Framing the Institution Medicine
The institution of medicine is structured in such a way that it aligns more favorably with economics than health; an alignment, that we shall see, is reinforced by human nature. This has become increasingly obvious over the last few decades, as pharmaceutical profits and influence have soared along with those of the device companies, hospitals, insurers, electronic health records companies and all of the purveyors of medical products. What is not so obvious is that this was largely inevitable. That is, from its inception, medicine as an institution, not as an individual practice, but as a professional guild distinct from others, was organized to assert its authority in defining the boundaries medical truths, in legitimizing and delegitimizing what constituted the practice of medicine, and in who could practice this profession. This was motivated, in small part, by a desire to monopolize the medical landscape. Health was a tertiary goal at best. From the drive for intellectual and economic authority, medicine as an influence based business emerged; one that would be amenable to all manner of economic enticements that were easily justified by the institutional assertion its own medical authority. From this perspective, the institution of medicine is fundamentally and structurally an economic system based upon peddling influence. It does this under the auspices of medical science, a concept adopted not strictly for an appreciation of what the practice of science might do for medicine in regards to improving human health, but rather, for the credence, authority, and economic benefits the use of this phrase would lend to the institution of medicine itself.
The boundaries of what we now recognize as scientific medicine were defined at the beginning of the 20th century to align with industrial notions of efficiency and economics. In much the same way the great rush of industrialization was managed and defined, so too was scientific medicine. Indeed, the wealthy purveyors of industrial mechanization drove the development of scientific medicine as way to rationalize the wealth inequality and social injustice resulting from their business endeavors.
“Scientific medicine, as part of the fervent campaign for science, helped spread industrial culture, albeit a capitalist industrial culture, throughout the land and indeed the world. But scientific medicine also developed into an ideological perspective that legitimizes the great inequities of capitalist societies and the misery that results from the private appropriation of human and environmental resources.” Brown pg. 127.
The goal was to medicalize social issues as a means to not only deflect attention from the environmental and economic causes of disease but also to establish a class of men who could wield the technology to define and treat these illnesses. Just as the growth of technology allowed for the development of professional managers and separated mental work from the physical work of laborers, so too did technology and the banner of scientific medicine, allow for the growth and consolidation of a professional medical class.
The push for rationalization did not spring up instantaneously, however. It began in the mid-1800s and gained steam at the turn of the century as healers of all sorts, from midwives to homeopaths, women and African Americans, were pushed out of the healing professions, first by the American Medical Association (AMA) in its efforts to assert the legitimacy and authority of the medical profession above all others, and later, with the help of the industrialists (Rockefeller, Carnegie et al.). In so doing, a broader sense of health, one that considered multiple aspects of the environment, gradually disappeared, as did personal sovereignty over health. In the transition to scientific medicine, the impetus for self-care, for home based care, even for knowledge about health that so dominated the American experience, diminished. Personal sovereignty was handed to the medical men whose practice domain became the hospital.
Under this new model of medicine, disease became an engineering problem; one that could only be solved by physicians deemed acceptable by the AMA and its funders, through methods that aligned with the industrialist view of mechanistic reductionism, and ultimately, in the factories e.g. hospitals where the trade was practiced. Moreover, illness of the body could only be understood in its component parts and its malfunction solved with technology and technological expertise. Biological reductionism, the disease model of medicine that emerged and to which we all hold sway even now, is precisely analogous to the industrial ideals of the time. It is a zero sum proposition both ideologically and economically; one that the profession of medicine both proffered and profited from.
Ideologically, the boundaries of scientific medicine were as clear then as they are today. Disease develops extraneously via invading pathogens or as random inborn errors in design, what we now know as genetics, and has no relationship to the greater environment. Medicine’s job then is to identify these agents of disease and treat accordingly. To the extent these agents are neither causative nor amenable to treatment, as so often they are not, the ideology then, as it does now, simultaneously forbade looking outwardly to the environment, while nevertheless demanding acquiescence to the physician, the representative of this model.
In its seminal code of ethics in 1847, the AMA asserted its demand for respect clearly and forcefully, this despite any justification for the superiority of medical care provided by physicians. At the time and for many decades later, physicians did more to harm than to heal.
“The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them…Patients should never allow themselves to be persuaded to take any medicine whatever that may be recommended to them by the self-constituted doctors and doctresses, who are so frequently met with, and who pretend to possess infallible remedies for the cure of every disease. However simple some of their prescriptions may appear to be, it often happens that they are productive of much mischief, and in all cases they are injurious, by contravening the plan of treatment adopted by the physician.” – Code of Ethics of the American Medical Association, Adopted May 1847, pgs. 12-13.
While some contend the reciprocity of the relationship between doctor and patient stipulated in the axioms of the 1847 code was revolutionary in its approach, it acknowledged the duties of both the physician and the patient after all. Others, myself included, suggest a more practical, and ultimately cynical, purpose for the doctrine – money and power. The demand for respect was not based upon an earned respect, but rather, a desire to dominate both the intellectual and the economic space.
