State v. Heffernan
State v. Heffernan
Opinion of the Court
This case comes before this court on certification from the District Court of the Sixth Judicial District for the determination of certain constitutional questions raised by the defendant in his special plea in bar.
The defendant was arrested on a warrant'dated November 6, 1912, issued on the complaint of Gardner T. Swarts, Secretary of the State Board of Health, charging that the defendant ‘ ‘ did open an office with intent to practice medicine, and did hold himself out to the public as a practitioner of medicine by appending to his name the title ‘ doctor,’ and an abbreviation thereof, to wit, ‘ Dr.,’ and by appending to his name the title of ‘ Neuzopathic Physician,’ also by appending to his name the title of * Neuzopath,’ and by representing that he was versed in and willing to practice for compensation the art of preventing, curing and alleviating disease and pain, and did *124 attempt to and did practice medicine and surgery after having received therefor, and with intent to receive therefor, directly and indirectly, a bonus, gift and compensation, said defendant not being then and there legally authorized to practice medicine within this State, and not being then and there registered to practice medicine according to law. ’ ’
On arraignment the defendant pleaded not guilty, but thereafter was permitted to withdraw his plea and to demur to the complaint. His demurrers being overruled, he thereupon filed a special plea in bar wherein he sets forth ‘ ‘ that although he may be competent to practice a system or systems of medicine, and although he has been and is willing to be examined as to his qualifications by a board of examiners legally constituted, according to the provisions of any law of this State which is not in conflict with the Constitutions of the State of Rhode Island or of the United States, nevertheless, it is impossible for him to conform to the requirements of the statutes in such case made and provided, for the reason that the said Thomas J. Heffernan is not a graduate of any college or school of medicine; that the system of medicine or therapeutics in which he has always been willing to be examined was originated by the said Thomas J. Heffernan, and said system is not taught in any school or college of medicine, so that it is impossible for the defendant to present to the State Board of Health satisfactory evidence of graduation from any college or school of medicine. Thus the said defendant is forbidden by statute to practice a system originated by himself or any other system included in the complaint and warrant, unless he has graduated from a college or school of mdeicine.' For this and for other reasons to be pointed out herewith the said Thomas J. Heffernan says that Chapters 19& and 115 of the General Laws of the State of Rhode Island are unconstitutional, being in violation of the provisions of the *125 Constitutions of the State of Rhode Island and of the United States in making it impossible for the said defendant to pursue his lawful occupation, and he specifies his objections as follows: ” stating ten different specifications wherein said chapters are unconstitutional. The first five charge that Section 3 of Chapter 193 of the General Laws is unconstitutional, and the fourth and fifth make a similar claim as to Section 5 of the same chapter. The sixth, seventh and tenth specifications allege that Chapter 193 in its entirety is unconstitutional. The eighth alleges that Chapter 115 of the General Laws is unconstitutional and particularly Section 1 thereof; the ninth makes the same charges as to said Section 1.
The first specification of unconstitutionality contained in defendant’s special plea is in the following words and figures: “ 1. Section 3 of Chapter 193 of the General Laws, which says that any person must present satisfactory evidence of graduation from a college or school of medicines in good standing before he will be permitted to take an examination to practice medicine, is unconstitutional because it is in conflict with Section 2 and Section *126 10 of Article I of the constitution of the State of Rhode Island, and with Section 1 of Article 14 of the Amendments to the Constitution of the United States in this: Section 3 of said Chapter 193 prohibits persons from qualifying to practice medicine and surgery who are not graduates of a college or school of medicine, and makes no provision for persons who are not graduates of such schools or colleges but who are qualified to practice medicine, nor does it make any provision for persons who desire to practice a system of medicine which is not taught by any school .or college. Said Section of said Chapter is not therefore made for the benefit of the whole people as required by Section 2 of Article 1 of the Constitution of Rhode Island; said Section 3 of said Chapter deprives this defendant of the right to pursue his lawful occupation, and thus deprives him of his liberty and property without due process of law. ’ ’
It is apparent that the provision in Section 3 of Chapter 193 that a candidate for examination must present “ satisfactory evidence of graduation from a medical school in good standing ” makes such graduation a qualification essential to the lawful practice of medicine or surgery within this State by anyone not thus in practice on May 22, 1908, and in effect excludes all persons without this qualification from such examination. This statutory bar to the practice of medicine by the defendant raises the important question in this case. The defendant in his plea admits his lack of this qualification, but claims that the statute is invalid in that it deprives him of his constitutional rights.
