The CHAIRMAN. Yes, in some industrial plants they have developed some excellent plans, of course; notably the Kaiser system on the Pacific coast; and they have, of course, in the mining areas like in Colorado; also, they have plans there to take care of employees working in mines; but they do not take care of their families, those plans; is that no true?

Dr. Low. They do take care of their families under a reduction in hospital rates as well as fees.

The CHAIRMAN. What is the extent of the reduction in the hospital rates?

Dr. Low. The hospital rate is one-half the private rate.

The CHAIRMAN. And also the medical rates are reduced?

Dr. Low. The medical rates are reduced approximately one-half. The CHAIRMAN. One-half.

Dr. Low. Surgical fees, and obstetrics, and medical care.

The CHAIRMAN. Still, of course, they have cases where for a large family having a great deal of sickness it would be a burden, even at half rates?

Dr. Low. Sure, but they could pay it off on pay roll deductions the same as under this proposed plan.

The CHAIRMAN. Yes, they could borrow money to pay it off or pay it in deferred payments?

Dr. Low. Senator, they have to pay these other things they have contracted for in advance-automobiles, iceboxes, and all that sort of thing.

The CHAIRMAN. But the expenses for medical care come sometimes when you are least expecting it and you have not budgeted for it, and it is sometimes quite difficult for them to pay it, and it embodies a debt, and sometimes continues as a burden over their heads for a number of years thereafter. We have carried on some studies of situations of that kind.

For instance, the New York Times publishes each year a list of the hundred neediest families, and those cases have been analyzed and it is found that largely their condition is due to the fact that they become involved in debt through sickness, illness in their family, at some stage of their lives which has followed them through and has finally placed them in a situation where they have become members of the hundred neediest cases in New York.

Thank you very much for your statement here, Doctor. I appreciate your presence.

Dr. Low. Thank you, sir. May I please ask permission to incorporate a statement of the secretary of this association, Dr. Frederick B. Exner, as a matter of record?

The CHAIRMAN. All right.

(The statement referred to is as follows:)

STATEMENT TO THE COMMITTEE ON EDUCATION AND LABOR OF THE UNITED STATES SENATE IN THE MATTER OF SENATE BILL S. 1606, A BILL TO PROVIDE A NATIONAL HEALTH PROGRAM

The bill under consideration has become the focal point in the struggle between two factions, both interested in providing the best possible medical care to the people of the United States. On the one hand we have those who would jettison our entire system for the distribution of medical care and would create over night a new system calculated to eliminate at one stroke all those factors which have

prevented too many people in this country from obtaining the med : need. On the other hand we have those who insist that we retain t aspects of our present system which they know to be necessary to a for our ability to provide the best medical care in the world to able to obtain it.

While charges of dishonesty, insincerity, and ulterior motives have b by both factions, it must be admitted by any reasonable person that are composed of honest, sincere, and intelligent persons who are in his own way, to promote better medical care for the people. T case, it seems strange that the two groups cannot achieve more some degree of cooperation toward the common goal. The fact that do so is due in part to mutual distrust and intolerance. Underlying ever, there has been a basis lack of acceptance and understanding y of facts, principles, and necessities which appeared central, basic, ani to the other.

Recently the second faction, which centers in the medical pro realized the importance and force of the matters which seemed others, and have been promoting a compromise in the form of volu medical care under the control of the physicians. This may r compromise, and may not even prove satisfactory, but it represe step by either side toward a solution of the dilemma, and I believe it given a full trial before being dismissed as unsatisfactory. In fact that the first attempt at a realistic compromise has come fr would seem to indicate that it is easier to teach economics to det teach the facts of life regarding medical practice to economists, soc idealistic reformers.

Meanwhile the first faction are not only unwilling to offer or se mise, but seize upon the willingness of the doctors to compromise as of weakness and are less willing than ever to admit any weakness position. They are bending every energy toward the passage of Se which would effectively destroy, once and for all, the practice of profession and impose upon the physician the status of a technician

It is easy to cry, and to deny, charges of "regimentation," " but until the accusation is based on something more substantial the prejudice, and the denial is based on something more substantial that worded expressions of good intentions in Senate bill 1060, neither 1* sidered seriously as an argument.

