THE PHYSICIAN OR THE SOCIOLOGIST--OR BOTH?
Commons, John R.
The Physician or the Sociologist--or Both? The Tuberculosis Problem From the Sociological and Medical Points of View* By JOHN R. COMMONS IT WAS suggested to me that I speak on a subject like...
...Stewart, superintendent of schools in Rowan County...
...I have a hard way of Living and making my Suport i Live in the Country and cant get anything frur my work, now you Let me no Just what you will do and Let me no what you will Pay a week for cooking if I cant get in School if i had Lurning I could make my mother Suport But as i am i cant Will close hoping to here frome you Soon your reSPCtiful P S Let me no if i can get in or if i cant "If these people were what the outside world has so long supposed them to be—savage, selfish, lawless, broilers, feudists, murderers—I would not try to help them, nor wish to do so...
...HERE, it might seem, is a field for the physician...
...He is a sociological practitioner...
...I do not hold that physicians are not, or may not, become alive to the sociological problem...
...Their very ex-pertness comes from their concentration on a restricted section of the facts...
...There could hardly be another department of government more far-reaching...
...Then his representative committees of employers, employees and other interests affected must be consulted upon the practicability of the expert recommendations...
...The business man does not leave his business to his engineer, or his accountant, or his lawyer—he gets their expert advice and information and then decides for himself...
...If the executive attacks tuberculosis he hits property and liberty...
...I only show that the medical man as such, does not start from the sociological standpoint...
...I am speaking of the strictly medical point of view, or starting point...
...They may require the services of other experts besides physicians, such as plumbers, engineers, architects, lawyers, or sociologists...
...He even opposes interference with property rights except when contagion requires martial law...
...They must get the architect or the engineer to construct the building or invent the contrivances that will secure ventilation and light, or will prevent excessive heat or excessive cold, or will provide in general for safety and sanitation...
...I only note that it is based on physiology or psychology — not...
...THE SOCIOLOGIST, too, should be looked upon as belonging to the class of experts rather than executives...
...If you could see the pictures of these people, if you could see how simple and earnest they are, how eager to learn, and how extraordinarily apt and swift they are to learn, you would understand my speaking for them as I do...
...He is useful for the education of the public in enlightening them as to actual conditions...
...What the state needs in the forward movement of organized society, is the co-operation of all kinds of specialists with all kinds of interests affected...
...He must act upon the unity of the body politic, just as the physician must act according to the oneness of the human body...
...EXAMPLES might be given of the sociological method of administration...
...for protection of each from contagion—for removal of each from his environment to a hospital or the open air—for rest and vacation...
...The sociologist is usually a statistician, and one of his limitations is statistics...
...Their problems are those that grow out of the hours of labor, child labor, factory surroundings, wages, employment, home and family conditions, opportunity for education or citizenship, and so on...
...Government by experts is scarcely more agreeable than government by despots or bosses...
...The fact is, when bureaus of labor or boards of health get into these fields where health conflicts with property, they must call in other experts besides physicians and sociologists...
...But the sociologist appeals for more police power, for the regulation of factories, labor camps and houses, for shorter hours of labor, for wider fields of recreation...
...If he is truly an expert, his attention must be absorbed by the particular problem on which he is engaged...
...His field is applied sociology...
...He discovers the microbes, the poisons, the toxins of fatigue, the neuroses of occupation...
...The sociologist goes further...
...My question is not, "Who is It...
...Can you picture to yourself a class in that night school made up of grown men and women, of families—one of the women with a baby on her arm— in all twelve adult Americans, all of them fine-looking people and every one of them over fifty years of age—and all going to night school to learn how to read and write...
...What is needed is such an organization of the departments of government as will bring this about...
...Following is an extract from his letter: "Can you think of a Baptist minister over fifty years of age, a preacher for more than thirty years, who could not read or write, but who learned to do both after the time most men are done with active business affairs...
...At the overlapping points there are those who call themselves sociologists, but who are really physiologists...
...It cannot content itself with an order to use spitting cups...
...If the physician, as expert, were in charge of such a department, he would run it towards pathology, dispensaries, hospitals, sanitaria, and would tend to neglect the factories, tenements, shops, hours of labor...
