Freud's Free Clinics

1923
less of her ability to pay. Moreover, the quality of free treatment would be
identical to the quality of privately paid treatment. The idea that patient confidentiality
and social class go hand in hand was hardly new: affluent patients
buy a form of medical privacy from which patients are excluded. But the
challenge at the Poliklinik was not so much making sure that poorer patients
got private care but that individual care in itself could be justified ideologically.
In other words, as Simmel would argue in The Socialist Physician of
1925, the paradigm of individual patient/individual physician is the stamp of
bourgeois medicine. In contrast, the paradigm for socialist medicine is the
group (medical teams/patient units) and is impossible to achieve without a
structural reorganization of the whole health care system. Julius Tandler was
attempting to do just this in Vienna. Both Tandler and Simmel shared a commitment
to equality and both criticized bourgeois medicine, but Simmel was
caught in a contradiction because he wanted bourgeois privileges for his patients.
He hoped that the “fundamentally egalitarian nature of psychoanalysis”
would transform this practice dilemma that, eventually, even radical psychoanalysts
like R. D. Laing failed to resolve. Simmel did insist that the
clinical staff could not choose their patients on the basis of “ethical or aesthetic
considerations.” Even Eitingon balked at the risk of overly personalized
relationships with patients. He reprimanded Therese Benedek for saying
hello and good-bye and for shaking hands with patients (a standard custom
of Freud’s), but demurred when she responded, “If I did not do that, I would
not be myself and that would not be good for my patient.” 17 Nevertheless, indigent
patients were regarded with more respect and fairness at the Poliklinik
than elsewhere, Simmel and Eitingon stressed, and they intended to make
sure that this sense of social justice governed all their policies. They were appalled
when fancier teaching institutions, and even the Charité, separated out
“high fee-paying patients” but compelled the “proletariat and the ill insured
[to] provide material for medical instruction.” 18
For Simmel, words like proletariat or exploitation or egalitarianism were
charged with particular political meaning. Within a human society caught in
a vast class struggle, Simmel thought, the “proletarian” class was oppressed
by its lack of access to material resources closely held by the upper classes.
Even more oppressive, limited access to nonmaterial resources like education
and personal insight impeded the individual’s natural Rousseau-like ability
to be self-regulating. Depriving poor people of the use of psychoanalysis—
the very instrument of liberation the rich used for personal enhancement—
was yet another dimension of class oppression. Furthermore, callously placing
human sickness on exhibit for the benefit (even if it is a teaching benefit)
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