The total effect of the bill must be considered in the light of the medical practice, rather than relying upon isolated pharses which direct conflict with other provisions of the bill and are at best er pious hope, comparable to a provision that the sun shall always ris after tomorrow; and often miss completely the point that they to cover.

An example is to be found on page 47, where we are told that; (f)% of administration, including the methods of payment to practi5* (2) promote personal relationships between physician and pate the only provision in the bill designed to safeguard the doctor-p ship. It should be fairly obvious that whoever wrote this pr very clear idea of how, or even whether it could be carried out; and merely introduced as a defense against the inevitable criticism that! destroy the essential "doctor-patient" relationship. This is especial you note that this is the only place in the bill where even a gestar toward preserving that relationship.

It should also be clear that the one who wrote this clause either d or did not want others to know that the essential aspect of the e relationship is not one of "personal relationships," but of pers and responsibility. The personal relationships of friendliness, gen cooperation, and mutual liking and respect are important and measurably to good medical care, but they are of very minor impor pared with the "fiduciary" relationship, which the courts for recognized as the central fact in the doctor-patient relationship negated by almost every provision regarding medical care in 8. 1

When the bill as a whole is evaluated it must be solely in ter on the well-being of the individual patient. This does not mean its "public" or on any theoretical and abstract "economic man" or, per cally needy man" who forms the unit of the public. It means each p personalized and unique individual.

hare things which we do to people as units of the public, to safeguard or heir health or that of the "public." These are "public health" activities ง 4 proper governmental function. They include those things which are eople because they are people and without regard to individual needs arities. They include such things as vaccination, tuberculosis caseodization of water supplies, quarantine, etc. We need much more and ry divity in these and many similar fields. These are matters which perLanezh degree of standardization and permit a uniform product of which și buy as much and as good quality as you are able and willing to pay for. known that the scourge of tuberculosis could be completely eradicated 15 years if every person had a chest X ray yearly and the enses found d for. In spite of this we have not X-rayed more than a small fraction pulation once, much less once a year Still the proponents of this bill you that one of its incidental benefits will be that everyone will have ly a chest film, but a complete physical examination at least once a year, ↑ they will tell you how the bill will benefit the pellagra ridden. South, thought for the fact that pellagra is a dosense of poverty and malnutrithat no amount of medical care can substitute for a decent standard of B.ll 8 1606, however, does not propose to provide mereiy “pubije health "oper care of an individual sick patient however, is a totally different This is a matter which defies standardization No one except the doctor examined the patient knows what the patient needs or what he should ve done to him. The patient does not know, or he wouldn't have gone to or in the first place. Another doctor cannot know unless he, too, has d the patient Certainly a lay social worker or administrator ennnof he could qualify as a doctor There is no possib'e way in which the n know what he shou'd do or have done except to take the word of the He is under the comp Ision of his illnes of fear of illt ess to entrust Be health to the hones y and judgment of the doctor he selects – He may, shes, shop around and get opinions from several doctors, but still all lo is decide which doctor he will trust, or device to trust none of them ***d on himself, his neighbor, or his grandmother. The trust is inescahe is to have a doctor.

f his arises the "duciary" nature of the relationship between the doctor patient. When the doctor necepts a patient he says, in effect. "I accent ist and the responsib lity which it entails. I ag.ve to act in your behalf intters pertaining to your health in accordat ce with your best interests, ing nothing to interfere with the full and honest pe forri nce of what best for you, and admi:ting no prior or superior oblig tions of a connature"

