By Jane M. Orient, M.D.

AAPS, at age 43 years, is at the time of the midlife crisis. We realize that we haven't saved the world yet. So what now? It is time to reevaluate our goals, to decide whether to proceed along the same pathway, or to throw away our gyroscope and possibly embark on a different course. Many have predicted the demise of private medicine, and have warned us that we must accommodate to the inevitable change.

Many have tried to compromise. Some have simply given up the fight. However, I would like to tell you what I think AAPS stands for, and why we should carry on for at least another 43 years. AAPS is the only American medical organization, as far as I know, which is a coherent philosophy, specifically the philosophy that underlies the practice of medicine according to the Oath of Hippocrates. The Association stands for a principle. It was not formed for some pragmatic purpose, such as increasing physicians' incomes, bashing HMOs, preventing the licensure of chiropractors, or supporting a certain political agenda.

Of course, we are sometimes remembered primarily for the things that we are against. But we are against things only because they are inimical to the things that we are, namely the sanctity of the individual patient-physician relationship, and the right to practice private medicine.

The meaning of AAPS is reflected in our name. The first part of our name tells us that we are an association. Not a union. We are in a cooperative venture, not a coercive one. We will work together to achieve our goals, but not to impose our conditions on others through the use of collective force. We hope that patients will choose to consult us, but if they don't, we do not intend to keep them from seeing someone else. Although we are independent physicians, we have formed an association because of our common purpose.

We are physicians and surgeons, not just a group of people who hold a doctor's degree. We are not employees, not gatekeepers, and not generic health care workers or "providers."

Our Common Purpose

As physicians and surgeons, we attend patients, we do not "do cases." In our endeavor of caring for the sick and the injured we work together. Our differences in specialty are much less important than our common purpose. Unlike some other organizations, we are not engaged in protecting turf for our specialty, or in making distinctions between "cognitive" and "procedural" services, or "primary," "secondary," and "tertiary" care. We must scrupulously avoid involvement in that type of strife among ourselves, since it makes us susceptible to the divide-and-conquer strategy that was used so successfully against British general practitioners and consultants.

A Distinctly American Tradition

We are American physicians and surgeons, and this part of our name does not simply describe our country of residence. AAPS has consistently defended a distinctly American tradition. This tradition, dating to the Revolutionary War, is quite unique. The motivation for that Revolution was not to overthrow the law of the land, but to fulfill it, to assert the rights to which the colonists felt they were entitled by the law of God and the law of the land, the rights of Englishmen. One of the early American flags pictured a snake and the motto "Don't tread on me." Ours was not a utopian revolution. The sacredness of the individual was a central tenet, and the "rugged individualism" (as its detractors call it) was a part of the American character.

The American Revolution proclaimed the rights to life, liberty and the pursuit of happiness. The Bill of Rights guaranteed that life, liberty, and property were not to be taken by the state without due process of law.

Shortly after the American Revolution, the monarchy in France was overthrown by the French Revolution, which differed from the American Revolution in many important respects. In contrast to "don't tread on me," the motto of the French was much more lofty: "Liberty, equality, and fraternity." The Declaration of the Rights of Man proclaimed the rights to "liberty, property, and security." To enable every man to have a secure house, a living, a wife and children, the property of the rich was taxed or confiscated.

"Equality" meant equality of property rather than equal treatment under the law. The laborer was worthy of his hire, but not entitled to an advantage. There was an attempt to abolish profit altogether, according to the account by socialist utopian H. G. Wells.

Government was by the commune, a group of 12 men, rather than by law. The Jacobin government re-planned not only the economic system, but also the social system. The French Revolution was a collectivist, not an individualist revolution, and it heralded the totalitarianism characteristic of so many revolutions of the 20th century.

The French slogan rapidly came to mean "liberty, equality, fraternity, or death." To assure the coming of utopia, it was necessary to get rid of the bad apples. An egalitarian (hence democratic) machine was adapted for the purpose: the guillotine. It shortened each of its victims by exactly one head. (This device was named for Dr. Joseph-Ignace Guillotin, who was not its inventor; it was actually perfected by the Perpetual Secretary of the Academy of Surgery, Antoine Louis.)

The guillotine made perfect sense, if we postulate society to be the highest good, while individuals are either obedient cogs in the machine or potential spoilers. This idea has been widely promulgated. For example, when the Soviet system didn't work too well, the "wreckers" and "saboteurs" were convicted in the

Moscow show trials. Today, the Chernobyl disaster is attributed to errors by certain individuals, rather than to an inherent flaw in the reactor design.

Of course, the French Revolution made some mistakes, for example, beheading Antoine Lavoisier. But they didn't have computers, utilization reviewers, objective criteria, and PROs. We have advanced far beyond the knitting of Madame Defarge in the scientific identification of who the bad apples are.

H.G. Wells apologized for the Reign of Terror, attributing it to the cult of the personality of Robespierre. Otherwise, he thought the new ideals and intentions of the French Revolution were "profoundly right and immensely vital." Robespierre himself had the best of intentions, according to Wells: he only wanted to save the Republic.

The Terror of the 20th Century

The French Terror was trivial compared with the terror of the 20th century. Yet modern totalitarians also find many apologists, who tend simultaneously to criticize the ideas of the American Revolution, as well as the ethics of Western medicine. "Unrestrained capitalism" they say, is a thief that plunders the poor, as well as a threat to public health. Of course, capitalism is restrained--but by a rather small number of "thou shalt nots."

Likewise, Western medicine has been restrained by just a few "thou shalt nots:" for example, "do no harm." Capitalism doesn't cure all our social ills, and Western medicine does not assure perfect health. Neither aspires to bring about a utopia. Because of this perceived deficiency, reformers want to supersede traditional Western ethics with a new code based on the "right" to medical care and other economic goods. They would replace personal responsibility with social responsibility, and "thou shalt nots" with a far more demanding list of positive obligations.

Stay tuned for Part II in the next newsletter issue.

Jane M. Orient, M.D is an internist practicing in Tucson, Arizona and Executive Director of AAPS

Banquet address to AAPS 43 Annual Meeting, Bermuda, Oct. 24, 1986

Reprinted with permission from the author, originally printed in the Journal of American Physicians and Surgeons Volume 9, Number 2 Summer 2004