patient or

his friends and the

depth of the obligation under which the weighed. Thus, a scale of fees must things a very flexible one ; and, however

latter consider themselves be in

the nature of



detailed such


scalo may

appear when



has, however,

pretty definitely

services shall be remunerated

that medical

1875. decided


prinservices; 2nd, a principle of fees for single services ; and, 3rd, a principle of special acknowledgments of exceptionally important or difficult services (cases of labour or operation). Now, considered in the light of these principles and qualifications, is the Madras scale (which will be found in detail on another page) fair or, as the Madras Government has ruled, excessive ? We are not ciples






of contracts for continuous

personally acquainted with Madras usage, but those who are so acquainted, the Surgeon-General and his Deputy, who write with authority and a sense of responsibility, pronounce the scale fair and in accordance with usage. We are, however, well acquainted with usage in this presidency, and, judged by that standard, we pronounce the scale moderate and very reasonable. The only feature in it which we deprecate is the mercenary spirit revealed in so positively declaring when payments are to be made, and laying down that remuneration for some services is to be settled by prior arrangement. The latter element we most particularly and emphatically disapprove. All prior bargaining should be religiously eschewed in cases where the cure of disease,'reparation of injury, or relief of pain is the service to be rendered. No medical man is justified in withholding his services in any case because the prior arrangement" is not to his liking. We, therefore, distinctly disown and condemn this feature of the case, and, knowing the high feeling which pervades the members of the service generally, are at a loss to understand how it crept in, unless?which is not unlikely?bitter experiences of postponed and forgotten acknowledgments found expression in this manner. Govern"

demanded is under the circumstan-


remarks on, 1st, the scale of fees ;

of the Madras doctors ;


to the latter, the Governor in Council



[November 1,

reduced to

writing, in practice it must be held as a very loose standard, and partake more of the nature of an average or mean than an exact instrument, so that doctors constantly find themselves, qua the scale, overpaid, underpaid or unpaid (very often).

ment lias, in



observe, ruled the scale to bo excessive, but

matter of this sort the voice of Government carries no

special authority or weight, and though the opinion is proclaimed a gubernatorial mandate, it cannot be held as anything else than the opinion of an individual, or, at most, a small section of the community. As this individual or section might be or become personally interested in the question, we should hardly have expected such a strong and final declaration on a question of social usage, more particularly in the face of the deliberate opinion of tho professional advisers of Government. We, therefore, feel ourselves justified in repeating emphatically, with the reservations above stated, that the scale in question is by no means an excessive one, but is on the contrary a very reasonable and moderate one. with all the force of

Now, as to the conduct of the Madras doctors, we are not in possessionof the circumstances or motives which led them, orsome of them, to agitate this delicate subject; but if tfliese were not of the most substantial and cogent character, we consider that they have committed a serious mistake in bringing the matter before the public. Their action, moreover, possesses the appearance of a combination, and this view has been somewhat viciously imputed by a Madras paper in an article which we cannot help characterising as both ungenerous and unjust iu a high degree. There are justifiable defensive combinations, however, as well as unjustifiable offensive combinations, and the apparent ''trade unionism" condemned so spitefully by our contemporary would most probably, wore the whole truth known, turn out to be really a movement of the latter sort, amply

justified by

the circumstances of tho


The mercsnary

Noyembeii 1, element, have




which appears


already condemned


in the

and, while



transaction, a posi-


judgment on the case in the absence of suffiinformation, and incline to conclude on general grounds the action of the Madras practitioners was necessitated by

tive and final cient that

circumstances which demanded

such assertion of their


rights, we would impress on the profession in India the serious responsibility which any member of it would incur towards his calling and society were he to substitute as a ruling motive for his dealings with the public any other principle than that which has ever governed them, namely, humanity. On one point in particular a caution is obviously needed, to wit, the returning of fees or the demanding of additional remuneration to that tendered. The Madras Government lias specially alluded to the first of these practices. It depends entirely on circumstances whether it is justifiable to return a fee deemed position


insufficient, a

insults the

to make




demand for more.



of this sort is offensive and wrong.


general rule, It


and it is both ungenerous and

ungentlemanly to spurn the modest acknowledgment tendered by a grateful patient unable to afford more. It is gratuitously insulting to kindly feelings which have sought substantial expression in a small pecuniary gift. But there are circumstances in which the return of a fee is justifiable. No medical man of right feeling will accept a fee, sufficient or insufficient, from a patient who is unable to afford it, and we have known men in such cases, in addition to rendering their professional services gratuitously, quietly slip a cheque under the pillow of the sufferer. Again, a medical man of proper feeling is not bound to

accept any bone which Dives may choose to cast at him off table loaded with the richest fare.