mpiled agreement is not a fliment of the Imagination and is net to be od "Ght v~ It is recognized by co arion law both of Englued and Atuerici, "he statutory Liw of most States as inspor ble from the practice of any varned professions – Padicit e, the law, and the navastry The pesnice professional responsibility is what dist nzur hes the practitioner of a from an arti-an, eräftst: an, or technician The pr. etitioner who This trust is deemed gyalty of midpractice and is 1«b'e for dian ages to i“༄s! ༈ **སཱ The State undert; kes through i'w licensing laws to assure - who profess themselves learned in mi tiers of both and who held es ont as waờng and, ble to accept this trist, which be both; trus work, y vent to fu'till it Your right to be a carpenter will not be rescinded of moral turpitude, but your lense to pactice med cine or law will,

piled promise cannot be n'ade in good faith however, if the plexi-lan etan u position where a third party can dictate what he tiỷ or luhy not • patient This he goes when he acts as "be erupi over or agent of aer r than his pit ent Again this is recognize 1 by the law both commen cutory, in the almost universal agroen eat that a pr. ctitioner my tot his profession as the et plovee or agırt of a cerporation or an unitest sed If such a course were wonctioned the legicd ren't would be that to atd bastess partnerships/mcht practice Liw, medicine, dentistry, other profession by the simple expedient of employing licensed a, er tæ *wore porn.ifted professional standards would be practically destroved, ** of 8 requiring special training wou'd be comittere.alized to the The eth es of any profession is based upon personal or inresponsibility One who practices a profession is responsible directly

prevented too many people in this country from obtaining the medic need. On the other hand we have those who insist that we retain the aspects of our present system which they know to be necessary to arr for our ability to provide the best medical care in the world to th able to obtain it.

While charges of dishonesty, insincerity, and ulterior motives have✨by both factions, it must be admitted by any reasonable person that b are composed of honest, sincere, and intelligent persons who are w in his own way, to promote better medical care for the people. T case, it seems strange that the two groups cannot achieve more ba some degree of cooperation toward the common goal. The fact that do so is due in part to mutual distrust and intolerance. Underlyi ever, there has been a basis lack of acceptance and understanding bị of facts, principles, and necessities which appeared central, basic, and to the other.

Recently the second faction, which centers in the medical pris realized the importance and force of the matters which seemed b others, and have been promoting a compromise in the form of volum medical care under the control of the physicians. This may not compromise, and may not even prove satisfactory, but it represe step by either side toward a solution of the dilemma, and I believe given a full trial before being dismissed as unsatisfactory. In fact that the first attempt at a realistic compromise has come from 'i would seem to indicate that it is easier to teach economics to doc teach the facts of life regarding medical practice to economists, soc idealistic reformers.

Meanwhile the first faction are not only unwilling to offer or a mise, but seize upon the willingness of the doctors to compromise as of weakness and are less willing than ever to admit any weakness position. They are bending every energy toward the passage of Se which would effectively destroy, once and for all, the practice of profession and impose upon the physician the status of a techniciat

It is easy to cry, and to deny, charges of “regimentation," "mis but until the accusation is based on something more substantial th prejudice, and the denial is based on something more substantial than worded expressions of good intentions in Senate bill 1060, neither sidered seriously as an argument.

The total effect of the bill must be considered in the light of the medical practice, rather than relying upon isolated pharses which a direct conflict with other provisions of the bill and are at best e pious hope, comparable to a provision that the sun shall always rise after tomorrow; and often miss completely the point that they wen to cover.

An example is to be found on page 47, where we are told that: (f) T of administration, including the methods of payment to practiti (2) promote personal relationships between physician and patient the only provision in the bill designed to safeguard the doctor-pa ship. It should be fairly obvious that whoever wrote this pie very clear idea of how, or even whether it could be carried out; and merely introduced as a defense against the inevitable criticism that t destroy the essential "doctor-patient" relationship. This is especial you note that this is the only place in the bill where even a gestur? toward preserving that relationship.

