On Who Regulates Medicine

Read the book, skip the movie.
Read the book, skip the movie.
From Louis Jolyon West, “The Medical World of Dr Stephen Maturin”, in Patrick O’Brian: Critical Essays and a Bibliography, 1994, edited by A.E. Cunningham, WW Norton, New York, First American Edition, pp 85-86.

In 1800 when we first met Dr Stephen Maturin, there were no fewer than nineteen medical licensing bodies in Great Britain, each with different and often conflicting powers and rights.

Medical men practiced with university degrees, various forms of licenses, sometimes a combination of these, and sometimes with none at all. Medical training varied from classical—university education and the study of Greek and Latin medical texts, on the one hand, to broom-and-apron apprenticeship in an apothecary’s shop, on the other—and sometimes involved no recognisable education at all. Quacks, ’empirics’, and drug peddlers practised freely with no legal sanctions against them, while a physician in London could be disciplined by his College for preparing and selling a prescription to his patient.1

Medical men of Maturin’s day were divided into three orders—physicians, surgeons, and apothecaries—which took corporate form in the Royal College of Physicians, the Royal College of Surgeons, and the Society of Apothecaries. Each had different duties, privileges, perquisites, and social status. The physicians were at the top of the ladder…

The Royal College of Physicians of London received its charter in 1518 and had a monopoly over the practice of physic in London throughout England. Fellows of the College, as opposed to ordinary license holders, enjoyed certain privileges…These ‘pure physicians’ were limited to examining patients, diagnosing disease, and prescribing (but not dispensing) medications…

The powers of the Royal College of Physicians were confirmed during the reign of Henry VIII by an Act of Parliament which declared that it was ‘expedient and necessary to provide that no person… [ellipsis original] be suffered to exercise and practice physic but only those persons that be profound, sad and discreet, groundedly learned, and deeply studied in physic.’ This meant a man with a university degree…”

1M. Jeanne Peterson, The Medical Profession in Mid-Victorian London (Berkeley, Calif: University of California Press, 1978), p. 5.

Now I just wonder (these are random musings, put down on my last day of travel; I leave it to readers to fill in the blanks) how it would be if the government did not involve itself in regulating medicine, except perhaps to collect various taxes and fees, i.e. those activities which drain but do not constrain. (The reader understands I merely use medicine as an example, and this brief sketch applies to many fields; i.e. do we really need to license barbers?)

Before the man-in-the-street was really aware there was such a thing as a medical profession in which he stood in need, there was no felt desire to regulate that profession. Once citizens began lining up in earnest, ducats in hand to pay for dubious cures, the lines attracted the notice of politicians who wanted in on the act.

Governments now say to doctors, “You may use these and not those drugs”, “You must fill in these forms and follow these rules,” and similar things. People are comforted, much as they were by bloodlettings and sugar pills, knowing the somebody is In Charge. Why, if the government did not regulate, they reason, anything might happen. What about the children?

Contrariwise, if the voluntary associations of physicians which sprang up in Europe in the seventeenth and eighteenth centuries persisted, then citizens would have to check with each physician with whom he would do business and see whether he was approved by one or many of these associations, and if approved how the physician was rated. If the physician was not rated or approved, the choice of approaching him for medical advice would still belong to the citizen.

People being what they are—a mixture of the base and grand, covetous and generous, etc.—there would be rivalries in and between these associations. If patients demanded, say, proven results (genuine healings, longer lives) then we can bet each association would see to it that they could boast of these attributes.

Mistakes would be made, as they always will be made, both by physicians and citizens. Quacks would appear, as they do now (chiropractors, homeopaths, naturopaths, etc.). Cut-rate associations would whither and demanding ones strengthen as they required more of their members. People would have a choice: they would rest their faith (it must be faith since citizens are not themselves physicians) in the voluntary associations and not governments.

The big changes would be, I think, better care because of more and faster innovation. Bad doctors and quacks would be easier to ferret out, their associations publicly and quickly naming them as menaces.

The self-regulators would themselves be physicians, which is much the same now, except the government feels itself superior enough to appoint non-physicians to write rules. The self-regulators would be much more responsive to citizen complaints and praise. Perhaps as part of this responsiveness—this may be the most important difference—would be softer expectations: reliance on the government as a Higher Power seems to imbue in people the idea they could live forever, or at least trouble-free, as long as the proper regulations existed.

If you don’t believe any of this, I ask what makes a man less moral and able when he belongs to a voluntary association than when the same man joins a government?