Section 2 of Article I of the Constitution of Rhode Island is as follows: ‘ ‘ Sec. 2. All free governments are instituted for the protection, safety and happiness of the people. All laws, therefore, should be made for the good of the whole; and the burdens of the state ought to be fairly distributed among its citizens. ’ ’
*127 Tlie defendant in Ms brief quotes the portion of Section 10 of Article I of the State Constitution with which he deems Section 3 of Chapter 193 in conflict, as follows: “ . . . nor shall he be deprived of life, liberty, or property, unless by the judgment of Ms peers, or the law of the land; ” and that portion of Section 1 of Article XIY of the Amendments of the Constitution of the United States, with which said Section 3 is claimed to conflict as follows: “. . . No state shall-make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any state deprive any person of life,' liberty, or property, without due process of law, nor deny to any person within its jurisdiction the equal protection of the laws.”
The defendant apparently does not question the authority of State legislative bodies to regulate in some manner and to a certain extent the practice of medicine, as in his brief he states that “ Statutes regulating the practice of medicine have been passed in all the states and have generally been upheld as being valid police regulations to protect the public health.” His claim, however, is that in Chapters 115 and 193 the General Assembly has exceeded its constitutional powers. This legislative authority to enact such statutes and the right on which it rests are well stated in State v. Vandersluis, 42 Minn. 129, as follows: “ That the legislature may prescribe such reasonable conditions upon the right to practice medicine or law as- will exclude from the practice those who are unfitted for it, is so well settled by decisions of the courts as to be no longer an open question. The power rests on the right to protect the public against the injurious consequences likely to result from allowing persons to practise those professions who do not possess the special qualifications essential to enable the practitioner to practise the profession with safety to those who employ him.” . . . “ The only limit to the legislative *128 power in prescribing conditions to tbe right to practise in a profession is that they shall be reasonable. Whether they are reasonable,— that is, whether the legislature has gone beyond the proper limits of its power,— the courts must judge. By the term ‘ reasonable ’ we do not mean expedient, nor do we mean that the conditions must be such as the court would impose if it were called on to prescribe what should be the conditions. They are to be deemed reasonable where, although perhaps not the wisest and best that might be adopted, they are fit and appropriate to the end in view, to wit, the protection of the public, and are manifestly adopted in good faith for that purpose. If a condition should be clearly arbitrary and capricious; if no reason with reference to the end in view could be assigned for it; and, especially, if it appeared that it must have been adopted for some other purpose,— such, for instance, as to favor or benefit some persons or class of persons,— it certainly would not be reasonable, and would be beyond the power of the legislature to impose.”
Dent v. West Virginia, 129 U. S. 114, is a leading case in this branch of the law. In referring to the right of a citizen to follow any calling and the limitations upon the exercise of this right by a state the court says, on page 121: ‘‘ It is undoubtedly the right of every citizen of the United States to follow any lawful calling, business, or profession he may choose, subject only to such restrictions as are imposed upon all persons of like age, sex and condition. This right may in many respects be considered as a distinguishing feature of our republican institutions. Here all vocations are open to every one on like conditions. All may be pursued as sources of livelihood, some requiring years of study and great learning for their successful prosecution.” . . . “ But there is no arbitrary deprivation of such right where its exercise is not permitted because of a failure to comply with *129 conditions imposed by tbe state for tbe protection of society. Tbe power of tbe state to provide for tbe general welfare of its people authorizes it to prescribe all snob regulations as, in its judgment, will secure or tend to secure them against tbe consequences of ignorance and incapacity as well as of deception and fraud. As one means to this end it bas been tbe practice of different states, from time immemorial, to exact in many pursuits a certain degree of skill and learning upon wbicb tbe community may confidently rely, tbeir possession being-generally ascertained upon an examination of parties by competent persons, or inferred from a certificate to them in tbe form of a diploma or license from an institution established for instruction on tbe subjects, scientific and otherwise, with which such pursuits have to deal. Tbe nature and extent of tbe qualifications required must depend primarily upon tbe judgment of tbe state as to tbeir necessity. If they are appropriate to tbe calling or profession, and attainable by reasonable study or application, no objection to tbeir vahdity can be raised because of tbeir stringency or difficulty. It is only when they have -no relation to such calling or profession, or are unattainable by such reasonable study and application, that they can operate to deprive one of bis right to pursue a lawful vocation.