...It marks off a deadline of quarantine...
...It must actually change the conditions under which the occupants work and live...
...It becomes policeman, calls out the militia, declares martial law, sets aside the Fourteenth Amendment...
...But the conditions spring from property rights and personal rights, and these are founded on social institutions which rest in turn on the constitution...
...but "How Shall Each Co-operate...
...There are, first, the courts, with their interpretation of the constitution and the police power...
...But what a variety of experts they would need to help them out and furnish to them a solid foundation of facts...
...But they are not that...
...If they are worthy the name of sociologist then they are expert in the investigation of one or more of these several subjects...
...Let us see the standpoint from which each starts...
...In this, however, we may say that sociologists are similar to the medical fraternity...
...IN OTHER WORDS, the physician, or rather physiologist, is the preliminary expert and investigator...
...They are a simple, bold, honorable, generous and able people, a splendid stock...
...Executive officials in this country must listen to the voters and the violators...
...The sick man calls in the doctor, but consents to be bossed by him only when he is too sick to help himself...
...It would jar the traditions and prejudices of the courts, of vested rights, of personal liberty...
...But generally it has been found that the physician's remedy stops where the sociologist's begins...
...Sociologists deal with the body politic rather than the body physical...
...It must go into court...
...This does not mean that the physician should become the executive...
...But the most superficial observation can tell that an eight-hour law applied alike to all industries, and even to different jobs in the same industry, is not based solely on health-protection...
...Yet we should judge the profession of sociology as we do the profession of medicine—not by its specialists or its freaks, but by the subject matter it operates upon...
...He shows where they come from and how they act on the individual...
...First, his committees of experts must work out the details from the technical standpoint...
...His methods are the martial law of the physician—not the police power of the executive...
...When a board of health determines that small-pox or diphtheria is afloat it rides over every property and personal right of the individual...
...Here is a letter written by a mountain girl living twenty-five miles from Oneida: Jan 15 1913 Prof Burns oneda Ky i though i Would write you to See if i could enter Schol with you all one a Free tuishen my father is ded and my mother is to Poor to send me to School and is not able to Furnish my Books and Close and would Like to help make Suport fur the Familey and the way i am i Cant my oge is 19 and if you Cant hold me a Place in Schol can i get a job of house work...
...These decisions are based on the public necessity of protecting the health of women...
...But this is not the practical question...
...I am not criticising this kind of legislation...
...The city, the state and the nation, are forced to take over what has hitherto been the academic discussion of scientists and experts...
...Here the physician must get beyond physiology, contagion, or infection, and deal with the institutions of property, the family, the state, that make environment what it is...
...Then they become a part of the information that the responsible executive must depend upon in reaching a decision and determining what to do in view of all the circumstances...
...Here the state demands that other experts and investigators come in — the engineer, architect, plumber, who can tell how to reconstruct physical property without destroying its value...
...Can work at most any thing in the house...
...There is no conflict of physician and sociologist until the state, the city or the nation takes hold...
...But such discretion would be fatal and a mere subterfuge for favoritism, if it were left to the inexpert judgment of the executive...
...Each may be expert in his own field, but dogmatic, misleading or futile, when he ventures to dominate the others...
...THE EXECUTIVE must organize all the forces of society to attack bis particular problem...
...The sociologist looks on them as owners of property...
...Here is where the expert, like the physician, is most pressingly needed in our system of government...
...Having established scientifically the need of a remedy, he should be the one authoritatively to enlighten the people and to lead in a popular demand for it...
...If the question of its adaptation is left to an executive who is supposed to have no discretion in its enforcement, then he necessarily but tacitly assumes discretion when he decides whether to prosecute or not...
...He throws up his hands...
...These other facts in labor and health legislation may be summed up as those which come against the constitution, or the confiscation of property, or popular dissent...
...In still other positions six or seven hours might end in nervous breakdown...
...THUS would I endeavor to show how the physician and the sociologist should co-operate...
...Experts disagree, and others not expert must decide between them, and others can decide only as the expert educates them...
...If the dentist strikes a sore tooth he makes the feet jump...
...It established by universal consent the authority of the federal government, in matters of labor legislation, to assume the police power by way of the taxing power...
