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Special Articles

U.S.A. VERSUS A.M.A.

THE great trial in which the American MedicalAssociation has to defend its attitude towards certainmethods of " group medical practice " is shown to bewell under way by an instalment (just received) of theverbatim report which the association is publishing in itsjournal.l Two counsel have made opening statementsfor the prosecution. The first has explained how theHome Owners Loan Corporation initiated the projectof Group Health Association, Inc., because H.O.L.C.(if we may adopt the convenient use of initials so welldeveloped in America) found that its borrowers neededso many loans to meet doctors’ bills, and thought thatan ampler and better medical service, preventive as wellas curative, could be furnished cooperatively throughG.H.A. The defendants include not only the A.M.A.but also the Medical Society of the District of Columbia-,the Harris County Medical Society, the WashingtonAcademy of Surgeons and 21 named individuals.Counsel alleged a conspiracy to prevent the 800 or moredoctors of the Medical Society of the District of Columbiafrom accepting employment with G.H.A., to obstructG.H.A. in its efforts to obtain doctors from practitionerswho were not members of the society, to attack doctorswho joined G.H.A. and to persuade them to abandon theconnexion under threat of professional discredit in theirpractices and in their hospital work, and lastly to induceall local private hospitals to join in the boycott ofG.H.A. by refusing to admit Group Health doctors tohospital privileges. A subcommittee of the A.M.A., itwas said, had reported that G.H.A. was unethical andthat participation in it by any member of the District ofColumbia Medical Society would make him liable todisciplinary action as well as deprive him of courtesyfacilities at various hospitals which the A.M.A. hadcoerced into the boycott.The additional opening statement by a second counsel

for the prosecution was mainly concerned with what,without any intended disrespect, might be called blue-book material. He outlined the general developmentsof preventive medicine, bacteriology, radium, cardio-

graphy and X-ray examination and dealt with the

report of the American expert Committee on the Cost ofMedical Care. His object was to show that families inthe lower income-groups receive too little medical serviceand find the cost of illness disastrous. This informationwas material to indicate that Group Health Associationand similar organisations improved the distribution ofmedical care and spread the cost by a system of periodicalpayments. The American College of Surgeons, saidcounsel, had recommended in 1934 the continuance ofexperiments with periodic prepayment plans becausethey gave hope of more adequate medical care for thelow-income groups. A week later the A.M.A. hadpassed a resolution condemning the college for itsrecommendations. The A.M.A. insisted that any suchplan should comply with its own general principles.One of these was that the plan should embrace all thequalified physicians within the locality ; anotherrequired the cost of medical service in any plan to beborne by the patient who could afford to pay at the timewhen it was rendered. The A.M.A., alleged counsel,was hostile to group practice on the prepayment basisand had gone beyond peaceful persuasion in its methods.

It may be convenient at this point to note that theseproceedings are criminal, not civil. There is an indict-tnent, running into 30 pages, alleging conspiracy andviolation of the so-called Sherman Anti-Trust Law.This statute, named after its sponsor John Sherman (theyounger brother of the famous general of the Civil War),was passed in 1890 and has since been modified. Notcontent to rely on the common-law doctrine which makesagreements " in restraint of trade " unenforceable, itprohibits under heavy penalties any contract, combina-tion or conspiracy which restrains trade or attempts toestablish monopoly. In England we should expect acase of this nature to be dealt with not by a criminalprosecution but by an application to a Chancery judge

1. J. Amer. med. Ass. 1941, 116, 601-630.

for an injunction and a declaration of the rights of theparties. Our classic authorities on the law of restraintof trade are mostly decisions in civil proceedings-theMogul Steamship case in 1892, the Maxim-Nordenfeldtcase in 1893, and the pronouncement by Mr. JusticeAstbury in the Firemen’s Union case in 1926 whichexercised no small influence upon the general strike.It is perhaps unnecessary to explain that the District ofColumbia is (like Canberra in Australia) a federal arealying outside the jurisdiction of the separate states. Itwas carved out of Maryland on the north and Virginia onthe south, and it accommodates the federal governmentof the whole country. There are in America manytowns called Washington ; this one is distinguished as" Washington, D.C."-Washington in the District ofColumbia. Its great and growing population is largelyofficial. The American law-courts are of two kinds-those belonging to the several states and those of thefederal government. In the latter class is the famousSupreme Court of the United States at Washingtonwhich says the last word upon all constitutional disputesand upon the validity of all legislation (whether state orfederal). The trial of the A.M.A. is proceeding atWashington in one of the district courts of the federalsystem. American forensic procedure often strikesEnglish observers as old-fashioned ; but the deliberateefforts to secure a jury which will eschew all bias aredoubtless necessary in this case where so many Washing-tonians may be members of G.H.A. or patients or friendsof the defendant doctors. The court has patientlyexamined all the prospective jurors to find out whetherthey are subject to any such influence and even whetherthey (or members of their families) are officials of theUnited States, the prosecutor. Jurors have been askedby the court if they or any members of their familieshave ever been sued by a physician, or if they have ever" had any occurrence which has aroused any antagonisticfeelings towards a doctor, a physician, or any group ofdoctors or physicians " ; had they formed any opinionabout the right of hospitals to select doctors for theirstaff, or about the right of doctors to organise themselvesin associations with rules and regulations governingprofessional practice ? And so on.To return to the trial, the two opening addresses for

the prosecution were followed by a spirited openingaddress by counsel for the defendants. He explainedthe constitution and standards of the A.M.A. ; itsformulated ethics were derived, he said, from an English-man named Thomas Percival who in 1803 framed themfor the College of Surgeons in the City of Manchester inEngland. The code, based on the oath of Hippocrates,had been proved to be the only safe standard for dis-tributing medical care to the public and the patient.The great developments in medicine, outlined by theprosecution, had been due to the efforts of the A.M.A. toprevent the destruction of progress by quacks andcharlatans who advertised their wares, in such languageas the G.H.A. was using-" You can’t sell medicalservice as you sell baked beans."

PLAN TO CHECK RHEUMATISM

RHEUMATIC disease, though widespread, painful,disabling and responsible for great economic loss, hasnever roused public sympathy or conscience as keenlyas tuberculosis, cancer or venereal disease. For onething it presents no clear-cut picture ; how can it, whenthe word has been used to cover at least two, andprobably more, distinct disease entities ? The acute andsubacute rheumatism of childhood, manifesting itselfas rheumatic fever, tonsillitis, chorea and growingpains and bringing in its train heart damage, invalidityand often death, has probably nothing in common withthe disabling muscular rheumatism, fibrositis or osteo-arthritis of later life ; and these again may prove to bedistinct from rheumatoid arthritis, and even from eachother. To devise a plan which will ensure the diagnosis,treatment and aftercare of all these is not simple, butLord Horder, in collaboration with the Empire Rheu-matism Council, has some practical suggestions to make.’Their plan was almost ready in 1939 but it seemed

1. Rheumatism: A Plan for National Action. London: H. K.Lewis. 2s.