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This chapter studies trade unions and how they helped promote the emerging private health insurance system, showing that the trade unions also led the drive for Medicare and disability insurance. It looks at the development of private health benefits and the events that led to the establishment of disability insurance and insurance for retirees. Finally, the chapter shows how those who supported medical insurance finally defeated the American Medical Association.

This chapter presents the regulatory structure for health care professionals with an emphasis on physicians. It traces the history of the formalization of the medical profession, initiated by the American Medical Association (AMA). This organization successfully induced every state to adopt a licensing process, and it standardized medical education based on the findings of the Flexner Report, issued in 1910. Regulation of the medical profession, including granting licenses to practice and imposing discipline, remains at the state level but with several federal and private organizations providing elements of national coordination. Oversight is also imposed by various other governmental and private bodies, including the federal Medicare program, specialty boards, health maintenance organizations, and hospitals. Similar regulatory arrangements govern osteopathic physicians and many allied health professions. The chapter concludes with a review of perennial policy conflicts, including that between licensure and consumer information as arbiters of professional quality.

American physicians have not always enjoyed the high incomes and social standing they do today. The American Medical Association worked with state governments in the late nineteenth and early twentieth centuries to implement licensure requirements and professional self-regulation of training to standardize practice, improve quality, and boost incomes by restricting entry. Federal workforce programs in the mid-twentieth century greatly increased the profession’s size. However, the most important driver of the profession’s standing today isMedicare. Its guaranteed reimbursement dramatically increased earnings, especially in specialties that focus onelderly patients. It also reinforced, albeit inadvertently, an income differential favoring specialty practiceover primary care. Additional public support has come from the National Institutes of Health, which helps to develop technologies on which specialists rely. Government programs did not create the medical profession, however without them, the profession would be smaller, less technologically capable, and far less remunerative.

This chapter describes the transformation of the American Medical Association's (AMA) instrument of ethical self-regulation—the 1847 Code of Medical Ethics—from an icon of professional pride into a loathed instrument of inquisition. It traces the origins of a revolt by an alliance of specialists, sanitarians, and scientists, who, led by the Medical Society of the State of New York, opted out of the AMA rather than submit to its code of ethics. As the balance of power and prestige in medicine shifted from general practice to hospital, public health, and specialist medicine, these rebels took charge of the AMA and substituted purely advisory laissez-faire principles for the “tyranny” of the AMA's code of ethics. The principle of laissez-faire was eventually adopted as organized medicine's approach to non-intrapractitioner medical ethics and this lasted through most of the twentieth century.

This chapter examines patents and trademarks in the antebellum period as it applied to the drug market. It argues that most manufacturers did not obtain patents on their goods, and that patent medicine manufacturers were unable to use early trademark law to protect their interests because trademarked names were assumed to be designating in nature and could therefore be freely adopted by competitors. The chapter also examines the origins of the American Medical Association and the conflict over Thomas Morton’s patent on ether. It further argues that a segment of pharmaceutical manufacturers self-consciously adopted the norms of the orthodox medical ethics, thereby rejecting the use of patents or secrecy for their goods. Finally, it examines early efforts by therapeutic reformers to pass laws regulating the practice of pharmacy and discusses the pharmacopeia.

This chapter looks at when the American Medical Association (AMA) introduced content into the yet-to-be defined concepts of “professionalism” and “professional ethics” that it inherited when it adopted Percival's language for its code of ethics. It first examines the scientific, moral, and social basis of the AMA's campaign to criminalize prequickening abortion, and then explores how the AMA interpreted the term “professional”. The AMA interpreted this in terms of traditional ideals of gentlemanly honor, creating a conception of a professional who, like an honorable gentleman, was engaged in a noncommercial, secular enterprise dedicated to high ideals of science and health, and who was white and male. In the post-Civil War period, this concept of professionalism and of the AMA's code of ethics became a lightning rod for controversy and an instrument of exclusion, wielded not only against “irregulars” but also against African-American and female physicians and specialists.

This chapter discusses the emergence of a new kind of medical consumerism in the 1930s as an alternative to the “marriage of medicine and business” that made Americans unwitting “guinea pigs.” Before considering the application of critical consumerism to medical care, the chapter traces the origins of calls for Americans to become more “intelligent buyers” of medicine in order to avoid the dangers of deceptive advertising, unsafe drugs and cosmetics, unnecessary medical procedures, and unaffordable doctors' bills. It then examines the strand of medical consumerism directed at drugstores that was built on longstanding complaints about proprietary drugs and their manufacturers' advertising techniques. It also comments on the disagreement among physicians over the consumerist ideal of the skeptical patient, with particular emphasis on the American Medical Association's refusal to admit the medical profession's flaws. Finally, it analyzes the growing conflict over what it meant to be a “good” patient.