New professions require more careful preparation by one who seeks to enter it than that of medicine. It bas to deal with all those subtle and mysterious influences upon wbicb health and life depend, and requires not only a knowledge of the properties of vegetable and mineral substances, but of the human body in all its complicated parts, and tbeir relation to each other, as well as tbeir influence upon the mind. Tbe physician must be able to detect readily tbe presence of disease, and prescribe appropriate remedies for its removal. Every one may have occasion to consult him, but comparatively few can *130 judge of the qualifications of learning and skill which he possesses. Reliance must be placed upon the assurance .given by his license, issued by an authority competent to .judge in that respect, that he possesses the requisite •qualifications. Due consideration, therefore, for the protection of society may well induce the State to exclude from practice those who have not such a license, or who are found upon examination not to be fully qualified. The same reasons which control in imposing conditions, upon compliance with which the physician is allowed to practice in the first instance, may call for further conditions as new modes of treating disease are discovered, or a more thorough acquaintance is obtained of the remedial properties of vegetable and mineral substances, or a more accurate knowledge is acquired of the human system and of the agencies by which it is affected. ’ ’
It might naturally be expected from the nature of things that the.“ healing art ” would early be in evidence. This appears to have been the fact. History shows that that there was a practice of medicine in some form by the Egyptians and Greeks centuries before the beginning of the Christian era. Books and treatises on medicine and its practice were written at an early date and in time its practice was recognized as a distinct art. In Bragg v. State, 134 Ala. 165, 58 L. R. A. 925, the court traces in a general way the history and development of the medical profession which m’ay be exanlined by those interested therein. See, also, State v. Biggs, 133 N. C. 729, 737. This brief reference to these cases will suffice for our present purpose without quoting therefrom. "While undoubtedly in stages of its history the practice of medicine has been to some extent empirical, it is safe to say as a matter of common knowledge that a vast amount of accurate information has now been accumulated as to the structure of tire human body, as to the functions of its various parts, as to the diseases to which it is subject or exposed and as to the discovery and use of remedies for the prevention and cure of disease, and that this information is included in the subjects of study in medical schools. It is also a matter of common knowledge that by increased facilities for research and experiment in laboratory by men scientifically trained within the last few years, great advances have been made in a more intelligent and successful practice of medicine and surgery. It is of these and kindred subjects' that the person seeking permission to practice medicine is required by our law to have knowledge. In State v. Mylod, 20 R. I. 632, 637, in discussing the meaning of the words “ practice of medicine ” in the statute the court said: “ The practice of medicine, as, ordinarily or popularly *133 understood, lias relation to the art of preventing, curing, or alleviating disease or pain. It rests largely in the sciences of anatomy, physiology, and hygiene; it requires a knowledge of disease, its origin, its anatomical and physiological features, and its causative relations; and, further, it requires a knowledge of drugs, their preparation and action. Popularly it consists in the discovery of the cause and nature of disease, and the administration of remedies or the prescribing of treatment therefor.” While doubtless there is a difference in the different schools of medicine as to the remedial measures to be employed in the treatment of disease, nevertheless an accurate knowledge of the human body, of the functions of its organs and parts, and of the diseases to which it is subject must furnish the foundation of medical practice in all schools of medicine. The defendant does not seek an examination in these matters, but says he has originated a system of medicine or therapeutics not taught in any school of medicine, in other words, that ho has originated a new method for the discovery, prevention and treatment of disease. It may perhaps be inferred that he is the only practitioner under the system thus originated, and that there is no one qualified to examine him in it. There is no suggestion that defendant’s system of medicine has ever been explained or submitted for examination to anyone or has ever been committed to print so that it may be examined or studied by others. A system thus unexplained with apparently no followers is scarcely worthy to be dignified by calling it a school of medicine. In these circumstances, while recognizing that progress in the discovery of the causes of disease and of its preventionis probably now being made, we think it is outside of all reasonable probability that the defendant has discovered such a large field of medical knowledge, hitherto unexplored by any student, investigator or practitioner of medicine, as to permit him *134 to originate a new system of medicine or therapeutics; In our judgment it is so utterly improbable, that a legislative provision which excludes one from practicing such a system upon his fellowmen must be held to be in the interest of the general welfare ’and to be a reasonable and proper exercise of legislative power.
