The Devil’s due - fees - a historical survey
C. M. Godfrey

The act of medical care has always been an occasion for rendering a fee by the patient. Payment in kind or cash has been the custom except in some aboriginal societies where no reward of any kind is expected or given. (It is ironic that such societies are termed ‘primitive’ by so many. Editor)

Negative fees
While reward has usually awaited the practitioner. he has also received negative fees - punishment for unsuccessful treatment. In Mesopotamia if an operation ended fatally, the surgeon’s hands were cut off. The Hammurabic and Visigothic Codes included a clause: ‘If a physician injures a free man by bleeding, let him pay 10 soldi; but if the patient dies let the physician be handed over to the relatives to treat as they please.

Considerations
John of Mirfield insisted his physician should treat the poor with all diligence.

Osler once charged 50 cents for the removal of a speck from the cornea. (Osler - and his celebrated pupil and biographer, Harvey Cushing - often ‘sanctified’ a large fee by spending it on rare books.)

When asked by a patient about his fee, John Hunter (1728- 93) replied, “Why, that you must determine for yourself. You are the best judge of your circumstances and it is far from my wish to deprive you of any of the comforts of life.”

The Faculty of Medicine in Glasgow had, as one of its original functions, the provision of free treatment of the poor and to this day concludes each meeting with the statement, “The poor were treated gratis and the Faculty adjourned.”

The Toronto Globe noted in 1886 that the salaries of doctors were comparable to those of churchmen; the clergymen; on the whole; having a higher income.

A philosophy on fees
Many physicians worked for nothing and received gifts from the community. Metadorus of Cos (the island in Greece that is better known as the home of Hippocrates) was voted a gold crown by a grateful community for twenty years of work in which he refused fees and lived a life of poverty. With the rise of professionalism, by the Middle Ages, there evolved several concepts of fees. John of Ardeme ( 1307- 1390) called the father of English surgery, advised, “Ask the fee boldly, more or less, but never be wary of asking. Take for your cure as much as you can get.”

A kindred soul, Isaac Judas, contemporary of Rhazes, said, “Ask that reward when the sickness is at its height. for being cured the patient will surely forget what thou didst. for him...” (It was he who also made the other, oft- quoted, statement: “Treating the sick is like boring holes in pearls and the physician must act with caution lest he destroy the pearl committed to his charge.")

Cordus (c 1500) wrote:
Three faces wears the Doctor:
When first sought
An angel’s - and the God’s,
The cure halfwrought;
But when, that cure complete
He seeks his fee,
The Devil then looks less
terrible than he.

By the time Samuel Johnson dominated the scene in London, the sentiments of the public with regard to fees were summed up in the words of a customs clerk to that worthy (non- medical) doctor - “After all you have said, my opinion of the profession is this: the ancients endeavoured to make medicine a science and failed and the moderns to make it a trade and succeeded.”

James Gregory (1799) offered an explanation for the avarice displayed by doctors - one that we continue to encounter: “Whatever the majority of us maybe, I am afraid we are not all perfect angels. Some of us at least appear to be made of the same flesh and blood, and to be subject to the same frailties and passions and vices, as other men.”

All this may have prompted Anthony Trollope to advise: “The physician should take his fee without letting his left hand know what his right hand is doing: it should be taken without a look, without a thought, without a movement of the facial muscles. The true physician should hardly be aware that the last friendly clasp has been made more precious by the touch of gold.”

The Lamet (1862) offered a counterpoint. It addressed society at large and considered it the bounden duty of the affluent class to reward their medical attendants not only justly but liberally. Only thus could doctors be compensated for the many services they performed for the poor.

Regulation of fees
Most codes have something to say on the matter. The Code of Hammurabi (25- 50 B. C.) itemsed charges. For opening an abscess and saving a gentleman’s eye, the surgeon should be paid ten shekels. If the patient was a free man, the fee was to be five shekels. In the case of a slave the owner was to pay two shekels. The gentry continues to be charged more than the peasants,

In 1880, Newcastle, Ontario had the following schedule:

Advice at the office 50 cents
Medicine $1- 2

By 1915, the tariff of fees in Peterborough was:
Advice at the office $ 1- 5
Vaccinations $ l- 2
Labour - natural, upto 4 hours $ 10- 15 .

Governments and other agencies have also had a say in the sums to be paid to medicine men. Ambroise Pare ( 1510 to 1590 - who, when praised for his successful treatment. said, ‘I dressed him, God healed him’) was paid a certain sum for each soldier treated during the military campaign and was given a share of the booty. Bernil, physician on the first voyage of Christopher Colombus, was paid 17 cents per day.

In some instances the community made an arrangement with the doctor. Dr. James Sampson settled to practice in Kingston, Ontario in 1822 after the twelve principal families there agreed to pay him 25 pounds a year for life. Such guaranteed income continued at Padua (where the teachers received 500 florins per month) and, indeed, in medical college hospitals today.

Legal Aspects
The relationship between the physician and the patient is contractural and the patient is always liable for the payment of medical accounts where treatment is reasonably necessary. As yet there is no legal procedure for determining what can be charged except in an action brought by a doctor to collect his account.

Humanity
John of Beaulieu accepted only whatever was offered by the patient, took from it what was suficient for his living expenses and gave away the rest to the poor.

In 1824 John Gilchrist received a letter from a teacher thanking him for his treatment but lamenting that he had no money to pay. He promised payment as soon as possible. Giichrist replied: “Sir,- When you see a fellow creature in distress,relieve him as far as your abilities will allow; and in doing so you will discharge the debts you owe too.”

Sir Andrew Clark was called to Cannes for a consultation. When he received a cheque for & 6,000 he returned the rest after retaining & 750 as the latter sum was sufficient to compensate for a week’s absence from London.

(This column will feature abridged essays and other features from the past on the broad subject of medical ethics.Dr. Godfrey’s paper was originally published in Applied Therapeutics, October 1965, pages 889- 902.)