Canadian Medicine: A Study in Restricted Entry by Ronald Hamowy (review)

REVIEWS 101 thantoextendearlierviews. Forexample,in hisarticle'The OrangeOrder in Toronto:Religious RiotandtheWorkingClass,' Kealeycomments, 'Orangeismwasneverracist ...'(3•,).Pennefather notesthattheUnitedStates hashad onlyoneRomanCatholic president, whileCanada hashadseveral such prime ministers.He states,'Orangemenclaim credit for this differenceon the Canadianscene'(6). Certainly someOrangemenvoted againstTupper in •896,butcanwereallycreditthenotionthatourOrangeOrderwassotolerant that it canbe considered responsible for Thompson,Laurier, St Laurent, Trudeau,Clark,or Mulroney?Someotherclaimsare quitestartling:'Asour contemporary worldagrees thatdemocracy mustneverforgettheHolocaust, sotooisOrangeism convinced thatthehorrorsofthese events [theMassacre of theHuguenots bytheCatholics of FranceandtheSpanish Inquisition] should continue tobeproclaimed' (x). There mightbesomevirtuein sanitizing the OrangeOrder, but thisistoomuch. The reprinteddocuments, whichcomefrom a varietyof newspaper and archival sources, are,atleastinsome cases, interesting. However,thesample of documents provided in Part• of TheOrange andtheBlack istoosmallto be accepted aseithercomprehensive or representative. R.S.Pennefather hasprovideda fewinsights intoOrangeism in Canada, andhasreprintedsome usefuldocuments. Unfortunately,thebookin general isepisodic in approach andsuperficial in interpretation. It addslittleto our growing knowledge of CanadianOrangeism. DONALD SWAINSON Queen's University Canadian Medicine: A Study in Restricted Entry.RONALD HAMOWY. Vancouver: TheFraser Institute•984. Pp.xxiv,394.$24.95 Thislatestmajoreffort bythe Vancouver-based FraserInstituteto persuade Canadians of the meritsof deregulationand increased competitionin the marketplaceexamines thesupplysideofhealthcare.The author,aUniversity ofAlbertahistorian of social andlegaltheory,recounts in detailthe'historical development of legalrestrictions onentryintomedicalpractice in Canada'up tothe•9•,os. The resultis•,6•,pages of refreshingly frankandgenerally well expressed prose,two-fifths on theperiod•887- •9••',analysing theadoption oflicensing, provincially andnationally, anditseconomic effects onconsumers and physicians. Twenty-onetablesprovide returns on medicalstudents, graduates, licences granted,physicians, and,from •946 to •98•, professional incomes. Explanatory notes, harshcriticisms of Canadian medical historians, andreferences to worksin the theoryand practice of occupational licensing andsources inCanadian medical history comprise another 9øpages. Aswell,in a ten-pagepreface senior Institute economistWalter Block assertsthat Hamowy's readingof thehistorical evidence andcurrentdataon physicians' 102 THE CANADIAN HISTORICAL REVIEW incomes justify replacing'monopoly licensing' with 'a competitive system of medical certification.' This isour mostdetailedhistorical surveyof licensing and practitioners' viewson their professionfrom a perspective criticalof their motivesand actions. Drawingextensively fromAmericanstudies of occupational licensing, from Canniff, Heagerty,MacNaband Godfrey for pre-•867 material,from medical directories andan •89• Illinoisreportonmedicaleducation in North Americafor post-•867data,andfromeditorialcomment inCanadian medical journalsandstatute books throughout,Hamowyisbestindescribing therules, changes tothem,andarguments usedbyleadingregulars todefendproposed or existingregulations.In this regard, becausehe quotesat length,and frequently, from medical journalsandstatutes andprovides extendednotes, Canadian Medicine isa usefulreferencework. In otherrespects thevolumeis far lesssatisfactory. Hamowy's analysis of'forcesworkingtowards' enactment oramendment of licensing is seriously flawed.He presents a reductionist viewof physicians' motivesin which their oft proclaimeddesire to protect the public from incompetence becomes a 'rationalization' maskingthe onlyreal objective of 'everypolicy legislated bytheprofession, everystatutory enactment forwhich theylobbied,'namely,'maximizingthe incomes,status,and prestigeof the profession's members, evenwhensuch legislation conflicted withthewishes of thenation's consumers of healthservices.' This seems amajordistortion of the regulars' position, a consequence perhapsof discerning motivation byresults aloneandof refusingto concede to regularsa genuineconviction thatrival therapeutics andhealthcareagents wereatbestuseless andatworstpotentially lethalalternatives offered to a publicill-equippedto recognize the allegedly scientific, hencesuperior, basis of allopathy. The analysis isequally reductionistin explaining whychanges camewhentheydidandwhythose alonewere implemented. The account isone-sided; weseethe practitionerateveryturn butseldom thepublic.ThusHamowyattributes toomuchpolitical influence to practitioners collectively and too little to what SamuelShorttterms'the pressures andexpectations of asociety increasingly concerned withmatters of health.'Littleissaidaboutshifts inpublicattitudes afterthe•85os towards the efficacy of regularand othertherapeuticsystems. Eventhe contribution of physicians inthepublichealthmovement tothisgradualchange inattitudes, a part of what Paul Starr termsmedicine's increasing'culturalauthority,'is ignored.In short,Hamowyvigorously deniesanyclaimfor the primacyof externalfactorsin the makingof the modern profession. His confidence seems, at best,premature.Recentpapersby GidneyandMillar, McCaughey andHowell,allapparently unreadbyHamowy,representthesortof detailed studies needed beforeHamowyandothersinthefieldcansatisfactorily explain thecontribution of practitioners to theriseof licensing in Canada. Hisanalysis oftheimpactoflicensing andcurriculumregulations isequally REVIEWS 103 problematic.The discussion of medical schoolenrolmentsand numbers graduating isatleastincomplete. It takes noaccount, forexample, of shifting demographic structures and careeropportunities across rural Ontario that helpeddirectyoungmentowards medicine. Thushisconclusions respecting thepower of theprofession to shape itsdestiny areoverly generous. Most disappointing is that Hamowyprovides almostno systematic analysis of physicians' incomes, wealth,and social standing in the crucial•85o-•9oo period;theimpactof licensing ismoreasserted thandemonstrated, again partly because appropriate evidence isnonexistent orincomplete anddetailed scholarly analysis of localandprovincial conditions islacking. If this volumedoesno more than spur further researchinto why the profession soughtandeventually attainedmonopolylicensing and whatits costs andbenefits havebeenovertheyears,Canadianmedicalhistorians, at least, willoweHamowya greatermeasure of appreciation thanthataccorded him in the daily and medicalpress.As for his and...