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Physicians and Authoritarianism in History

This text is exerpted from a paper to be published in "The Hazards of Harassing Doctors : Regulation and Reaction in transatlantic healthcare" © CMPI, NY 2008

"The fate of individuals who choose to devote themselves to the art of healing has varied greatly in the course of history. Some healers became saints or icons; others were burnt at the stake. The status of physicians in society intimately reflects perceptions and beliefs related to illness and disease at given times and places. The institutional architecture and social or legal frameworks produced by dominant creeds or ideologies also impinge on the outcome of their endeavours as healers. In his first aphorism, Hippocrates, the "father of medicine" overtly acknowledged this influence of "external circumstances" on successes or failures of the art.

The professed objectives of doctors, the knowledge that they are perceived as holding or that they duly acquire, compounded by the strong emotional impact of suffering and disease has naturally tended to put them in position of authority. Their power has seldom found itself in open conflict with that of rulers. The might inherent to medicine and that wielded by kings or presidents do not operate at the same levels and are of a different nature. Physicians however, have had to contend or to compromise with existing societal power structures often at the expense of the essence of their trade. The tragic history of totalitarianism in 20th century Europe shows how indiscriminate allegiance to state authority or to reigning ideologies can easily pervert medical power.

At the dawn of medicine, the power of primitive healers emerged from magic, superstition or religion. It seldom strayed far from that of kings or rulers who invariably draw their legitimacy from the same sources." In ancient Mesopotamia, all strata of society were ultimately subjected to the rule of the king. Certain categories of healers enjoyed the status of priests. Religious privileges partly shielded them from the monarch's authority. Others: in particular the street surgeons were answerable to arbitrary laws and decrees. The Hammurabi Code established fees for given procedures. It also set sentences for unsuccessful treatments; compensation was based on the eye for an eye principle with some exceptions: a doctor’s eye had less value than a nobleman’s tooth, while a doctor’s finger was worth more than a slave’s life. This heavily authoritarian environment produced little progress in the art of healing. Ailing Babylonians took to the custom described by Herodotus of shunning healers and exposing their ailments on the marketplace hoping that some passer-by who may once have suffered from the same symptoms might stop and give advice.

The scientific foundations and the ethical principles that have guided and enlightened medical progress throughout its history can be traced back to Ancient Greece. They were the product of a society that combined great intellectual liberty, a deep respect for reason and a strong marketplace. Greek physicians contracted directly with patients in an extremely competitive environment. They had to rely on good prognosis and on reputation rather than on protection from the state or from the gods to earn their living. If one looks at the history of medicine to this date one can see significant advances whenever physicians have practiced their trade without intrusion of religious or secular authority. When they relinquish professional autonomy for whatever cause, physicians forsake responsibility with effects on their ethical commitment and on the progress of their art.

As from the 19th Century, physicians have had to cope with ideologies that attempted to empty medicine of its market essence. Bismarckian and Marxist concepts on the omnipotent, omniscient and omnipresent functions of the state captured the medical trade with lasting consequences. The effects of socialist dialectics on medical minds are felt to this day. Modern doctors are not at ease with the thought of patients as consumers or illness as a market even though this notion was self evident to their predecessors, starting with Hippocrates. They fail to grasp the mechanisms of exchange and contract in a free society or the functions of price and profit (a Marxist sin). This has made physicians vulnerable whenever their earnings have been questioned or attacked by those who wished to socialize and subdue their profession.

Before laws did the rest, the whiplashes that drove the medical profession out of the market were not altogether painful. Collectivist ideologues lured and lulled the mainstream of the profession into seemingly secure state protected cartels or state enforced monopolies. Subtle perks and short-lived privileges bought the submissiveness of doctors, though there were instances when the goading was less tactful. Aneurin Bevan's celebrated “I shall stuff their mouths with gold!” at the inception of the NHS, still rings loudly in the ears of older British physicians yet left to wonder where the gold went. Alternatively pressures bedeviling profit as incompatible with their altruistic mission, inhibited doctors from openly striving for high revenues.

By yielding on incomes, European physicians forfeited economic power and gradually lost their grip on their tools. Doctors can no longer afford to purchase some of the heavy hardware that goes in par with modern health technology, let alone to own and run hospitals. Property means control. In the best of cases, professionals are able to partner with business investors or charitable foundations for the acquisition and management of heavy technical equipment, surgical facilities or hospitals. In most instances however doctors have allowed these to fall into the hands of government and its subsidized proxies. The interests of patients rarely conflict with those of physicians. The same cannot be said of government planners and regulators. Healthcare is but one among many conflicting priorities that modern policy-makers choose to tackle.


Alphonse Crespo

February 17, 2008