There are many cases in which the constitutionality of a statutory provision requiring the production of a diploma from a school in good standing as preliminary to practicing the profession has been upheld — some in dentistry and others ifi the medical profession. As for example, Dent v. West Virginia, supra; State v. Vandersluis, supra; Scholle v. State, supra; Kettles v. People, 221 Ill. 221; Gothard v. People, 32 Col. 11; Fox v. Territory, supra; State v. Creditor, supra; People v. Phippin, 70 Mich. 6.
We are of the opinion that specification 2 raises no constitutional question, but simply a question as to the interpretation of the words ££ reputable physician.” Whatever their meaning, it does not appear in the present case that they in any way are the cause of the defendant’s exclusion from practice, or that they affect him.
As has heretofore appeared, this court in State v. Mylod, supra, held that the words “ practice of medicine ’ ’ must be construed to relate to the practice of medicine as ordinarily and popularly understood. On page 637 of 20 R. I. the court discusses the rule of construction to be followed and reaches the result already stated, summed up in this sentence, “ Popularly it ” (the practice of medicine) “ consists in the discovery of the cause and nature of disease, and the administration of remedies or the prescribing of treatment therefor. ’ ’ This interpretation was reaffirmed in Swarts v. Siveny, 35 R. I. 1, 7. While the defendant has called our attention to several cases in discussing this specification, we think none of them sustains his claim. We do not find that Chapter 193 is in conflict with either the State or Federal Constitution as alleged in the specification. From some of the cases cited it seems as if defendant’s counsel had in mind and was considering the question of the sufficiency of a criminal complaint charging one with the unlawful ‘ ‘ practice of medicine ” without other description of the offence, and was urging that such complaint does not satisfy the requirements of Section 10 of Article I of our constitution as to informing the accused “ of the nature and cause of the accusation.” The specification, however, does not raise the constitutional sufficiency of the complaint which was the question in State v. Murphy, 15 R. I. 543, where the form of complaint was prescribed by the statute. That also was the question in State v. Carey, 4 Wash. 424, 430. The statute of that State specifies certain things, as constituting the practice of medicine, as does Section 8 of our Chapter 193. The Washington court clearly implies that if the complaint had defined the of-fence as described in the statute (as the complaint in the present case does) it would have been held good.
*138
The provisions of Section *1 of Chapter 115 objected to are, “ There shall be a State Board of Health which shall consist of seven persons, two from the county of Providence, one from each of the other counties, and one from the state at large. At least four members of said board shall be well-educated physicians, and members of some medical society incorporated by the state.”
The members of the board are appointed by the Governor, with the advice and consent of the Senate for a term of six years each. Their duties in general aré set forth in Section 2 of Chapter 115, as follows: “The board shall talce cognizance of the interests of life and health among the citizens of the state; they shall make investigations into the causes of disease, and especially of epidemics and endemics among the people, the sources of mortality and the effects of localities, employments, conditions and circumstances on the public health, and shall do all in their power to ascertain the causes and the best means for the prevention of diseases of every kind in the state. They shall publish and circulate, from time to time, such information as they may deem to be important and useful for diffusion among the people of the state, and shall investigate and give advice in relation to such subjects relating to the public health, as may be referred to them by the General Assembly, or by the Governor when the General Assembly is not in session.”
