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* From the Annals of Internal Medicine, Philadelphia, PA.
Correspondence to: Harold C. Sox, MD, Annals of Internal Medicine, 190 North Independence Mall West, Philadelphia, PA 19106-1572; e-mail: hsox{at}mail.acponline.org
Abstract
The purpose of this article is to trace the development of medical professionalism in medicine from its origins to the present. Codes of professional conduct are the tangible expressions of professionalism. I use them as a window into contemporary circumstances of medical practice. The medieval guilds are my framework for examining the relationship of the medical profession in relation to society. The craft guilds of postmedieval Europe wielded considerable power. They controlled entry into a craft, training, and standards of quality. By controlling the volume of production, they controlled price. The craft guilds flourished until their monopoly powers began to hinder the forces of capitalism, which influenced the state to limit the powers of the guild. The professions are the offspring of the medieval craft guilds. Since the early 19th century, the medical profession in the United States has sought guild powers. The triangular relationship between state, capitalism, and the medical profession explains the rise of the profession during the 19th century and its decline since the mid-20th century. I argue that the codes of conduct of the profession reflect what it needs to maintain its guild powers against the forces of capitalism and the state. The Charter on Medical Professionalism calls on physicians to take into account both the individual patient’s needs and those of society. I believe this important clause reflects the conflict of the profession with the state and capitalism over the aggregate costs of medical care.
Key Words: medical ethics • professional conduct • professionalism
The 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. 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 Medicine2 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,1 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.
Rise and Fall of the Craft Guilds
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 maintained—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.
Origins of the Professions
Although the medieval craft guilds died off, several of what we now call professions first became organized as guilds and still have many of the trappings of the craft guilds. One is the university professoriate. It has encountered little opposition from capitalists because universities do not threaten the economic interests of capitalists enough to pose a real threat. The universities have enjoyed the financial support of governments for centuries, perhaps because governments recognize the importance of higher education in sustaining governance and the surrounding government bureaucracy. Of all professions that began as guilds, the professoriate survives with its powers largely intact.
Lawyers and doctors began to form guilds in the late medieval and early Renaissance periods. The status of their guilds depended on the family connections of members: lawyers’ guilds usually had more prestige than doctors’ guilds. However, both guilds were among the elite because of their ties to university education and the professoriate. While craft guilds were falling victim to the forces of capitalism and the state, lawyers’ and doctors’ guilds survived, probably because their interests did not conflict with the interests of capitalism, at least not until our own era.
I will use a model described by Krause,1 in which three forces are at play: the guilds, the state, and capitalism. The guild we already understand. Krause defines the state as "bodies that possess a monopoly over the means of force, as well as most of the means of sustaining the society through education and professional training." Capitalism he defines as "a political-economic system with organized corporations in production and finance." A capitalistic state regulates capitalism but avoids a heavy handed approach that would threaten the basic health of capitalism. We have already seen what happened when the craft guilds had interests that conflicted with capitalism. In the next section, we will see how the public, the state, and business influenced the rise and fall of guild powers of the medical profession in the United States. These guild powers include control over entry into the profession, the standards of the profession, the rate of production, and the price of services.
Guild Power and the Profession of Medicine in Early America
The profession of medicine has come a long way in public esteem in the United States.2 In the early days of the republic, physicians strove for recognition as elite healers who deserved a monopoly on medical practice. In fact, healers of all types existed on more-or-less equal footing, for several reasons. First, democratic ideals encouraged people to consider themselves equal to anyone else. Status was earned, not hereditary. And so, natural healers asserted that they had as much right as anyone to diagnose and treat disease. Second, doctors did not have much to offer sick people. Scientific understanding of disease was weak, and treatments were ineffective and, in the case of blood letting, often dangerous. Third, the public, especially during the decades of Jacksonian democracy, did not recognize physicians’ right to set the standards of medical practice and judge one another. Guides to self-care were bestsellers, in part because the US economy was weak and few could afford medical care. Transportation was painfully slow, which limited access to physicians and raised its cost. To make a living in this world of do-it-yourself health care, physicians developed side occupations such as selling medicines, fruits, and vegetables, which further blurred the distinction between professionals and other people.
