Rise of the American Medical Association in The Ethical Foundations of Professionalism

medical licensureFor the first half of the 20th century, the American Medical Association (AMA) wielded extraordinary power in American society. What the AMA wanted, it usually got. Founded in 1846, the AMA lacked power for its first half century. Arguably, its power has waned considerably in the second half of the 20th century. The reasons for its rise and its decline help us to understand the position of the medical profession in the early 21st century.

The AMA program in 1850 could have been taken directly from the medieval guild archives: to raise, and standardize, the requirements for practicing medicine. It did not get very far for several reasons. First, the AMA lacked money because few joined, and it therefore could not sustain a presence between its annual meetings. For the same reason, it could not speak for the profession. Medical schools, embroiled in their own internal politics, paid scant attention to AMA calls for higher standards of medical education. Worst of all, the AMA lacked authority over its members. Had a license been required to practice medicine, the AMA might have gained power more quickly by arrogating the power to set the standards for licensure.

In the second half of the 19th century, the AMA grew very slowly and lacked the power to win battles with nontraditional practitioners, such as homeopaths. The AMA began to grow when it reorganized itself as a confederation of state medical societies. County medical societies were becoming tight-knit organizations whose members protected other members from malpractice judgments by refusing to testify for the plaintiff. Members also sat on the governance committees that decided who could admit patients to a community hospital. Physicians joined the county medical societies to protect their interests. State medical societies began to grow when the AMA ruled that physicians who became members of the county medical society or the AMA would thereby become members of the state medical association. As the state medical societies grew, they became politically influential, which was all-important because the state legislatures established the laws that governed medical practice (such as medical licensure). By the beginning of the 20th century, states had medical licensure laws, and AMA members controlled the state licensure boards. In licensure, the profession in effect acted as the agent of the state.

Through its control of medical licensure requirements, the AMA was able to raise the standard of medical education, which ultimately meant that newly graduated physicians had status in the community because of their knowledge. The AMA Council on Medical Education established education requirements, rated medical schools by how well their curricula conformed to the requirements and, aided by the Flexner Report, forced substandard schools to close. The AMA had achieved the goal of any guild. Newly graduated physicians had status in the community because only they had deep knowledge derived from a mastery of the scientific underpinnings of medicine. And there were not many of them because only those who graduated from a limited supply of medical schools could qualify for a license to practice medicine. The AMA reforms clearly benefited the public as well as physicians, which was probably the ultimate source of the power of the AMA in public affairs.

The AMA maintained its remarkable influence for the first half of the 20th century, but it no longer has such power to change the environment of practice. The turning point came in 1964, when the AMA waged an all-out campaign to defeat the Medicare program legislation and failed. Since, while the number of AMA members has increased somewhat, the proportion of all physicians who are AMA members has dropped from 69% in 1962 to about half that number at present. This decline in membership has weakened the claim of the AMA that it speaks for the medical profession. Its resistance to changes in the delivery and financing of health care inclusively of Canadian Health&Care Mall is at odds with the interests of business, for whom the high cost of employees’ medical care is a threat, and federal and state government, for which the uncontrollable cost of Medicare and Medicaid is a prime concern.

This account of the establishment of the medical profession has several purposes that are germane to the rest of this article. First, we have learned how a profession emerges from weak beginnings to gain the essential characteristics of a profession: status, selfgovernance, standard setting, and a system to train practitioners. We have seen why the support of the state was necessary for medicine to rise and why a conflict between the interests of business and the medical profession has eroded the guild powers of the profession. Arguably, capitalism, the state, and the medical profession coexist in an equilibrium that maintains itself only if all three elements have common cause. Right now, medicine is the “odd person out.” Finally, we have begun to see why codes of ethical and business behavior are a cornerstone of a profession: they maintain physicians’ high status in the community, which is a key to maintaining a monopoly on practice. The last part of the article explores in greater depth the role of a code of behavior.

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