...To the individualist physician this is often unthinkable...
...This is the method of multiplication of individual units to be cared for...
...A new microbe means a new activity of government...
...Experts can investigate and furnish exact information on details...
...But the expert can decide only on a part of the facts, and the disagreement among experts makes it possible for others to find a place for other facts, which must be taken into account anyhow...
...The one sees them as physiological units, the other as possessors of power and of that intangible property which we call "opportunity...
...These semi-sociologists are seen to branch off into such studies as eugenics, inebriety, insanity, feeble-mindedness or crime...
...The physiologist whether physician or sociologian, when he asks the state to step in, does so, not in order that it may modify the social institution of property that creates environment, but in order to tie up individuals so as to stop their breeding, or to let the physician operate upon them...
...A law of this kind should be based on the expert investigation of physicians...
...He must know what each can contribute and where each will be affected...
...Compare a Board of Health with a Bureau of Labor...
...It must act at once and effectively, upon the facts known and at hand...
...It cannot shut down the factory in order to stop the clouds of dust, steam or fumes...
...Each profession of experts contributes its essential part, but each is only a part and is ineffective without the other parts...
...But the physician alone cannot show this...
...If the sociologist, as an expert, were in charge, it would run towards statistics and summaries of the condition of the masses...
...This is biology, not sociology...
...They have been sustained by the courts as a proper exercise of the police power...
...Prior to this event each investigator has his own way...
...and it is the business of political science, of government and administration, to work out the methods and machinery by which each shall do so...
...She learned to do that in the same night school with the Baptist minister, in one of our counties in Kentucky...
...The experts would not govern— they would advise those who are responsible for governing...
...It would have to touch every property and personal interest of the people...
...The physician starts with the individual...
...Such qualifications belong to no scientific profession as such—they are the qualities of the business man, the organizer, promoter, executive, the judge, the politician...
...In some industries, or for short periods in other industries, ten or more hours might not be injurious...
...He would do this by changing the conditions of work and living—by lifting off from the masses the downward pressure of environment...
...Then, if it be an emergency of contagion or infectious disease, the state endows him with martial law and makes him dictator...
...And at the same time, neither legislature nor executive is in a position to reduce the hours to six or seven in the cases where needed...
...Sociology, of course, being younger than physiology, and not a means of livelihood, has not yet clearly distinguished its internal orders and disorders...
...If the executive attacks tuberculosis he hits property and liberty...
...He is a sociological practitioner...
...I can understand why physicians should resent the pretensions of quasi-sociologists, who decide questions of pathology or eugenics on the basis of statistics—who, because they are authorities on infant mortality, proceed to issue instructions on babies and milk...
...It would have to go into every home, factory, hospital and public building...
...And when they are called upon to enforce a rigid law that does not fit the variety of circumstances, it is difficult for them to draw the line between a case where the letter of the law goes beyond what is necessary and another case where the influence of voters and violators makes its enforcement precarious...
...Consequently, either the legislature, under the influence of the lobby, makes artificial exceptions, or the executive does so in its administration...
...There are also mental healers and drugless physicians, just as there are metaphysical and mental sociologists...
...So the executive must secure the co-operation of all interests and all experts—all charity workers, all child labor societies, visiting nurses, the police force, sanitarians, physicians, schools, priests, employers, landlords...
...While a serious ailment, the number of cases is so small as to have raised the question among certain medical men whether attention should not have been given to something more important, like tuberculosis...
...Here the state calls upon the sociologist and the lawyer to tell how far the rights of property and persons shall be restricted—how far we can regulate child labor, woman's labor, hours of labor, competition, wages, employment or unemployment, house construction and maintenance, poverty and property, without forcing the individual away from his job or home, and without confiscating property or business...
...Yet that class did attend the night school of Mrs...
...ALMOST all lines of research bearing on health lead sooner or later to some kind of action on the part of the state...
...Where Grown-ups Are Seeking "Learning" IN THE May American Magazine appears a letter written by J. A. Burns —known as "Burns of the Mountains" —who founded a college at Oneida, Kentucky, where he is doing a great work educating mountain whites...
...This is sometimes spoken of as the distinction between prevention and cure...