Physicians did not begin to organize themselves effectively until the mid-19th century, but they recognized earlier the powers on which the success of the guilds rested and strove to gain these powers. One way to accomplish this goal was to become an educated elite. The first US medical school opened in 1765; by 1850, there were 42 schools, and their diplomas were accepted as equivalent to a medical license. Unfortunately, standards were low, and one could obtain a medical diploma after only 1 year of study. Another route to recognition as an elite was licensure, which in principle should deny nonphysicians the right to practice medicine. However, in a country swept by Jacksonian democracy, state legislatures abolished medical licensure, which paved the way for anyone to assert themselves as a healer. Efforts to establish high standards of care and gain the exclusive right to police the profession also failed. The problem, according to Starr,2 was that high standards were necessary to establish a monopoly on practice but few physicians met those standards. Consequently, medical professionals did not become an effective political force that could sway legislatures to write laws that would enforce the role of the profession in maintaining high standards. In the eyes of the state, the medical profession had little standing.
From this low point, the professions began to ascend in public esteem, starting around 1850. A key element was the advance of medical science. Because the scientific basis of medicine was weak, physicians’ scientific understanding was scarcely better than the public’s understanding. As the scientific basis of medicine advanced, physicians-in-training had to master a body of knowledge that had legitimate complexity (in Starr’s words), required years to master, and was beyond the general public’s comprehension. Physicians became the exclusive purveyors of this knowledge, which made them increasingly indispensable.
The environment of medical practice changed during this period of rising scientific understanding. The largest effect was on access to care. Key elements were the rise of industrialism, the growth of great cities, and improved transportation. People had more money at the same time that better transportation improved access to physicians. People came to the doctor, rather than the reverse. As hospitals improved, the sick were more likely to seek care in institutions, which made it easier for physicians to see many patients in a day’s work. All of these developments made medical care easier to obtain. People came to depend on physicians, who had increasingly expert scientific knowledge. The stage was set for physicians to assert their right to protections in the law, such as licensure, that assured the profession of a monopoly on medical care.
Starr2 calls the rise of medicine from the 1850s "one of the more striking instances of collective mobility in recent history." What happened? Starr’s answer places emphasis on the reason that a profession gains power: it has authority.
To accumulate authority, a group must first agree. Speaking with one voice conveys authority. Physicians of the early 19th century tended to disagree, but the environmental factors that made it easier for patients to visit physicians also made it easier for physicians to congregate and start a dialogue that could lead to agreement. And with the rise of science, there was more to agree on. Consensus led to a gradually accumulating canon of medical practice, which lent authority to what the physician said to his patient.
Rise of the American Medical Association
For 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 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, self-governance, 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.
Codes of Professional Behavior
Starr2 defines a profession, and the role of a code of ethics, as follows: "A profession, sociologists have suggested, is an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than profit orientation enshrined in its code of ethics." This definition illustrates the way that the functions of a profession operate at different levels. One function is collective: self-preservation. A profession preserves itself by taking collective action, such as setting, and enforcing, high standards of practice, which make it indispensable to the public. A second function operates at the individual level: requiring behavior that increases the well-being of society. Unlike business, the physicians’ code of ethics elevates service, not profit making, to an ethical principle. But the code also reflects self-interest at the individual and collective levels.
Codes of ethics over the years have encouraged behaviors that help to preserve the guild powers of the profession. Table 1 summarizes the key elements of various codes of ethics through the ages. Many elements of the first code of ethics, the Hippocratic Oath, have endured. The Hippocratic Oath emphasizes an attribute of guilds, solidarity, in its clauses that enjoin a physician to teach the sons of other physicians but against teaching medicine to "other people." The obligation to teach is a theme that recurs in Louis Lasagna’s 1964 reformulation of the Hippocratic Oath (shown in Appendix), but none of the four subsequent codes mention keeping special knowledge within the profession. However, other elements of guild behavior do appear in later codes of ethics, most notably the first AMA code of ethics in 1847. Only part of this long document appears in Table 1. The 1847 AMA code said that doctors should resolve their disputes in private and show a united front to the public. It tells physicians to seek consultation rather than attempting to do things that others are better qualified to do, which is a recurring theme in other codes, starting with Hippocrates. This advice is commonsense and in the public interest but also seems to encourage the physicians to respect the divisions within the profession, as if each subspecialty were a guild unto itself. The AMA code also told consultants that they should avoid language that might impugn the ability of the attending physician, a teaching that continues to this day. Other clauses, says Starr, encouraged professional solidarity,2(p94) such as excluding nonphysician practitioners from professional courtesy and barring them from professional gatherings of physicians. A 1903 revision of the code eliminated reference to "irregular practitioners," an indication that the battles between conventional physicians and homeopaths had exhausted the medical profession.2(p107)
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Both of the most recent codes call on physicians to report deficient physicians. The profession has a weak record of disciplining its own, as many have noted. Enforcing discipline within the ranks was a feature of the guilds and is part of many definitions of professionalism. These clauses recognize that physicians are best qualified to decide if a colleague is performing badly. That they appear as strong directives in recent codes reminds us that physicians too often look away instead of getting involved when a colleague is impaired or incompetent.
