During the latter half of the nineteenth century few states in this country had strict medical licensing laws. During this period of therapeutic freedom the United States had its “Golden Age” of active therapeutic minorities and the American people had the benefit of many therapies. My own specialty of homeopathy, although first systematized in Germany, gained a peak in numbers and influence not reached before or since by any homeopathic body. In addition to therapeutic approaches arising from within the medical profession, during this period the United States made many original therapeutic contributions from outside the medical profession, such as Palmer’s osteopathy; Still’s Chiropractic; Eddy’s Christian Science; and Thompson’s Botanic system. New scientific breakthroughs often came from amateurs like Pasteur, a chemist, who founded bacteriology, and Mendel, a priest, who founded genetics. This paralleled a similar period of technological expansion in the United States of America, also by amateurs, such as Morse’s telegraph, Bell’s telephone, McCormick’s reaper, Sholes’ typewriter and Fulton’s steam boat.
Although the American economic system has remained relatively free, the therapeutic system has not. Its freedom was to a large extent destroyed by three blows, two legislative and one judicial. In the 1860’s and 1870’s when many states set up their new licensing boards they provided, in a democratic manner, special examining boards and grievance committees for the chief existing therapeutic minorities; the homeopathic, osteopathic and eclectic therapeutic approaches. Unfortunately, this democratic example has not been followed automatically for more recent therapeutic minorities, save as the result of citizen pressure.
In 1910 Abraham Flexner, under a grant from Andrew Carnegie (ironically Carnegie was a homeopathic patient), studied the medical schools in the United States and classified them as A, B and C. Flexner?s criteria naturally reflected his own training in Germany, which emphasized the technical and chemical laboratory approach to medicine. This was also ironic since Carnegie was a Scot, and Scottish medicine was, and is, particularly strong in the natural human clinical approach. With his bias, Flexner rated down the more natural medical schools of osteopathy, homeopathy, and eclecticism, whose practitioners did not need as much laboratory analysis of their patients before starting therapy. Flexner carefully said his report was purely suggestive.
However, in 1913 Vermont set another nail in the coffin of therapeutic freedom in this country by requiring that only graduates of medical schools rated A by the American Medical Association, who had taken over the Flexner classification system, would be admitted to licensure examination. Many other states followed this example in the next few years. At that moment the constitutionality of the Vermont decision might have been challenged, by the homeopathic school, which was the largest of the therapeutic minorities in this country. Unfortunately, the homeopathic organizations chose to cooperate with the classifying agencies and state legislators. Since there were thousands of homeopathic physicians, 27 homeopathic medical schools and more than a hundred homeopathic hospitals and clinics in this country, homeopathy had the opportunity of fulfilling its therapeutic potential as a powerful vocal, naturalistic and clinical medical minority group a counter balance to the technologically and laboratory oriented dominant group. Unfortunately they lost this opportunity, to their own loss and to the loss of therapeutic freedom in this country. The result was foreordained. More states followed the Vermont precedent, and by gradual political and legislative pressure the homeopathic hospital and medical schools have withered away until now there is only one elective course at the University of California in Berkeley, and only a few hospitals allow it to Ix used. 1 he eclectic medical schools no longer exist A bright note is that the osteopathic schools have flourished, as have the chiropractic schools, but both of these groups are outside of the medical communities. By the Vermont action the states assigned, in essence, the education of physicians to one therapeutic group. This would be comparable to the states assigning all religious training to one sect.
Paralleling state action, the federal government has followed a similar policy by staffing the Public Health Department, the Food and Drug Administration and the National Institute of Health solely by therapists of the dominant school. As these organizations have increased in power, particularly since World War II with the massive research grants made through the national Institute of Health, the dominant therapeutic group has gained further power. Thus, at both the state and national level, in the past 50 years the education, testing and licensing of physicians in this country has been assigned by legislative action to one therapeutic group.