Physician trustworthiness is the best protection against error-prone modern healthcare. This chapter discusses how medical education can nurture and sustain trustworthiness in future physicians using appropriate admissions criteria, explicit learning objectives, and rewards and sanctions for professional behaviors. It argues institutions should also be clear in articulating expectations, commitment, and values from students and faculty through an approach similar to the Compact Between Teachers and Learners of Medicine, which is a model compact designed by the Association of American Medical Colleges (AAMC). Other initiatives the AAMC is developing to improve education include the Institute for the Improvement of Medical Education and measures of professionalism for peer evaluation.

Cleanliness sidled up to godliness, and the sanitarian movement was born around the middle of the nineteenth century. Sanitarianism was viewed as a battle against a grave social problem. The sanitary movement was now in the genteel business of the cultivation of individual character. Cleanliness had taken its seat next to godliness. The Gilded Age cremation movement was an effort to purify America, and that effort had social and spiritual and sanitary import. The U.S. cremation movement capitalized on and contributed to the cultural preoccupations. Committees of the American Public Health Association, the Society of Medical Jurisprudence and State Medicine of New York, the Boston Homeopathic Medical Society, and even the American Medical Association (AMA) concluded that cremation was a sanitary necessity. At least in the nineteenth century, cremationists won the sanitary argument. The sanitary and social reform movements can themselves be viewed as ritual demonstrations.

This chapter shows how the American Medical Association's failure to address not only the ethics of human subjects research but a host of other ethical issues confronting post-World War II American medicine created the conditions for the emergence of a new paradigm of the relationship between physicians and patients, and medical researchers and their subjects—“bioethics.” It addresses the question of why American governmental agencies and professional societies could not expand government regulation and professional ethics to provide human subjects protections without engendering a bioethics movement. It suggests that American medical societies embraced a laissez faire ethics in which individual practitioners' consciences substituted for authoritative ethical policymaking. This ethos created a vacuum of authority with respect to medical ethics policymaking. When individual conscience proved inadequate to prevent ethics scandals in research or to resolve ethical issues surrounding emerging medical technologies, American society sought an alternative source of ethical guidance, leading to the emergence of bioethics.

This chapter describes the allopathic response to the democratic challenges of alternative medical sects, particularly homeopathy. It describes the formation of the American Medical Association (AMA) and its early practices as an organizational response to the problem of adjudication. The organization has three goals: educating the public on medical issues, reforming allopathic medical education, and combating “quackery” in all its guises through legislative efforts.

In the waning years of the nineteenth century, despite (or perhaps because of) the inroads of laboratory science, uncertainty still hung heavy over the future shape of the medical curriculum. Although currents of change now flowed freely through the medical schools and conditions of study were shifting in every country, agreement was far from universal on such primary questions as the place of science and the laboratory in medical study, how clinical medicine should best be taught, the best way to prepare for medical study, the order of studies, minimal requirements for practice, and the importance of postgraduate study. “Perturbations and violent readjustments,” an American professor told his audience in 1897, marked the life of every medical school in this “remarkable epoch in the history of medicine.” Similar to the era of change a century before, students were again confronted with bewildering choices. Old questions long thought settled rose in new form. Did the practical study of medicine belong in a university at all? Was bedside instruction still needed by every student in training, or was the superbly conducted clinical demonstration not as good or even better? Should students perform experiments themselves in laboratories so as to understand the real meaning of science and its promise for medicine, or was it a waste of valuable time for the vast majority? And what about the university—now the home of advanced science, original research work, and the scientific laboratory—was it to be the only site to learn the medicine of the future? What about the still numerous hospital and independent schools, the mainstay of teaching in Anglo- America in 1890—did they still have a place in the teaching of medicine? Amidst the often clamorous debates on these and other questions, the teaching enterprise was still shaped by strong national cultural differences. In the final years of the century, the Western world was experiencing a new sense of national identity and pride that ran through developments in science and medicine as well as politics. The strident nationalism and industrial-scientific strength of a united Germany, evident to physicians studying there, thoroughly frightened many in the rest of Europe.

This chapter focuses on what New York Times reporter Milt Freudenheim called “shopping mall medicine,” dedicated to providing quick and convenient service to patients every day of the week. It traces the emergence of for-profit health care companies such as Humana and the Hospital Corporation of America and examines how they transformed the economic dynamics of medical care, particularly as they affected physicians. It also considers the rise of a new medical-industrial complex, financed in part by postwar funding for both hospitals and physicians, and some of its most visible elements, including health maintenance organizations. Finally, it examines other factors that dealt a blow to the medical profession's sense of autonomy, such as the Supreme Court's 1982 ruling for the Federal Trade Commission in its lawsuit against the American Medical Association over the issue of physician advertising.

