The Doctor's Dilemma
By Avinash Patra, Sr. | June, 26 2015
George Bernard Shaw let it be known that he wrote The Doctor's Dilemma in 1906 to meet a challenge from his friend, the theatre critic William Archer. Archer had claimed that GBS could not be regarded as a supreme dramatist until he had written a tragedy involving "the King of Terrors" – death. Shaw responded by writing an extravagant burlesque, which carried his cast of medicine men to the verge of farce, making them more vivid than real doctors yet recognisable as comic characters in the medical profession. Then he added a subtitle to the play: "A Tragedy".
The actual tragedy of the medical profession he addresses in a long, ingenious, belligerent and sometimes passionate preface to the play. In his opinion, the medical service in Britain at the beginning of the 20th century (the play is set in 1903) had reached a state of lethal absurdity. It was not reasonable, he argued, to expect doctors in private practice to be impartial when confronted by a strong pecuniary interest. Since we all come under their attentions at some time in our lives, we are tempted to impose on them an infallibility that camouflages their ignorance. "Molière saw through the doctors," Shaw wrote, "but he had to call them in just the same." And so did Shaw – though he regarded their illegible prescriptions as little more than the paraphernalia of medieval witchcraft. The blind trust that many Victorians and Edwardians had in competitive private doctors protected them from unbearable mistrust and anxiety – and who could say that such misplaced confidence did not sometimes increase the patient's chances of recovery? It was the philosophy of the placebo.
"If you cannot have what you believe in," Shaw wrote in his preface, "you must believe in what you have. When your child is ill or your wife dying," when you are confronted by "the spectacle of a fellow creature in pain or peril, what you want is comfort, reassurance, something to clutch at, were it but a straw. This the doctor brings you. You have a wildly urgent feeling that something must be done; and the doctor does something. Sometimes what he does kills the patient."
Shaw believed that at this period of medical history we had become helplessly dependent on the spurious cures of doctors at the expense of the social hygiene and good housing that would form a "sanitary blockade" against many infections. Unfortunately, this social solution was considered too expensive by politicians. Shaw looked forward to a time when doctors as competitive tradesmen were replaced by a medical profession that had been brought under responsible and effective public control. Until this body of men and women were "trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credulity and human suffering". In other words, he was looking forward to the creation of a National Health Service.
He already saw hopeful signs of this happening when he wrote The Doctor's Dilemma. "Every year sees an increase in the number of persons employed in the Public Health Service, who would formerly have been mere adventurers in the Private Illness Service," he wrote in the preface. In 1909 Beatrice Webb was to publish her minority report to the Royal Commission on the Poor Law, which contained a collectivist scheme that amounted to a blueprint for the welfare state. Shaw recognised this as an important document that would make a significant difference in sociology and political science. "It is big and revolutionary and sensible and practicable at the same time, which is just what is wanted to inspire and attract a new generation." The person whom it did inspire was William Beveridge, the founder of the National Health Service, whose report on social insurance in 1942 Shaw welcomed as an instalment of Fabian socialism that would help to integrate society. Our taxes were an investment in our health, and anyone who evaded such a tax would be seen as an enemy of the people.
Shaw's opinions on municipal politics and public health at the turn of the century were formed and sharpened by his years as a vestryman and borough councillor for the St Pancras district of London. He campaigned for women to be legally entitled to serve on metropolitan boroughs, fought against reckless borrowing from the banks and attempted to change the rating system so that it fell more heavily on the idle rich (whom he called "the unemployed"). He was particularly active on the health committee, visiting hospitals, sweatshops and the homes of the poor where he saw under-nourishment, destitution and disease. He mocked the confusing jargon and circumlocution of physicians and he pressed for the re-examination by the London School of Economics of untrustworthy medical statistics. Some of his recommendations, such as the danger of alcohol and the wisdom of vegetarianism, are as uninvitingly valid now as they were over a hundred years ago, and some of his indictments (against cowpox vaccination, for example), which had some validity in the late 19th century, are now mercifully out of date. But his horror at the practice of vivisection is particularly relevant today, after the last government's manifesto pledge to reduce it was laid aside and the importation of more animals to Britain for experimentation has recently been advocated on financial grounds. As a seasoned political campaigner, Shaw knew that each battle won would have to be re-fought in the future, and he would have been particularly scathing about any move to extend privatisation into the health service – an "economic efficiency" leading to cheap incompetence.
Shaw brought his six years in local politics into several of his plays. The picturesque brigands of the Sierra Nevada in Act III of Man and Superman are holding what appears to be a St Pancras vestry meeting. The municipal characters in Getting Married owe their existence to the borough councillors with whom he had spent so many unventilated hours. And the conflicting opinions of the medical specialists he met on the health committee are made into a wonderfully orchestrated theatrical entertainment in Act I of The Doctor's Dilemma as the doctors gather in Sir Colenso Ridgeon's consulting room to congratulate him on his knighthood.