Until recent years the courts have repeatedly held that once a physician is duly licensed to practice he may do so in any manner he elects. Two recent legislative decisions now threaten even this right. The California decision to allow the state to determine which therapies may or may not be used in the treatment of cancer certainly bodes poorly for the therapeutic freedoms of licensed physicians in this country in the future. Also, in recent years, as the result of the thalidomide scare, the powers of the Food and Drug Administration have been extended from passing on the safety of foods and drugs, to passing on their therapeutic effectiveness. Since the Food and Drug Administration already has police powers and can withdraw from interstate commerce articles of which they do riot approve, and jail offenders, this new legislation extends the Food and Drug Administration’s power of judge, jury and policeman over dangerous therapies, to all therapies. This situation is particularly serious since the Food and Drug Administration is a branch of the executive arm of the government, whose members are appointed and not elected, and are not as subject to citizen pressure as are our legislators. The Food and Drug Administration is, of course, only one of those numerous government bureaus which have mushroomed since World War II, and once created by executive or legislative action tend to become hard, crystalline harriers in what should be the fluid response of government to the wishes of the electorate. The creation of these semiautonomous bodies in our government is a matter of concern to many scholar sand workers in the field of political science. They fear that we may create a self perpetrated self oriented bureaucracy which may emasculate the other functions of our government, similar to the crippling of the executive and legislative functions of other nations by an entrenched bureaucracy. Therefore, the need to define and limit the powers of the Food and Drug Administration is one with a greater need to so define and limit these appointed agencies and bureaus throughout all the levels of our federal and state governments that, in Lincoln’s words, “Government of the people, by the people and for the people shall not perish from the earth.” In our own small way, by fighting for therapeutic freedoms we help preserve the freedoms of all the citizens of our country, for tyranny is a cancer whose appearance at any place in the body of freedom threatens not just that part, but the whole.
The right to grant licenses implies the right to withdraw them. So far, the states in this county have revoked licenses largely for illegal acts such as frauds, abortions, infringements of the narcotic act, etc. However, licenses may be revoked for “unethical conduct” and once again, who defines “unethical conduct”? Why the same body which revokes the licenses, of course! With the recent state and national trends there appears also to be grounds for concern here. A more subtle method of revoking licenses is to require periodic reexamination for them to remain effective. This was hinted at in a recent article in the American Medical Association News. In this manner the strait jacket of therapeutic conformity could be periodically tightened around the corpus of therapeutic freedom. Also discussed is the possibility of the federal government taking over the licensing of physicians from the individual states, to promote standardization and uniform reciprocity.
Possibly, the National Health Federation is now ready to mount the offensive, to initiate legislation which will not only prevent further erosion of our precious therapeutic freedoms, but will regain ground already lost to previous decisions. A triple approach might be launched via the legislative, judicial and executive branches of our state and federal governments. This would require a staff of the finest legal talents and the best thinkers and planners available. A thorough study would need to be made of the entire development of judicial and executive actions regarding therapeutic minorities in this country and also in other pluralistic democracies.
For instance, we need to consider such basic questions as the right of governments to examine candidates for therapeutic licensure, and the right of governments to deny any citizen the privilege of treating the sick for a fee, regardless of his therapeutic training. Many nations differ from ours in these regards. Although every state in this country requires of each candidate for therapeutic licensure an examination as well as a diploma from a recognized school of therapy, many nations among them Ireland, Austria, Israel, Pakistan, grant a license to practice medicine without examination to anyone possessing a suitable degree from an approved medical school. And although every state in this country specifically prohibits the practice of medicine and surgery by persons not holding suitable licenses, the laws of Great Britain specifically state: “The law does not prohibit any person from practising medicine or surgery, but the legislature has declared that it is expedient that those requiring medical aid should be enabled to distinguish the qualified from the unqualified practitioner.” It then outlines penalties if a therapist not in the Medical Register claims to be a physician, surgeon, etc. Evidently the British feel that it is the function of the government to provide a legal definition of the various registered therapeutic practitioners, but that the average citizen is intelligent enough to choose whether he wishes to go to a registered or unregistered practitioner. The state governments in this country appear to lack this confidence in the intelligence of the average citizen since they make the choice for him and deny practice by unregistered therapists. This substitution of rule-by-the-state for citizen self-rule occurred about the turn of the century and represents a shift to a continental European approach from the laissez faire British approach of the United States to therapeutic legislation in the 19th century. This “continentalization” of American medicine was further intensified, as already pointed out, by the Flexner report. Thus, the permissive, clinically oriented medicine of the whole person, which is our heritage from Britain, has been to a large extent supplanted by a rigid, paternalistic, highly specialized, laboratory and oriented approach from the European continent. These elements of materialism, rigid authoritarianism and a highly specialized separatism have been suggested as possible determinants of the militaristic tyranny of Germany in the past 100 years, and certainly are not conducive to creative contribution, etc. American medicine might well ask itself whether these elements engrafted onto our liberal Anglo-Saxon heritage, may not underlie many of the pressing social, economic and legal problems in our medicine of today.