...In the words of Justice Holmes, it is that power of the state that "may be put forth in aid of what is sanctioned by usage, or held by the prevailing morality or strong and preponderant opinion to he greatly and immediately necessary to the public welfare...
...He must get popular consent...
...There are other fields of disease and environment where physiology and sociology overlap...
...There is some hesitation in defining exactly what sociologists are — they differ so widely in the fields they cover, all the way from plumbing and kitchens to philosophy and psychology...
...Can you think of a woman eighty-six years of age going to school to learn to read and write...
...WHEN we come to the administration of laws under the police power we have a similar situation...
...And the facts which they unearth have the same limitations and the same uses as the facts which the physician determines...
...His field is applied sociology...
...If experts are left to themselves, then they conflict with each other and nullify each other by trying to dominate each other...
...The physician should be called upon to classify occupations and positions according to their actual effect on health, and the executive should then be guided by this expert classification...
...The government needs experts just as the business man or the sick man needs experts—not to govern, but to advise...
...THE DIFFERENCE shows itself in administration...
...The association began at the end of the problem exactly opposite to that of the physician and by a decisive campaign wiped out "phossy jaw" from the American list of occupational diseases...
...But this should not blind us to the function of true sociology as the science of organized society...
...He is useful and indispensable to the executive in furnishing information...
...First, the laws themselves, which depend on the police power, should be made adaptable, so that the administrator will be openly recognized as having a margin of discretion in fitting them to actual conditions...
...If the physician's appeal were the only one that reached the ear of the people, then each increase of expenditure made by the public in providing for his remedy would be followed by another increase, and so on, in order to take care of the numbers not reached on the first appeal...
...The same is true of other experts...
...Each profession of experts contributes its essential part, but each is only a part and is ineffective without the other parts...
...The physician looks on other individuals as sources of contagion or infection...
...There are eye doctors, ear doctors, homeopaths, allopaths, and all kinds of schools and specialists...
...Only when it can be shown that there is a great public necessity will the courts let the police power get past the constitution where it can step on private property...
...To do this he must ride over the other facts...
...He must know what each can contribute and where each will be affected...
...It must follow due process of law...
...Individual physicians have done and are doing wonderful service on the sociological side, and there is no profession that in any way compares with the medical profession in the service it has rendered to the state towards making the work of its practitioners unnecessary...
...STARTING from opposite standpoints, the physician and sociologist approach each other and overlap...
...Instead of giving orders, each should modestly co-operate...
...He must act upon the unity of the body politic, just as the physician must act according to the oneness of the human body...
...But afterwards the problem is—"How to make government effective...
...But when a Bureau of Labor finds tuberculosis in a factory or tenement, it comes dead against the vested rights of the owner, the poverty of the occupant, and the federal constitution...
...Take the laws regulating the hours of labor for women...
...This has been the occasion of inefficiency and even corruption in law enforcement in this country...
...But his facts and statistics are not final and conclusive, until they have been correlated with the work of other experts...
...So the executive must secure the co-operation of all interests and all experts—of charity workers, of child labor societies, visiting nurses, the police force, sanitarians, physicians, schools, priests, employers, landlords...
...He does not see how it can be done...
...So it is in the administration of the police power...
...All of the facts which these various experts reveal must be taken into account, and only then does the decision of the responsible executive reach that standard which the courts describe as "reasonableness...
...But, from the sociological standpoint, that investigation started a new epoch of legislation...
...Starting from his individualistic standpoint, he is concerned about arrangements for individuals...
...What is needed is such an organization of the departments of government as will bring this about...
...Let the experts realize their modest but indispensable talents, their narrow horizon, but solid foundation, and then they will co-operate by assisting those who are called upon to execute...
...But in the slow diseases that feed on poverty and occupation, the state is slow to attack vested rights with martial law...
...It cannot offer empty advice for the occupants to go to a sanitarium...
...The Tuberculosis Problem From the Sociological and Medical Points of View* By JOHN R. COMMONS IT WAS suggested to me that I speak on a subject like this: "Who is It—the sociologist or the physician...
...In the particular field of tuberculosis, if the fatigue of long hours of labor, or the contact with unwholesome surroundings, or the emaciation of poverty wages, is found by the physician to be a predisposing condition of tuberculosis, then the necessity of the police power in shortening hours or modifying the surroundings or mini-mumizing wages, gets support on the basis of expert investigation...