Both the 2001 AMA code and the 2002 Charter for Professionalism call on physicians to keep their medical knowledge up to date. Why did the leaders who formulated these codes include this clause? Perhaps they believed that the profession has been deficient in self-discipline, is losing its self-regulatory powers to government and business, and risks further losses. Indeed, the record shows that the practices of older physicians are less likely to meet written standards of care than those of younger physicians.4 Here, the profession is taking corrective action. Ongoing, lifelong measurement of competence has become the paradigm of specialty certification across all specialties of medicine.5 Those who pay for health care, government and business, are also taking action. Monitoring physicians’ adherence to practice norms is becoming widespread. These developments reflect the growing concerns of government and business with the quality and cost of care provided by physicians. This intrusion into a realm that should be a professional obligation shows a loss of guild powers.
Both recent codes call on physicians to improve access to medical care (Table 3 ). This clause would be unnecessary in many countries, but 44 to 46 million Americans have no health insurance in 2007. Many physicians give charity care within their practice or in community clinics, but the widely documented existence of health-care disparities is a clear message that the profession is not meeting the need. Some professional organizations are taking a lead role to persuade the government to expand health insurance coverage to all Americans.
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Does the "just distribution" clause signal the end of the long-enduring ethical principle that the individual patient’s needs are the highest priority for the physician? Some argue that less care can be in the interest of the individual patient when the care is unlikely to benefit and could harm the patient. This proposition draws support from existence of wide variation in the intensity of care in different geographic regions without any corresponding variation in outcomes.67 This view avoids taking a position on the ethical dilemma of choosing less benefit for one patient in order to do more for another. It says, simply, we can safely accommodate the needs of the patient and society by being more astute about what we choose to do for the individual patient.
Codes of Ethics and the Medical Profession
The purpose of this essay has been to place the concept of professionalism in the context of history. This essay asserts that the history of the craft guilds and of the medical profession in the United States is a good background for understanding codes of professional conduct. Codes of conduct were designed to help physicians to rise in public esteem at a time when the public made little distinction between physicians and folk healers. Many factors led to the elevation of medicine as a profession. Did adherence to codes of conduct help the rise to power of the profession in the 19th century? Would it help now?
Changes in the environment of practice in the late 20th century have led to change in codes of professional conduct. At mid-century, the profession was all-powerful in matters that touched on medical practice. Then, organized medicine lost the battle over the Medicare legislation of 1964, which was a crucial inflection point. It was far more than a failure to impose the political will of the profession. More importantly, the cost of medical care became a fiduciary concern of legislators. As medical care advanced technologically, the cost of care led to grave concerns within the business community and government. Now the profession finds itself in conflict with business and government because decisions for individual patients are leading to what is becoming an unsupportable financial burden for business and government. As resources become constrained, codes of conduct are changing as if to acknowledge anew the physician’s obligation to society as well as to the individual patient.
Codes of professional conduct, arguably the way a profession defines itself to the public, have evolved over the centuries. Amid change, the physician’s obligation to give first priority to the interests of the patient has remained a fundamental principle of medical practice. Business and government are telling the profession that the country cannot afford the style of practice that patients want and that physicians provide. A recent code of conduct, the Charter for Professionalism, states that a physician is obliged to consider the right of other patients to care when deciding about an individual patient. As pressure from business and government erodes the autonomy of the profession, the code of conduct may soon be the sole vestige of its historical position as a powerful guild. The code of conduct is changing with the times. Will the profession keep pace? If it does, might it regain its heritage of guild powers?
Appendix
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Abbreviation: AMA = American Medical Association
The author has no conflict of interest to disclose.
Received for publication February 20, 2007. Accepted for publication February 23, 2007.
References
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  H. C. Sox Medical Professionalism and the Parable of the Craft Guilds Ann Intern Med, December 4, 2007; 147(11): 809 - 810. [Full Text] [PDF]
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