These two results of considering medicine globally, rather than solely in terms of our country, have been examined in some detail merely to indicate the richness of the available material. Many other facets of medical legislation in this country might also be so examined.
As a further suggestion, medical legislation rests to a great extent on medical terminology, and medical terminology is a jingle of ill-defined terms used by therapists of different persuasions to describe opposing therapeutic systems.
As many of you probably already know, the politically dominant group of therapists in this country have their own nest of terms for adherents to therapies different from their own. These terms are often used as “smear words” emotional labels with little consistent, rational content similar to other politically charged words such as “deviationist” as used by biased persons in the USSR. We must be aware of the existence of these words, and of their biased, emotional meaning as well as their actual meaning. Otherwise, unthinkingly we might use them, with the same emotional bias as the dominant group does, and by so doing tacitly lend our support to their misuse.
Of most immediate concern to us is the word “quack” from the Middle Dutch “quacksalver,” quacken; to boast, and zalf; salve, or medicine, loosely used by a group of our colleagues meeting down the street, but so far not defined by them. Since they have not bothered defining it, possibly they mean to use quack in the usual dictionary sense of “an untrained person who practices medicine fraudulently,” “pretentious claims with little foundation” or “dishonestly claiming to effect a cure.” Or possibly they use it solely as an epithet directed against any one who disagrees with them, much as the late Senator McCarthy used the word “communist.”
Whenever possible, I believe we should ask persons who use the word “quack” in what sense they use it. If in the sense of “an untrained person who practices medicine fraudulently,” does this imply that both elements of training, and fraud, must be present? If so, would a trained person who practiced medicine fraudulently not be a quack? If the presence of either lack of training or committing a fraud makes one a quack, the definition is broader. As to lack of training, Pasteur was a chemist and not a physician and on this ground alone the French Medical Academy refused him an audience. However, his discoveries founded modem bacteriology. Was he a quack? And Robert Koch, the iso later of anthrax bacilli and Jenner, the discoverer of vaccination, were both obscure country physicians with no hospital or academic connections, and would certainly have been considered unqualified by the professors in their respective countries to conduct any important medical research. Yet their discoveries revolutionized medicine. Were they quacks? Numerous other examples could be given. In other words, who is to say what is, and what is not, proper training?
If by “quack” one means a “fraudulent practitioner” of medicine, then we stand on firmer grounds since “fraud” is a word with legal existence as “intentional deception to cause a person to give up property or some lawful right,” or a colloquial use as an impostor or cheat. However, anyone who uses “quack” in this sense must be careful since such a charge, if untrue, is subject to suit for libel. In this sense, the test is a conscious attempt to deceive, not whether the type of therapy used has been effective or not, since in those terms much of the bleeding and cupping used by physicians a hundred years ago would be fraudulent by present standards.
Another definition given for quack is “a person who with little or no foundation, pretends to have knowledge or skill in a particular field.” By this definition certainly every therapeutic field has its share of quacks. Surely the criticism of one type of therapy by someone with no experience or training in that therapy would be quackery. Both the dominant and minority therapeutic groups are guilty of this. The correct scientific position, in the face of a lack of knowledge or experience, is to withhold judgment.
If “quack” has been used in none of these dictionary definitions, but merely as an emotional epithet to describe an opponent, then it deserves no more attention from serious, thinking persons than do the colorful terms used in the heat of political elections.
Since it is subject to so many shades of meaning, why not avoid the word “quack” and use more definite terms in its place such as “fraud,” “untrained”, “impostor,” “ill-founded,” “ignorant”, etc.
A companion term to quack is “charlatan,” from the Italian cerratano, “one who cries out in the market place.” This is a synonym for quack, but without the implication of fraud, in the sense of “one who pretends to have knowledge or ability that he does not have.”
Another frequently misused word is “cult,” in the sense defined by Morris Fishbein , M.D., long associated with the A.M.A. as “A sectarian or cultist is one who in his practice follows a dogma, tenet, or principle, based on the authority of its promulgator to the exclusion of demonstration or experience.”
This definition is rather different from that given in the Shorter Oxford English Dictionary Based on Historical Principles of “Devotion to a particular person or thing.” Therefore, since its value rests solely on the authority of its promulgator, Dr. Fishbein, and not on the demonstration and experience of the scholarly and public communities, the Fishbein definition of “cult” is by its own terms “cultist,” verifying once again that “with what judgment ye judge, ye shall be judged.”
