Canadian Health&Care Mall: Rise and Fall of the Craft Guilds in The Ethical Foundations of Professionalism

medical ethicsThe word professionalism has a particular meaning to contemporary physicians. It connotes everything that we admire in our colleagues and strive for in ourselves. Historians and sociologists view professionalism through a different lens, They tell us that the codes of conduct that we associate with professionalism have been part of a strategy for convincing the public that physicians should be the sole purveyors and standard setters of medical care including Canadian Health and Care Mall. In this article, I will entwine two stories. The first is the story of the professions, starting with the medieval guilds and ending with the medical profession in the United States. The second will be the evolution of codes of professional conduct that embody the behaviors we associate with the term professionalism. I will argue that present-day codes have evolved in part to restore balance in the relationship of the medical profession to government and business. This relationship has been changing, much to the disadvantage of the profession.

I am neither a historian nor a sociologist. I have relied on Elliott Krause’s book The Death of the Guilds1 and Paul Starr’s The Social Transformation of American Medicine to bring us from the Renaissance to the late 20th century. I have tried to connect this history to changes in codes of professional conduct.

In the introduction to his book, Krause asks a question that should concern physicians at the outset of the 21st century: “Is the organized political power of traditional professions—medicine, law, engineering, and the university professoriate—slowly fading in the West? Are some professions losing their guild powers—to control their association, their workplace, the market, and their relation to the state faster than others? And if so, why?” These questions, so pertinent to our own time, are about guild power: the power to set standards, train the workforce, limit entry into the workforce, and limit production.

Guild powers have strong historical precedent. In feudal times, people did not have the freedom to associate as they wished. Gradually, from 1100 to 1500 ad, guilds became the organizing principle for skilled work in many European cities. Guilds controlled the way that skilled handwork was done, so that the public could count on the quality of the product. Guilds ensured quality by setting up rules for performing work and insisting on long apprenticeships. They also controlled the opportunity to work by limiting the number of apprentices and the number of apprentices that advanced to master craftsman status. Control of the size of the workforce meant that members of the guild would have enough work to keep themselves busy and well paid. Guild masters owned the tools and the workshops and could control the rate of production so that quality— and price—remained high. Thus, the guilds main-tained—against incursions from other workers— high-quality products, a public good, by controlling access to the skills and the workshops and the rate of production. They also assured themselves of comfortable working conditions and a good income.

The apprenticeship model—in which only the best craftsmen became masters—benefited both the public and the guild members. However, apprentices who did not become masters became journeymen, workers with good skills but unable to make a living by using the skills they acquired during apprenticeship. The journeymen were a labor force waiting for someone to give them the right to work, While they waited, they grumbled at the elitism of the masters. Perhaps the public was a ready audience for their complaints, since many could not afford the high price of high-quality goods produced by masters. Still, the guilds flourished, perhaps because their interests were not in strong conflict with the interests of business and the state. In fact, the state (usually city governments) benefited from a tax that it levied against the guilds in return for supporting their monopoly on production.

The rise of capitalism, together with the existence of the journeymen, created a counter-force to the power of the guilds. Guild power was a threat to free markets because guilds could hold the price at artificially high levels by slowing production. And so, capitalists began to break the monopoly of the guilds by paying the city government more to dissolve the monopoly of the guilds than the guilds were able to pay to maintain their monopoly powers. Slowly, the craft guilds lost their power, quickly in France and England, which had strong central governments, and more slowly in Italy, which had no central government, and more slowly still in Germany, where capitalism was a late development. This interplay between the guilds (and later the professions), the state, and capitalism will be a recurring theme as we examine the rise and fall of the medical profession in the United States and the evolution of codes of professional conduct.

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