It is important to remember that at the time this code was written, medicine had little more in its tool bag than a trio of very dangerous practices, such as bleeding, blistering, and poisoning with mercury. Surgical asepsis and antisepsis had not yet been accepted. Hand washing was controversial and antibiotics were another 80 years away. The state of medicine was dangerous at best, but that did not matter. Capitalist fervor was sweeping America, and along with it, many professions would be subsumed under industry. In order to survive, and maintain intellectual and financial independence, physicians had to assert their authority and dominion in the market, and so they did. With the creation of the AMA, the institution of medicine was born and boldly proclaimed its superiority over all other practices. Of course, this required no small degree of hubris given the lack of supporting evidence at the time. Nevertheless, when a strong belief that medicine could be more, or that it was more already, it is not clear that physicians at the time recognized their limitations, was combined with the recognition of market possibilities, the result was a code of ethics that demanded patient obedience to the physician and his prescriptions while simultaneously prohibiting the consultations with other healers by either the patient or the physician. It was respect by caveat; an ethos that undergirds medicine to this day.
Economically, the inherently technical nature of this new profession, necessarily discriminated. Up through the turn of the 19th century, medical schools were funded largely by student fees, through an apprentice style type of education and they coexisted with other specialties, some legitimate and others quite unscrupulous. The range of incomes and experience for practicing physicians was significant. In many regards, the AMA’s quest for authority was driven by existing economic pressures and future ambitions, each of which necessitated reform. The adoption of the 1847 code, as its creators saw it, would serve multiple purposes. It would unite the profession, set standards for education, and in so doing, limit entry into the profession. This would then diminish the number of practicing physicians, while improving skill level and income of those that remained, laudable goals to be sure.
The code was by no means an easy sell to the practicing physicians or to the public. Within the AMA, there were entrenched ideological and financial structures that required containment. Namely, whether the duties of the physician articulated in the code, should even exist. At the time, many believed that ethics and morality arose from character and needed no description. Similarly, other factions found the proposed economic monopoly distasteful, particularly the prohibitions against consultation with ‘irregular’ physicians, specialists and alternative practitioners, whom the AMA deemed non-orthodox and ultimately, non-scientific. Thus, the consultation clause, as it was known, was a huge sticking point; one that almost became the AMA’s downfall, if it were not for the interest in medical matters by the American industrialists a few decades later.
Despite the discord amongst physicians and other physician groups regarding the consultation clause, the AMA held steadfast in its goal to control the intellectual space. It, and it alone, would define what constitutes medical science, medical education, and who would be permitted to practice this endeavor. The AMA would effectively define truth and all of the rules by which truth would be established and recognized. This was and remains one of the most comprehensive power plays in the history of intellectual thought.
For just a moment, imagine yourself as an arbiter of reality. You, along with select individuals of your choosing, decide what is real and what is not. Your group sets the rules by which others are allowed to recognize that reality, effectively preventing the ability to see anything else but what is deemed acceptable. Your group determines who is allowed to see or not see certain truths, what hoops they must jump through to be included in this fraternity, and who must remain ignorant of this expertise. This is a power unlike all others. The decisions you and your group make are, by definition, incontestable. It is absolute authority. Since the group defines both the reality and the rules by which that reality can be identified, that reality will always and inevitably coincide with the group’s goals. By distinguishing who can and cannot be privy to this reality, and grooming the accepted few, fealty to the organizational goals is maintained. The group will always be right and risk little push back so long along control is maintained. And how is control maintained? With financial reward and the promise of intellectual certainty, each endlessly reinforcing the other. Intellectual certainty was additionally reinforced by an agreed upon willful ignorance; an ignorance that yet plagues the profession to iatrogenic illness. Per the 1847 code, professional disagreement and incompetency of fellow physicians should be handled in silence.
“In many passages of the 1847 Code, oblique reference is made to the circumstances of professional disagreement or to the incompetence or deficiency of colleagues. In each passage … discretion and silence are the rule. In consultation, for example, “all discussions should be held as secret and confidential. Neither by words nor manner should any of the parties to a consultation assert or insinuate that any part of the treatment pursued did not receive his assent.” Furthermore, the consulting physician should not make any hint or insinuation that “could impair the patient’s confidence in the attending physician or negatively affect his reputation.”
Silence shielded the organization and the individual from doubt and reinforced the sense of infallibility for both. The prospect of intellectual certainty, of being on the right side of a movement or ideology is compelling fodder for the dynamics of any group. When bolstered by the prospect of not just economic gain, but of a sort of economic authority, it is difficult to contemplate the error in one’s endeavors, no matter how egregious. This is what undergirds the institution of medicine; a self-determined and endlessly perpetuated infallibility, protected by silence, economics, and the license to define and mold its truths to fit its needs. And this is what invited industry influence.
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