*141 Section 3 requires them to investigate the subject of diseases among cattle or other animals, and their duties also have been enlarged by subsequent enactments. ■ See Chapters 386, 728, 1070 and 1226 of the public Laws. See, also, General Laws (1909), Chapter 113, Section 4, Chapter 114, Sections 13, 14, 15, Chapter 116, Chapter 121, Sections 20 to 23, Chapter 276, Section 7, Chapter 356, Sections 30 to 32.
The board was established by Public Laws, Chapter 680, passed at the January Session, 1878. It was then composed of six persons, three of whom were required to be “ well educated physicians and members of some medical society incorporated by the State.” Prom the beginning their duties included those set out in Sections 2 and 3 of Chapter 115, supra. Prior to the -passage of Chapter 680 the several town councils and boards of aldermen were ex officio boárds of health in their respective towns and cities. The creation of the State Board of Health did not divest the local boards of their powers and it may reasonably be inferred that the former was expected to cooperate with and to supplement the activities of the latter. By Chapter 794, passed January, 1880, the board was authorized “ to elect a well-qualified physician as their secretary,” who became ex officio a member of the board, although since January, 1915, he has not been such member. He was not by statute required to be a member of any medical society. By Chapter 1519, passed March, 1908, Section 1 of Chapter 96 of the General Laws (1896) was amended to read as Section 1 of Chapter 115 of the General Laws of 1909 now reads. The situation from time to time has been this: from 1878 to 1880 of the board of six, three were required to be physicians who were members of a medical society of the State; from 1880 to 1908 the board consisted of seven members, four of whom were required to be physicians, three of them members of a state medical society; from *142 1908 to 1915 the board consisted of eight members, five of them physicians, four of whom - were required to be members of a state medical society; and since 1915 seven members have composed the board, four of whom are to be physicians who are members of a medical society. An examination of the defendant’s brief, in discussing Chapter 115, discloses no objection to the act creating the State Board of Health, because for the most of the thirty-eight years since its passage the provision has been that the majority of the members must be physicians. An inspection of the act itself and the various amendments thereto setting forth the powers and duties of the board relative to the measures to be taken for '-the prevention and spreading of disease and for the, guarding of the public health would seem to put it beyond discussion that a majority of the board ought to be men trained to deal with such matters. The provision that such majority should be physicians is, therefore, in our opinion a reasonable exercise of legislative power. The real objection is to the requirement that the physicians must be ‘ ‘ members of some medical society incorporated by the State,” in that it is legislation for a class, and not for the public welfare, and is thus obnoxious to the State and Federal Constitutions. It is to be borne in mind that in 1878, when the State Board of Health was created and long after, that is, until 1895, there was in Rhode Island no statute regulating the practice of medicine or defining the qualifications of a practitioner. The term “ physicians ” was used in the statutes and certain duties were imposed on them, but any man, irrespective of whether or not he had prepared himself therefor, might practice medicine, if he could find people willing to trust their health and lives to his head and hands. Under such conditions it might be expected to be and undoubtedly was the fact that some poorly educated and ill-trained, but well-meaning men, and some unscrupulous pretenders and quacks *143 were practicing medicine and were popularly classed as physicians.
Prior to 1878 charters had been granted to three medical societies and no question is made as to their previous incorporation and to their existence in 1878. The first was the Ehode Island Medical Society. The act was passed in February, 1812, and names forty-six incorporators, and their names would indicate that they represented the different portions of the State. The preamble to the act is as follows: “As the medical art is important to the health and happiness of society, every institution calculated to further its improvement, is entitled to public attention; and as medical societies, formed on liberal principles, and encouraged by the patronage of the laws, have been found conducive to this end: Be it therefore enacted, ’ ’ Sc. Section 7 of the act is as follows: ‘ ‘ The president and members of said society or such officers or members as they shall appoint for that purpose shall have full power and authority to examine all candidates for the practice of physic and surgery (who shall offer themselves for examination) respecting their skill in their profession; and if upon examination said candidates shall be found skilled in their profession and fitted for the practice of it they shall receive the approbation of the society in letters testimonial under the seal of said ’.ociety, signed by the president, or such other person or persons as shall be appointed for that purpose.”