It should also be clear that the one who wrote this clause either or did not want others to know that the essential aspect of the relationship is not one of "personal relationships," but of person.* and responsibility. The personal relationships of friendliness, gent

cooperation, and mutual liking and respect are important and co

measurably to good medical care, but they are of very minor impr pared with the "fiduciary" relationship, which the courts for ce recognized as the central fact in the doctor-patient relationship. negated by almost every provision regarding medical care in 5. 10 When the bill as a whole is evaluated it must be solely in terms on the well-being of the individual patient. This does not mean its "public" or on any theoretical and abstract "economic man" or, pe

cally needy man" who forms the unit of the public. It means ench pa personalized and unique individual.

are things which we do to people as units of the public, to safeguard or heir health or that of the "public." These are "public health" activities mama proper governmental function. They include those things which are to people because they are people and without regard to individual needs arities. They include such things as vaccination, tuberculosis caseodization of water supplies, quarantine, ete We need much more and tivity in these and many similar fields These are matters which pergh degree of standardization and permit a uniform product of which buy as much and as good quality as you are able and willing to pay for. i known that the scourge of tuberculosis could be completely eradicated 15 years if every person had a chest X ray yearly and the enses found ed for. In spite of this we have not X-rayed more than a small fraction pulation once, much less once a year Still the proponents of this bill you that one of its incidental benefits will be that everyone will have ly a chest film, but a complete physical examination at least once a year. r they will tell you how the bill will benefit the pellagra-ridden South, thought for the fact that pellagra is a disense of poverty and malnutrithat no amount of medical care can substitute for a decent standard of Bill S. 1606, however, does not propose to provi je merely “pubite health roper care of an individual sick patient however, is a totally different This is a matter which defies standardization. No one except the doctor exat dined the patient knows what the patient needs or what he should ve done to him. The patient does not know, or he wouldn't have gone to or in the first place. Another doctor cannot know unless he, too, has # the patient Certainly a lay social worker or administrator ennnot he could qualify as a doctor There is no possible way in which the - know what he shou'd do or have done except to take the word of the He is under the corope Ision of his fines or fear of illness to entrust and health to the hones, y und judgm- nt of the doctor he selects. He may, shes, shop around and get opinions from several doctors, but still all lo is de ide which doctor he will trust, or device to trust none of them end on himself, his nel, hbor, or his grandmother. The trust is inescahe is to have a doctor.

【 this arises the "fiduciary" nature of the relationship between the doctor Latient When the doctor neeepts a patient he says its effvet" "I accent ist and the responsibility which it entails. I agove to net in your behalf atters pertaining to your health in accordar ce with your best interest, g nothing to interfere with the full and honest pe formance of what best for you, and admiting no prior or superior ob igctions of a connature"

to

mpiled agreement is not a fl.ment of the imagination and is not to be d''ightly. It is recognized by co amon law both of En,led and America, The statutory law of most States as insepat b'e from tue pra tice of any erned professiotis medicite, the law, and the ministry The pestice professional responsibility is what dist nêm hes the practitioner of a an from an artisan, etafstean, or technician The pt. ettioner who This trust is deemed guilty of milprit. Pées d is 1 b'e for d Led party. The State undert; kes, 11 rotgh its levneity laws to a**thle - who profess themselves learned in the Pets of berth and who beid ༄་།། ངེས Wu ng and, ble to acep! this trist, shali be boil, trus wifi V ent to fulfill at Your right to be a carper for wit not be testit de l f moral turpitude, but your bevnse to pactice medicine or law w II, 1

nded promise cannot be made in good faith however, if the p2 vsi dan lin at position where a third party can dictate w},' he toxỷ or pass not Patient Th ́s he goes when he acts as the cupcover of dg nt of any For than his patient Again this is recog, padd by the law bith common tatory, in the altuost u iversal agreeme at that a prrctitioner m s hot his profession as the er sp oyee or 92nt of a corporation or in up" oer sed If sn ha corse were sanctioned the logical rexgif wond be that tes it d business partnerships m„17 practice law, ncdicine, dentistry, her profession by the simple expslient of et ploying licensed agents, * were permitted profesional standards won:d be practically destroyed, * «slots requiring special training wou'd be cotaflete c'ized to the Hehr ment The ethics of any profession is based upon personal or inresponsibility One who practices a profession is respons b'e directly