In such



he is bound

divine, to brook a positive token of contempt of himself and his calling. Such cases are, however, happily rare ; and, in all cases, if we hold humanity and a delicate consideration for the feelings of others as our paramount principles and motives in our dealings with our patients, we shall not by


law, human


often go wrong. less hesitation in




Government of India in this matter



laid down




by the They

act honorably and generpresume that the service generally will ously in their capacity as private practitioners, reserving however the right to deal with the exceptional black sheep, who may behave differently. These exceptional cases are, we have reason to know, very rare, and, with the aid and advice of its responsible

medical advisers, Government ment



where blame exists.

no difficulty in deciding inflicting suitable punish-


to their merits and

The action of the Madras Govern-

very different principle. The Acting Governor has affixed a brand of rapacity on the whole medical service in Madras by, accepting the manifesto of a few as ment




all on insufficient grounds ; " vide sufficient warrant for a formal Go-

the united declaration of newspaper,




2nd, pronouncing the scale by medical officers for professional services, in the face of the opinion of those best qualified to judge, excessive; and, 3rd, proclaiming publicly that the intervention of Government is necessary to protect the public against the exorbitant demands of the doctors. In addition to vernment resolution of this kind ; of remuneration claimed


the insult



threat that he will intervene in


Acting Governor has special cases which may be brought to his notice on behalf of the patient and against the doctor. Now Mr. Robinson has, we consider, paradoxical as the statement may appear, done both too a

in this


much and too little.

He has done too much in promulgating principle the exact opposite of that laid down by the Imperial Government; he has done too much in gratuitously insulting a whole service which has always deserved well of both Government and the public on the score of hard work, loyal service and unselfish devotion to the main objects of their calling; he has done too much in committing, while holding a brief and temporary authority, the Government of Madras to a course, which, if persevered in, must cause infinite annoyance and heart burning, and which we do hope will either be overruled by the Government of India or repudiated by his successor. He has, on the other hand, done too little in failing, while he pronounced one scale of fees to be excessive, to lay down for the guidance of medical officers, another which would not be considered excessive; he has done too little in throwing the segis of Government protection over the patient, while he denied it to the doctor ; if Government is to set itself up a court of appeal in such cases it is lound in all fairness and justice to be a

accessible to


heavily He





the recusant

has, in fine, done ''

to the other, and to come down





little in

public servants,"

authority official public to



rapacious doctor. promising the aid of his on

while he has left the outside non-

the unchecked

rapacity which

his order

exposes and proclaims. The action of the Madras Government in this matter is, on the whole, we conclude, eminently


weak and

unjustifiable. by any of the remarks which we have feeling of foolish independence on the officers. We are the servants of Government,

We would not encourage made in this article any

part of medical and may

subject impose.

to any conditions of service which Government It is to the advantage of Government, of Govern-

ment servants, of the

As regards the action of the Madras Government,




public and of ourselves that we should practice our profession privately, in addition


to permitted rendering the official service which constitutes our main duty. In the adjustment of civil medical salaries Government has effected no little pecuniary saving by permitting its officers the right of private practice and the privilege attracts a much higher class of men to India than would otherwise enter the service. The public too obtain much better and cheaper medical attention by employing service men than if they had to make their own arrangements. Extra official practice must in the nature of things be regulated more by professional than official canons, and Government has recognized this truth fully in the principle of non-intervention, except in cases of disgraceful conduct, which it has laid down. If a new principle of Government interference, wholesale insult and one-sided justice is introduced, the effect will surely be to demoralise the service, and, by adding to that feeling of discontent and dissatisfaction which has already of late been making itself known in the pages

of the Lancet, to prevent any man who retains self-

respect and has any prospect of success elsewhere from enter, ing the service. We have written somewhat lengthily on this subject, because we consider it to be one in which principles of vital importance to the welfare of our service are involved ;


302 and in tlie




presumed to record we feel sure sympathy of the whole Indian

that we carry the consent and

medical service.

[November 1,


The Medical Fee Question in Madras.

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