This chapter examines the television broadcasting of medicine in the United States. It discusses the role of the American Medical Association in the sponsorship and financing of medical dramas, and describes the first remote television broadcasting of surgery at Johns Hopkins University in 1947. The chapter also highlights the effectiveness of television dramas about hospitals, operations, diseases, and charismatic physicians in bringing medical information more effectively than most of other educational programs. It also describes some of the notable medical dramas of the 1940s and 1950s, including City 〉Hospital, The Doctor, and Medic.

This chapter describes how two items of business during an otherwise uneventful Yale Corporation meeting on March 21, 1910 shaped the future success of the medical school. “The Secretary read the confidential report prepared by Dr. Abraham Flexner on the condition of Yale Medical School,” and later in the meeting “the President spoke of possible changes in the scope of Professor Smith's work in the medical school, but no formal action was taken.” Flexner's report had been prompted by growing discontent with medical education amid a proliferation of proprietary schools across the country. The Council on Medical Education of the American Medical Association approached Henry Pritchett of the Carnegie Foundation for the Advancement of Teaching about conducting a study of medical education in the United States and Canada.

By the end of World War I, the basic structures of undergraduate medical education in both Europe and America were largely in place. Future practitioners on both sides of the Atlantic now began their training with a lengthy preparation in liberal studies, with special attention to physics, chemistry, and biology, then studied for two or more years in laboratory based courses in the preclinical medical sciences followed by a like period of clinical study, and finally spent at least a year in acquiring practical, hands-on training in a hospital. With few changes, except for the growth of postgraduate education, this basic pattern prevailed everywhere in the interwar years before 1945. In the transatlantic nations, in short, these were years of consolidation of patterns formed well before 1914. The study of medicine now consumed a minimum of five years beyond the school-leaving or college experience and frequently took six to ten years to complete. Except for the hospital schools of London, nearly every medical school in the Western world was attached to a university. Almost no school of medicine was without its teaching hospital where training students was a primary concern. Governments everywhere played an ever larger role in setting basic requirements and providing financial support of medical education. Physicians’ associations became more and more powerful and sometimes dominant in setting standards of education and licensure. And in these postwar years, the practice of medicine became an almost wholly middle-class occupation, exacting high standards of preparation and social expectation and open to only the most exceptional among the less affluent. The costs of study were rising so steeply that it was largely unavailable to the poor, even in the United States. The national differences of a quarter-century before, though evened out in many particulars, were still discernible in 1920. The war, after all, permitted no major changes in instruction, equipment, or curriculum in Europe, and reform efforts after the war were hampered by the need to restore and rebuild.

This chapter looks at the transformation of asylum care that was initiated by the Civil War. At the Eastern Lunatic Asylum, the biggest change came after the suicide of Superintendent John M. Galt during Union occupation of Eastern Virginia. Ultimately, Galt’s death created opportunities for his professional rivals in the Association of Medical Superintendents of American Institutions for the Insane to end his experiments with outpatient care and to insist upon the creation of segregated institutions for black and white patients. In the interim, the asylum was run by a series of Union doctors and civilians with the aid of former staff, including enslaved attendants. Operating during wartime was especially difficult for enslaved staff because their legal status was in limbo, and they were liable to seizure by raiding Confederates. Wartime shortages further compounded these challenges.

This chapter examines the alternative strategy of those advocating physician-assisted death (PAD): passing legislation that allows death with dignity. It begins with an overview of the slippery slope argument and other arguments presented by those opposed to legalization of PAD, including the American Medical Association (AMA) and the Roman Catholic Church. It then considers the political battles in the states over the right to die, with particular emphasis on initial efforts to legalize PAD through the use of the initiative and the referendum processes. It also discusses efforts in various states, including Washington State and California, to pass PAD legislation and concludes by outlining six factors that determine the success or failure of PAD initiatives at the state level.

This chapter looks at travel aimed at accessing experimental stem cell therapies that may not be available or legal in the patient's home country, so-called “stem cell tourism.” It uses interviews with ten patients who engaged in stem cell tourism. It first introduces the professional guidelines that are important to stem cell tourism, concentrating on guidelines from the American Medical Association (AMA) and from the International Society for Stem Cell Research (ISSCR). The AMA and ISSCR guidelines indicate that physicians are expected to have knowledge of stem cell-based medicine developments. The opinions of patients' physicians have also acted significantly in convincing patients to pursue the unproven stem cell-based interventions (SCBIs). It is then noted that different ways are needed to help prepare physicians to provide appropriate advice about alternative and unproven interventions.

The U.S. health care system is driven as much by centralized bureaucracies as by market dynamics and suffers from information shortcomings as a result. Neither patients nor healthcare providers have access to good information, leading to a highly inefficient system. Better systems for rating doctors and hospitals and for understanding health care spending are beginning to emerge and can be accelerated.