This successful 50-year-old physician who claims to have found a cure for tuberculosis is based on a celebrated and fashionable bacteriologist called Almroth Wright, who had been knighted shortly before The Doctor's Dilemma was written. Shaw sensed there was something dubious about Wright's high reputation (he was later nicknamed Sir Almost Right). In 1905, when Wright sent him a pamphlet on anti-thyroid inoculation with an invitation to discuss it in his laboratory at St Mary's Hospital, Paddington, Shaw accepted the invitation but challenged the validity of his vaccine treatments. So began a long series of fierce debates between the two men. This gave Shaw an opportunity to use his dialectical brilliance to undermine the presumed authority of doctors over matters of life and death – an authority that he aggressively attacked in his preface to The Doctor's Dilemma and agreeably ridiculed in the play itself.
At one of these debates, when a discussion arose about using a new treatment on someone who had arrived that day, one of the students pointed out that they had "too many patients on our hands already". Shaw then asked what would happen if more people applied for treatment than could properly be looked after, and Wright answered: "We should have to consider which life was worth saving." This became the pivotal plot point in Shaw's play.
The common-sense answer to this problem is given not by Ridgeon, but his colleague, the cheery hit-or-miss physician Sir Ralph Bloomfield Bonington, who has accidentally cured a prince but is less fortunate in Act IV of the play with the consumptive and unscrupulous young artist Louis Dubedat. "I have never been able to say No, even to the most thoroughly undeserving people," he tells his fellow doctors. "Besides, I am bound to say that I don't think it is possible in medical practice to go into the question of the value of the lives we save." He ends on a dark note of Shavian pessimism, concluding that if you asked yourself whether your patients were of any use to themselves or anyone else, you would probably be driven to the conclusion that most of them would be better off dead. Shaw himself believed that we should not seek to outlive our natural lives. He would have been appalled by cases of people being kept clinically alive for long periods, such as Ariel Sharon, still held up at the border post between life and death. Invalids "who cannot keep themselves alive by their own activities, cannot, beyond reason, expect to be kept alive by others," he wrote. It followed that suicide and properly controlled assisted suicide should be brought within the law.
Unlike Bloomfield Bonington, Ridgeon cannot make an objective medical decision because he is not at all well. "There's something the matter with me I dont know what it is … I have a curious aching … I cant localise it … It unsettles me completely," he tells the eldest, most sensible of the physicians, Sir Patrick Cullen, who, knowing there is nothing so disturbing as an ill doctor, recognises that he is about to make a fool of himself. "I thought that the days of my vanity were past," Ridgeon says. "Tell me: at what age does a man leave off being a fool?"
The answer is: never. We are being presented with a circus of Shavian lovesickness. Ridgeon loves Jennifer, who loves her husband Dubedat, who loves himself, while the doctors who surround him love their profession. All of them deceive themselves. The idealism of love fills the play; the lure of money animates the preface. "There are two things that can be wrong with any man," says Cullen. "One of them is a cheque. The other is a woman." Both these wrongs find a welcome home in the talented Louis Dubedat. The first two acts of the play, deftly edited and played fast, are among the best comic drama Shaw wrote. The difficulty begins in Dubedat's studio in Act III, as it does in many scenes that introduce one of Shaw's artistic young men – such as the sentimental poet Eugene Marchbanks in Candida. Fortunately, Dubedat is saved from sentimentality by a comprehensive amorality that is akin in some respects to that of Shaw's best virtuoso characters, such as Billy Dunn the philosophical burglar in Heartbreak House and the millionaire dustman Alfred Doolittle in Pygmalion.
The part of Louis Dubedat was written for Harley Granville Barker, who played the death scene in the first production at the Royal Court Theatre so realistically that some of the audience were shocked and became tearful. A similarly soft interpretation today would be more likely to provoke tears of laughter (as Oscar Wilde believed the death of Little Nell must do among modern readers). A more rewarding forerunner perhaps was a production at the Mermaid Theatre in 1975, which had Kenneth Cranham as a forceful Dubedat opposite Lynn Farleigh's Jennifer, played not as a relentlessly naive and tragic heroine but as a wife who treats her husband as an exciting possession. This made the pair into a partnership of confidence tricksters just right for modern comedy.
Shaw could write tragedy: Saint Joan, Heartbreak House, Back to Methuselah and Too True to Be Good are all tragedies. But if he had really intended The Doctor's Dilemma to be a tragedy, he would have made the doctors in the title plural and damned the whole profession.