But, if for purpose of discussion we accept this generally unrecognized definition of cult, we find that the accuser is also judge, jury and executioner, for of course the standards of “demonstration and experience” are those of the accuser, and not of the accused or of some impartial mediator.
In its generally accepted sense we are all cultists, since we are all devoted to many persons and things. We are patriotic cultists, and family love cultists, and religious cultists, etc. One of the major cults in this country is the cult of baseball. And which therapist, of any school, has first personally tested every therapy before he uses it on a patient? We all stand on one another’s shoulders, and base the whole pattern of our lives on the demonstration and experience of authorities we respect. For the laboratory oriented physician the authority is chemical or physiological; for the clinically oriented physician the authority is patient response; for the psychologically oriented physician the authority is a personally meaningful psychiatric schema with origins as diverse as the teachings of Freud, lung, Adler or Wilhelm Reich.
Physicians, like all men, differ widely in their views. Therefore, no one man can speak for all physicians. Tyrants, who claim by self-election to speak for all men, often speak only for themselves. What was a loud cry in the market place ends as a lonely babbling; a frustration of all ends; a paranoid obsession with ghosts of one’s own creation.
Each member of the National Health Federation needs to become an expert on therapeutic legislation. A test case similar to that of Brown vs. the Board of Education of Topeka. Kansas (347 US 483-1954) which was the opening wedge in the fight against racial discrimination in the schools, might he set up to test the constitutional position of therapeutic freedom.
These, then, represent some of the specific problems and opportunities facing the National Health Federation. But underlying these specific instances is a deep and general problem of which we are already aware, but which may bear restatement.
It would he hard to improve on the basic therapeutic ideal of Dr. Benjamin Rush, the first Surgeon-General of the Continental Army of the United States and a signer of the Declaration of Independence, when he said:
“The Constitution of this Republic should make special provision for Medical Freedom as well as Religious Freedom … To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un-American and despotic. They are fragments of monarchy and have no place in a Republic.”
With each year, there is a continual increase in the monolithic fusion between the state and federal governments and a single therapeutic approach.
This monolithic centralization of power in one therapeutic group poses a serious threat to our government which may well extend beyond the therapeutic field. To a large extent our constitution, rooted in the pragmatic humanism of John Locke, was in part a reaction against the horrors of the Inquisition. The framers of our Constitution must have frequently thought of the sad fate of human freedoms which resulted from the establishment in part of Europe of a militant theocracy, in which the state became the arm of one church. Although we pride ourselves on our own religious freedom, and justly so, we must beware that another inquisition does not become established, this time in the name of scientific medicine rather than in the name of God. The devil prefers the back to the front door. Although we have had as yet no auto-da-fes, the therapeutic minorities already have a substantial list of martyrs. One of the first was Dr. Wiley, the founder of the Food and Drug Administration, and one of its first victims. Here, as elsewhere, revolutions may devour their own children. Dr.WiIhelm Reich, the founder of Orgone therapy, died in May, 1957 in the Federal prison in Pennsylvania. His books and equipment were burned, as the result of FDA action (this was in the United States in 1957, not Nazi Germany in 1933!). His associate, Dr. Michael Silveri, served one year and committed suicide in May, 1958 on his release. Because of the recent Thalidomide scare the FDA is being granted even stronger powers, so that its excesses may wax rather than wane. The fire of tyranny, once ignited, consumes everything in its path. Possibly the greatest quality of our Constitution is that although idealistic in aim it is essentially humanistic in method. Our Founding fathers recognized that effective government of mere humans must include a system of checks and balances. The average person put in a position of unrestricted power, operating in a field to which he is both professionally and personally dedicated, may lose a proper focus and become paternalistic or even dictatorial, But for the check and balance system to work the minority must be as vital and effective as the majority. By standing for its rights, a dynamic minority protects those in a position of power from succumbing to the tyranny of their own majority. Possibly a large part of the present subjection of the therapeutic minorities in this country is the result of our own lack of unified action in the past. It is the privilege of this group to consider how to remove certain therapeutic legislative inequalities. We cannot strike a pose of moral righteousness since, if the roles were reversed, can we be sure that if those of us now in a minority position were suddenly in a majority, we would not be just as paternalistic and dictatorial as those we, in a sense, oppose. The note to sound is not one of condemnation but one of sympathy and hopeful cooperation.
May the time soon arrive when we can look back on a correction of the present legislative excesses against certain therapies with the same satisfaction with which many of us must view those laws passed to right the wrongs of our Negro and Indian minorities.The Erosion of Our Therapeutic Freedoms in the Twentieth Century