At the October session in 1827 the Ehode Island Central Medical Society was incorporated, nineteen persons being named as corporators. Its Section 7 is in effect the same as Section 7 just quoted from the earlier charter. The Ehode Island Medical Eeform Society was incorporated at the October session of 1854 (p. 36). Its preamble runs thus: “ Whereas certain persons have associated themselves together, for the purpose of aiding and encouraging the medical reform practice, which excludes in *144 a great measure the use of the lancet, and also the use of mercury and antimony and have petitioned this assembly to grant them a charter of incorporation, with the privileges and powers following: ” This charter contains no provision similar to Soption 7 of the last two charters. By an act of amendment passed at the January Session, 1872 (p. 207) the name of this corporation was changed to Rhode Island Liberal Medical Association and the preamble of the original act was mack; to read: ‘ ‘ Whereas certain persons have associated themselves together for the purpose of mutual improvement and protection in the practice of medicine and surgery, and have petitioned,” etc.
The first two charters provide for the election of “ suitable persons ” as members by a majority of those present at any legal meeting. The expression “ suitable ” implies that membership in the two older societies called for qualifications of some kind. We think this is also implied in the amended preamble of the third societj7'in the words “ associated . . . -for mutual improvement and protection in tiie practice of medicine 'and surgery.” The provision of Section 7 giving authority “ to examine all candidates for the practice of physic and surgery (who shall offer themselves for examination) respecting their skill in their profession ” and to issue letters testimonial to those-11 ‘ found skilled in their profession ” is a recognition by the General Assembly of qualifications on the part of the society officials to examine candidates and to determine their skill in the profession. This section seems to point to an effort to improve and in a mild way to standardize the practice. The examinations were wholly voluntary and'the testimonial was an endorsement of fitness in practice, which would be of such value to the holder as the public might give to it. In the light of all the surrounding circumstances it does not seem unreasonable to presume that at least a *145 great majority of the more eminent, skillful and experienced practitioners of medicine would be members of these societies, and that most of the poorly trained, unskillful and ignorant practitioners would not be included in such membership. In other words membership in such societies would afford, to a certain extent a test of professional standing and ability in that at least the quacks and those least qualified for practice would not be found in them. Having regard to the prevailing conditions and the objects to be accomplished, was the requirement of the original act that the physicians on the board should be ‘1 members of a medical society ’ ’ in the State reasonable or arbitrary and capricious? We have hereinbefore referred to the rule governing classification with citation of cases from the Supreme Court of the United States illustrative of the application of the rule. It is sufficient to say that the reasonable inference is that the General Assembly was providing for the selection of physicians likely to be competent for the duties assigned them as members of the board, and named membership in a medical society as a qualification, because it tended to ensure competency. Our attention is called in the brief for the State to the fact that since 1878 eight medical societies have been incorporated in this State, five by special act and three under the general corporation law passed in 1896. Inasmuch as that law now requires but five persons to form such a society, it is plain that any school of medicine in the State having as many as five members may form such a medical society, and its members thus become eligible for appointment to the Board of Health, if they also be “well-educated physicians,” As under Chapter 115 the duties of the State Board of Health do not include any relating to the regulating of the practice of medicine, and as by legislative enactment since 1878 the list of eligibles for appointment to the *146 board as physicians may now include practitioners in the State of every school of medicine, if they number as many as five, we think there is no sufficient ground for the claim that Section 1 of Chapter 115 was passed not in the interest of the public welfare but for the benefit of a particular class. The history of the origin and development of this legislation indicates a legislative intent the reverse of that claimed by the defendant.
We are of the opinion that none of the objections properly raised by the defendant to the constitutionality of Chapter 193 and especially Section 3 thereof are well founded and valid.
Tlie papers in the case will be sent back to the District Court of the Sixth Judicial District with our decision certified thereon for further proceedings.
Reference
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- State v. Thomas J. Heffernan.
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