Tom Ferguson MDYour doctor’s medical license makes it harder for you to take care of yourself—at least that’s the opinion of Dr. Charles Baron of the Boston College Law School. Baron suggests that our present medical licensure laws should be reconsidered:
“These laws were passed with a worthy purpose,” he explains. “To maintain the high standards of medical care and to protect patients against unscrupulous and inadequately trained practitioners. Back in the heyday of antibiotics this arrangement may have seemed somewhat reasonable. But now that virtually everyone agrees that laypeople do more than doctors to improve the nation’s health, these laws are doing more harm than good. Medical licensure laws increase health care costs, stifle competition and innovation and, in many cases, prevent consumers from obtaining the skills, tools, and information they need to take better care of their own health.”
Dr. Baron is not alone. A variety of other experts, among them economist Milton Freedman, former Federal Trade Commission Chief Michael Pertschuk, and American Bar Association Foundation Research Fellow Laurie Andrews, have questioned the need for medical licensure laws.
History. Medical licensure is a relatively recent development in the U.S. Up until the early 20th century, Americans took it for granted that people were responsible for their own health. But for the last 50 years, Americans have “let the doctor do it” until, in recent years, we have entrusted virtually all health matters to a system of professional care dominated by physicians.
But the tide has now begun to turn. We are becoming painfully aware of the limits of professional medicine. There is growing interest in the role of alternative therapies, self-care, and social support in treating illness and maintaining health. New medical tools are being created for—and adapted to—consumer use. But the role of the consumer is limited by laws which reserve the right to practice medicine to physicians alone. “A medical license was supposed to protect the consumer,” Baron says. “Instead, it has been used to justify the complete domination of health care by the physician.”
Our present health care system is created in our doctors’ image: highly technological, disease-oriented, hospital-based, expensive, with heavy reliance on diagnostic testing, prescription drugs, and hospital-based surgery. But the present system suffers from physicians’ “tragic flaw”—a nearly exclusive focus on high-tech solutions to end-stage problems. The implanting of an artificial heart is dramatic and newsworthy. But where was that surgeon through all the years of smoking, inactivity, stress, social isolation, and high-fat diet it took to destroy the patient’s original heart in the first place?
The emerging health care system is being created in the image of the health-active layperson. It emphasizes home testing, self-treatment, preventive health, self-responsibility, shopping-center medicine, chronic and long-term care, and home care.
Hard On Docs. The responsibilities we have heaped upon our doctors have proved a heavy burden. They are charged to cure illness, yet are all too frequently unable to do so.. Little wonder that there is a shockingly high level of suicide, alcoholism, drug dependence, psychiatric disease, and other forms of impairment among physicians.
“Most physicians live in a state of chronic stress,” says Dr. John-Henry Pfifferling, director of the Center for the Well-Being of Health Professionals in Chapel Hill, North Carolina. “Very few are truly healthy. Every year this country loses the equivalent of several entire medical school classes to doctors’ suicides, drug addiction, and alcoholism. Experts estimate that about 10 percent of all physicians are seriously impaired.” ‘
A change in the present medical licensure laws would allow our physicians to step out of the parental role that has been forced upon them. They could—as one physician put it— begin shedding their Superman suits at last.
The medical licensure laws also give organized medicine very tight control over the practice of local physicians. Physicians who wish to follow experimental or nonstandard treatments are often severely disciplined and may be threatened with the loss of their licenses. Deregulating medicine would break the hammerlock that organized medicine has on the practice of physicians.
Quacks. The argument for medical licensure assumes that consumers are too ignorant to protect themselves from fraudulent claims, thus their range of choice should be limited to licensed physicians. In fact, the risk of injury from orthodox medicine’s surgery, invasive diagnostic tests, X-rays, and powerful prescription drugs is substantially higher than the risk from alternative practitioners’ herbs, vitamins, homeopathic remedies, massage, and spiritual healing.
Medical licensure laws assume that unrealistic claims and false hopes occur only outside the medical profession. Yet the sick and injured may be even more vulnerable to exploitation by M.D.s. Thus medical licensure does not in itself protect consumers from quackery. It only helps to cover up quackery among licensed physicians.
Paramedics. Present laws also limit the range of services non-MD health workers can provide. But these paramedics (dental hygienists, nurse practitioners, and others) could, in many cases, provide adequate services on their own—and at substantially lower cost.
Deregulating medicine would allow consumers to consult an experienced nurse practitioneer directly. It would free acupuncturists, herbalists, faith healers, nutritional consultants, and traditional native healers of all cultures to offer their services openly. This would increase the quality of care and decrease health costs without in any way limiting consumers’ access to physicians. Indeed, it could only increase communications and encourage partnerships between orthodox and alternative healers.
Medical licensure laws protect physicians from all outside competition. They allow physicians to be authoritarian and patronizing, to set inconvenient clinic hours, and to be chronically late in keeping appointments— because their customers have nowhere else to turn.
Under a deregulated system, there would be more alternatives. Physicians would still receive the same training and have the same credentials. Consumers who wished to do so could continue to consult them. But physicians would not be granted an exclusive license to provide health services. Such an unrestricted health care system would force physicians to be more responsive to consumer preferences.
Health Literacy. Existing medical licensure laws have created an expensive and ineffective over-reliance on physicians. They have seriously undermined many laypeoples’ confidence that they really can take care of themselves. A change from a license based, monopolistic system to a credential-based, deregulated system would help transfer power and responsibility for health to the informed consumer.
A necessary element in such change would be a national commitment to universal health literacy. A good school-based health education program could turn out high school graduates with a level of health knowledge comparable to that of some paramedics.
Today’s health consumer is ready to accept this more active role. Present research suggests that the number of people who say they have a strong or moderate commitment to self-care should increase from 20 percent in 1984 to 51 percent in 1990.2
It is no longer reasonable to leave all serious health matters to our doctors. “Medical licensure,” Baron suggests, “is an idea whose time has come—and gone.”
Editor Tom Ferguson would like to hear from those who are working toward a self-care-based health care system.
REFERENCES
1. Iohn-Henry Pfifferling. Personal communication.
2. Helping Ourselves to Health: The Self-Care and Personal Enhancement Market in the US., The Health Strategy Group, New York, 1983.
R E S O U R C E S
A good review article from the legal literature is Dr. Baron’s, “Licensure of Health Care Professionals: The Consumer’s Case for Abolition,” in the American Journal of Law and Medicine, Vol. 9, pp. 335-356, 1983. (Reprints are available from: Charles H. Baron, Ph.D., Professor of Law, Boston College Law School, Newton Centre MA 02159.)
Deregulating Doctoring: Do Medical Licensing Laws Meet Today’s Health Care Needs?, by Lori B. Andrews, 1983, 82 pages, $10.95 from the People’s Medical Society, 14 East Minor Street, Emmaus PA 18049.
Daniel Redwood DC
