In the Public Interest: Medical Licensing and the Disciplinary Process

Chapter 2. How Licensure Became a Medical Institution

32 Chapter 2 Eliot Freidson argues that the handful of occupations deemed to be “professions ” proper have credentialed practitioners given the exclusive right to provide designated services.1 Other social scientists provide lists of characteristics of professions or stages distinguishing emerging professions. While there is no checklist against which one can gauge an occupation’s professional standing, there are features that clearly enhance a field’s prestige and give its members reason to claim coveted status enjoyed by established professions like law and medicine.2 A body of theoretical and technical knowledge and the extensive training needed to master it mark established professional fields. Those in these fields are generally required to attend an institution of higher education and pass a licensing exam before being allowed to practice. Practitioners typically form professional organizations that establish norms governing behavior and claim the right to police themselves with minimum outside interference. To legitimize their claim as professionals, practitioners often proclaim their commitment to public service and protection of community interests. According to Harold Wilensky, “The service ideal is the pivot around which the moral claim to professional status revolves. . . . [The professional] norms dictate not only that the practitioner does technically competent, high-quality work, but that he adhere to a service ideal—devotion to the client’s interests more than personal or commercial profit should guide decisions when the two are in conflict.”3 Some professions adopt formal ethical codes, but how well professionals live up to their professed ideals is open to question.4 The debates about a trade’s professional status almost invariably touch upon its members’ role as How Licensure Became a Medical Institution How Licensure Became a Medical Institution 33 guardians of common good. Professionals are eager to present themselves as faithful public servants mindful of their obligation to safeguard established values and responsive to community needs. Yet as early as 1901, Dr. T. J. Happel, secretary of the Tennessee Medical Board, wrote in the Journal of the American Medical Society (JAMA), after complaining that the attorney general would not prosecute board cases, “We are ready to assert that [medical laws] can not be enforced except through and by the medical profession. . . . The enforcement of medical laws interest[s] chiefly physicians, not the general public.”5 The professionalization of medicine in the United States testifies to the central role that knowledge and the service ideal played in legitimizing the medical profession at the end of the nineteenth century. Yet as the following discussion shows, the major players in the professionalization process— doctors, patients, legislators, judges, investigative journalists, community activists—routinely disagree on what the public interest is, which style of medicine or standards of practice it favors, and how one should go about safeguarding communal values. Even before the American Revolution, some doctors hailed licensure as a way to improve the quality of medical care. Others staunchly opposed licensing on grounds that it limits the public’s right to choose among health-care providers. And the public was split on the merits. Many doctors espoused the belief that the public was in no position to judge its own interests, which standards of care were right, or how to enforce ethical standards. As late as 1968 Dr. Milford Rouse, an American Medical Association (AMA) president, opined that the “public recognizes it does not have the knowledge or other qualifications to evaluate medical education, medical practice, or medical competence. The public has of necessity been forced to put its trust in physicians to insure that physicians practice competently and ethically.”6 In other words, the public good is so precious and the issues of medical standards, professional misconduct, and disciplining wayward doctors are so complicated that the public should defer to professionals and stay out of the deliberations. Licensure permitted occupational market closure and also permitted the medical profession to decide the public interest. The following historical overview centers on licensure as a focal point in the professionalization of medicine and the rhetoric of public good that various factions involved in the process invoked to justify their agendas. It should be noted that the reasons behind the licensure movement are complex, that commentators disagree about its origins and outcomes, and that even its contribution to the prestige of the medical field is open to question. One popular narrative starts with the premise that physicians are selfless professionals determined to obtain the best possible education to provide superior treatment [3.138.102.178] Project MUSE...