12 Comments

  1. Ah, Dr. Briggs, then you would advocate the restoration of the priestly class, i.e. medicine men (or women)? Would these association members be exclusionary and all be white Anglo-Saxon Protestants of proper social connections and breeding, tall, and handsome or pretty? Would there be room for some token Papists like ourselves and our Jewish, Muslim, and Hindu, etc. friends? Would they also maintain high price levels? Curious minds may want to think about it before we take that well worn path backward in time.

  2. Bob,

    You’ve lost me, brother. Why are physicians now (largely under government direction) not a priestly caste? The citizen in picking which doctor to patronize must rely both on his wits and some outside authority. Why is government the preferred and sole authority?

  3. One fly in your ointment would be the lawyers. A minor benefit of moderate certification by government is that trivial lawsuits tend to be surpressed. With only voluntary associations to regulate, one might expect litigation between them in addition to the usual malpractice suits. Even among libertarians restricting infringement of rights is recognized as a legitimate activity of government. The courts are an expensive and time-consuming method for doing this. Standardized licensing seems more efficient and beneficial for the consumer. As always, though, that power must be applied with a light hand and only when there’s no better solution.

  4. The root of the problem is how, uninformed about the complexity of various arts and sciences, do we find the best practitioner, be it medicine, accounting, attorney, architect or engineer to solve our problem. Does government licensing confer competence? Does non-governmental membership confer competence? Do self regulating professional associations confer competence? My opinion, no. We learn about professional competence by word-of-mouth; we also learn of professional incompetence by the same means. And, a lot of word-of-mouth information is of questionable value. Even the best professional practitioners fail for we are human and not perfect. I’d rather have the choice of selecting the best practitioner for my problem, performing my due diligence, and enjoy the results or suffer the consequences.

  5. Ah, the three ancient professions, divinity, physic, and law–were given the outline of their current form by the Victorians. As society was moving toward industrialization, those in these professions were considered to be the head of the Middle Class. It was natural that standards of education, examination, and certification be instituted, but in the early days, the fields did the regulating. In the case of England, attaining a Royal Charter was a recognition that one’s field attained professional standing. At it was the Charter that was allowed to dictate the terms for the field. Those thusly chartered were jealous of their position, and sought to have legal restrictions barring others than themselves from performing their duties (‘closed shop’). In the early days, “government meddling” was desired (although very rare and hard to come by) in that there were clear benefits for members of the profession.

    To the point of micro-management of the medical profession–who benefits? That answer will tell all.

  6. Does government really license barbers [etc.], or, do citizens acting thru their elected representatives create licensing requirements and other barriers to entry (that’s an economics term) so that competition is effectively stifled? The answer, of course, is much, and in many areas mostly, due to the latter.

    RE: “Mistakes would be made, as they always will be made, both by physicians and citizens. Quacks would appear, as they do now (chiropractors, homeopaths, naturopaths, etc.)….”

    BUT, when science is involved such “grey area” distinctions & inevitable are disregarded and the extremist “scientism” perspective is invoked…right?

  7. Presumably, licensing of doctors conveys a minimum level of competence — in theory. In practice, not so much. There are good doctors and there are atrocious ones. Licensing doesn’t seem to help in indicating which. OTOH, if there were NO requirements would there be even worse ones?

    I live in a state that has license addiction. You need a license to apply toenail polish although surprisingly none is required to be a real estate appraiser. Over the years, I’ve had several licenses. One was an insurance brokerage license. It was by far one of the toughest exams I’ve ever taken. For that matter, so was the sales exam. Harder even than the NASD series exams. Harder than my engineering tests in school. It actually covered aspects of insurance while the home improvement license (I once sold doors, windows, gutters and what not) covered only contract law with nada on improving homes. DC’s test was whether you could successfully remit the license fee (for both insurance and home improvement). Go figure.

    In this state, it’s more of grabbing a share and applying meaningless “public safety” measures than an actual need.

  8. Ken asks:
    “Does government really license barbers [etc.], or, do citizens acting thru their elected representatives create licensing requirements and other barriers to entry (that’s an economics term) so that competition is effectively stifled?”

    Or, do the barbers, craftsmen, unions, and assorted professionals lobby their government to create and tighten licencing rules to maintain their privilege, keep out competition, and keep prices high? Rent-seeking to use another economics term.

    Probably goes both ways.

  9. Self-regulating medical associations originated in the middle ages, as too did university curricula for Doctors of Medicine.

  10. Briggs,

    Time to read Mises’s Human Action. Then some Rothbard, Hoppe, Bastiat, Spooner, etc. We’ll have you in our camp soon.

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