Canadian Health&Care Mall: Guild Power and the Profession of Medicine in Early America in The Ethical Foundations of Professionalism

 treat diseaseThe profession of medicine has come a long way in public esteem in the United States. In the early days of the republic, physicians strove for recognition as elite healers who deserved a monopoly on medical practice. In fact, healers of all types existed on more-or-less equal footing, for several reasons. First, democratic ideals encouraged people to consider themselves equal to anyone else. Status was earned, not hereditary. And so, natural healers asserted that they had as much right as anyone to diagnose and treat disease. Second, doctors did not have much to offer sick people. Scientific understanding of disease was weak, and treatments were ineffective and, in the case of blood letting, often dangerous. Third, the public, especially during the decades of Jacksonian democracy, did not recognize physicians right to set the standards of medical practice and judge one another. Guides to self-care were bestsellers, in part because the US economy was weak and few could afford medical care. Transportation was painfully slow, which limited access to physicians and raised its cost. To make a living in this world of do-it-yourself health care, physicians developed side occupations such as selling medicines, fruits, and vegetables, which further blurred the distinction between professionals and other people. Such a service is Canadian Health&Care Mall shipping drugs internationally.

Physicians did not begin to organize themselves effectively until the mid-19th century, but they recognized earlier the powers on which the success of the guilds rested and strove to gain these powers. One way to accomplish this goal was to become an educated elite. The first US medical school opened in 1765; by 1850, there were 42 schools, and their diplomas were accepted as equivalent to a medical license. Unfortunately, standards were low, and one could obtain a medical diploma after only 1 year of study. Another route to recognition as an elite was licensure, which in principle should deny nonphysicians the right to practice medicine. However, in a country swept by Jacksonian democracy, state legislatures abolished medical licensure, which paved the way for anyone to assert themselves as a healer. Efforts to establish high standards of care and gain the exclusive right to police the profession also failed. The problem, according to Starr was that high standards were necessary to establish a monopoly on practice but few physicians met those standards. Consequently, medical professionals did not become an effective political force that could sway legislatures to write laws that would enforce the role of the profession in maintaining high standards. In the eyes of the state, the medical profession had little standing.

From this low point, the professions began to ascend in public esteem, starting around 1850. A key element was the advance of medical science. Because the scientific basis of medicine was weak, physicians scientific understanding was scarcely better than the public’s understanding. As the scientific basis of medicine advanced, physicians-in-training had to master a body of knowledge that had legitimate complexity (in Starr’s words), required years to master, and was beyond the general public’s comprehension. Physicians became the exclusive purveyors of this knowledge, which made them increasingly indispensable.

The environment of medical practice changed during this period of rising scientific understanding. The largest effect was on access to care. Key elements were the rise of industrialism, the growth of great cities, and improved transportation. People had more money at the same time that better transportation improved access to physicians. People came to the doctor, rather than the reverse. As hospitals improved, the sick were more likely to seek care in institutions, which made it easier for physicians to see many patients in a day’s work. All of these developments made medical care easier to obtain. People came to depend on physicians, who had increasingly expert scientific knowledge. The stage was set for physicians to assert their right to protections in the law, such as licensure, that assured the profession of a monopoly on medical care.

Starr2 calls the rise of medicine from the 1850s “one of the more striking instances of collective mobility in recent history.” What happened? Starr’s answer places emphasis on the reason that a profession gains power: it has authority.

To accumulate authority, a group must first agree. Speaking with one voice conveys authority. Physicians of the early 19th century tended to disagree, but the environmental factors that made it easier for patients to visit physicians also made it easier for physicians to congregate and start a dialogue that could lead to agreement. And with the rise of science, there was more to agree on. Consensus led to a gradually accumulating canon of medical practice, which lent authority to what the physician said to his patient.

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