...Suppose we had in every city and state and in the federal government, a department commissioned by the people to wipe out tuberculosis...
...Here the sociologist must get into physiology if he would not go wrong in dealing with institutions...
...The executive must organize all the forces of society to attack his particular problem...
...Moreover, he must be able to demonstrate, to the satisfaction of the public, the executive and the court, that his findings are correct...
...That is to say, the physician starts from the field of individual pathology...
...the sanitary engineer from that of physical surroundings, the sociologist from that of social environment...
...His remedy is nothing less than elevating the entire mass of individuals...
...The more far-reaching the remedy, in order to take in the lower and more numerous masses, the more necessary the work of the sociologist to lift the mass as a whole by the reorganization of society, and thus to reduce the necessity of taking care of individuals thrown out from the mass...
...If we do this, then, for the purposes of this discussion, we may say that the field of the sociologist is that of elevating the masses of the population by changing their legal and social surroundings...
...The executive must put their details together and then decide...
...What the country needs in the forward movement of organized society is the co-operation of all kinds of specialists with all kinds of interests affected...
...The competent executive uses them all at the points where they are useful...
...I can conceive of such an organization of the executive or administrative branches of government as will utilize promptly the work of experts and yet not be dominated by them...
...This is the reason why the expert is often a poor executive...
...As such it is a necessary equipment of the successful executive...
...The essence of the police power is its reasonableness—that is, its adaptation to all of the circumstances in each case...
...It goes beyond the doctor, partly because his methods are the individualistic methods that depend on taking the individual away from his means of living to the hospital or sanitarium, or else the drastic methods that confiscate property, jeopardize business or suppress personal liberty...
...England Aids Ambitions Youths The English Government is planning to provide scholarships and other aids which will make possible a university education for every boy or girl who makes a certain standard...
...He decides the case on his knowledge of the particular facts on which he is qualified...
...So when he moves towards the enlightenment of the people he appeals for more appropriations towards sanitaria, for more care in personal habits, for avoidance of contagion...
...Engineers, chemists, physiologists, sociologists, statisticians, would all be called in—but they would be called only when needed on the particular problems where they are expert...
...If the sociologist is blind to this service, he is simply impossible as an executive...
...And in my own county I have taught grown men and women to read and write...
...The one starts with the individual constitution, the other with that of the United States...
...Those in charge of such a department would require, first of all, wisdom, tact, energy and force, rather than expert knowledge...
...It is also the remedy of the police power of the state, distinguished from its taxing power...
...The sociologist starts with his institutions...
...At that point, his word is final...
...Address before the national association for the study and prevention of Tuberoulosis at washington, May 9, 1912...
...Popular consent is just as important in administering a law as in getting it enacted and declared constitutional...
...If the dentist strikes a sore tooth he makes the feet jump...
...Tuberculosis and occupational disease, safety and sanitation, infant mortality, hours of labor of women and children — these are some of the fields of scientific research and governmental administration where the physician and the sociologist meet...
...Government cannot wait until the speculative questions are settled...
...They must call in the plumber to let off the sewage and sewer gas...
...One of them is the campaign of the American Association for Labor Legislation against phosphorus necrosis...
...Then the executive must coordinate the work of all into a workable plan of administration...
...How far over he gets towards that standpoint is an individual matter...
...If an expert, whether physician or sociologist, turns out to be a wise executive, then the others must defer to him, not as to an expert but to an executive...
...The police power is not merely expert opinion—it is popular opinion...
...sociology...
...and they must not be allowed to go on as they have— they are too good for that...
...Their sociological program goes as far as repressive or sumptuary laws, where they propose that the state shall directly interfere with the freedom of the individual...
...We must remember, again, that the necessity, and indeed the compulsion, that requires this co-operation, springs from the fact that the problems which both are studying are fast becoming the problems which government must handle...
...A law that goes very far ahead of what the people understand to be reasonable and necessary cannot be enforced...
...OTHER FIELDS of labor and social legislation call for similar service from the physiologist...
Vol. 5 • May 1913 • No. 20
