Tag Archives: health care policy

Medical Freedom, Then and Now

“A nation’s liberties seem to depend upon headier and heartier attributes than the liberty to die without medical care.”                                                                        ~Milton Mayer, “The Dogged Retreat of the Doctors” (1949)

Conservative supreme court justices who voice grave skepticism about the constitutionality of the Patient Protection and Affordable Care Act of 2010 would have been better suited to judicial service in the decades following the Revolutionary War.  Issues of health, illness, freedom, and tyranny were much simpler then.  Liberty, as understood by our founding fathers, operated only in the interlacing realms of politics and religion.  How could it have been otherwise?   Medical intervention did not affect the course of illness; it did not enable people to feel better and live longer and more productive lives.  With the exception of smallpox inoculation, which George Washington made mandatory among colonial troops in the winter of 1777, governmental intrusion into the health of its citizenry was nonexistent, even nonsensical.

Until roughly the eighth decade of the nineteenth century, you got sick, you recovered (often despite doctoring), you lingered on in sickness, or you died.  Antebellum (pre-Civil War) medicine relied on a variation of Galenic medicine developed in the eighteenth century by the Scottish physician John Cullen and his student John Brown.  According to Cullen’s system, all diseases were really variations of a single disease that consisted of too much tension or excitability (and secondarily too little tension or excitability) in the blood vessels.  Revolutionary-era and antebellum physicians sought to restore a natural balance by giving “overstimulated” patients (read: feverish, agitated, pain-ridden patients) large doses of toxic mercury compounds like calomel to induce diarrhea; emetics like ipecac and tobacco to induce vomiting; and by bleeding patients to the point of fainting (i.e., syncope).  It was not a pretty business.

Antebellum Americans did not have to worry about remedies for specific illnesses.  Except for smallpox vaccine and antimalarial cinchona tree bark (from which quinine was isolated in 1820), none existed.  Nor did they have to worry about long-term medical interventions for chronic conditions – bacterial infections, especially those that came in epidemic waves every two or three years, had no more opportunity to become chronic than diabetes, heart disease, or cancer.

Medical liberty, enshrined during the Jacksonian era, meant being free to pick and choose your doctor without any state interference.  So liberty-loving Americans picked and chose among calomel-dosing, bloodletting-to-syncope “regulars,” homeopaths, herbalists, botanical practitioners (Thomsonians), eclectics, hydropaths, phrenologists, Christian Scientists, folk healers, and faith healers.   State legislatures stood on the sidelines and applauded this instantiation of pure democracy.  By midcentury, 15 states had rescinded medical licensing laws; the rest gutted their laws and left them unenforced.  Americans were free to enjoy medical anarchy.

Now, mercifully, our notion of liberty has been reconfigured by two centuries of medical progress.  We don’t just get sick and die.  We get sick and get medical help, and, mirabile dictu, the help actually helps.  In antebellum America, deaths of young people under 20 accounted for half the national death rate.   Now our children don’t die of small pox, cholera, yellow fever, dysentery, typhoid, and pulmonary and respiratory infections before they reach maturity.  Diphtheria no longer stalks them during the warm summer months.  When they get sick in early life, their parents take them to the doctor and they almost always get better.  Their parents, on the other hand, especially after reaching middle age, don’t always get better.  So they get ongoing medical attention to help them live longer and more comfortably with chronic conditions like diabetes, coronary heart disease, inflammatory bowel disease, Parkinson’s, and many forms of cancer.

When our framers drafted the Constitution, the idea of being free to live a productive and relatively comfortable life with long-term illness didn’t compute.  You died from diabetes,  cancer, bowel obstruction, neurodegenerative disease, and any major infection (including, among young women, the infection that often followed childbirth).  A major heart attack usually killed you.  You didn’t receive dialysis and possibly a kidney transplant when you entered kidney failure.  Major surgery, performed on the kitchen table if you were of means or in a bacteria-infested, dimly lit, unventilated public hospital if you weren’t, was all but nonexistent because it invariably resulted in massive blood loss, infection, and death.

So, yes, our framers intended our citizenry to be free of government interference, including an obligatory mandate to subsidize health care for millions of uninsured and underserved Americans.  But then the framers never envisioned a world in which freedom could be safeguarded and extended by access to expert care that relieved suffering, effected cure, and prolonged life.  Nor could they envision the progressive income tax, compulsory vaccination, publicly supported clinics, mass screening for TB, diabetes, and  syphilis, and Medicare.  Throughout the antebellum era, when regular physicians were reviled by the public and when neither regulars nor “alternative” practitioners could stem the periodic waves of cholera, yellow fever, and malaria that decimated local populations, it mattered little who provided one’s doctoring. Many, like the thousands who paid $20.00 for the right to practice Samuel Thomson’s do-it-yourself botanical system, chose to doctor themselves.

Opponents of the Affordable Care Act seem challenged by the very idea of progress.  Their consideration of liberty invokes an eighteenth-century political frame of reference to deprive Americans of a kind of liberty associated with a paradigm-shift that arose in the 1880s and 1890s.  It was only then that American medicine began its transition to what we think of as modern medicine. Listerian antisepsis (and then asepsis); laboratory research in bacteriology, immunology, and pharmacology; laboratory development of specific remedies for specific illnesses; implementation of public health measures informed by bacteriology; modern medical education beginning with the opening of Johns Hopkins Medical College in 1893; and, yes, government regulation to safeguard the public from incompetent practitioners and toxic, sometimes fatal, medications – all were  all part of the transition.

“We hold these truths to be self-evident,” Jefferson begins the second paragraph of the Declaration of Independence, “that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”  What Jefferson didn’t stipulate – what he couldn’t stipulate in his time and place – was the hierarchical relationship among these rights.  Now, in the twenty-first century, we are able to go beyond an eighteenth-century mindset in which “life, liberty, and the pursuit of happiness” functions as a noun phrase whose unitary import derives from the political tyrannies of King George III and the British Parliament.  Now we can place life at the base of the pyramid and declare that quality of life is indelibly linked to liberty and the pursuit of happiness.  To the extent that quality of life is diminished through disease and dysfunction, liberty and the pursuit of happiness are necessarily compromised.  In 2012, health is life; it is life poised to exercise liberty and pursue happiness to the fullest.

Why is it unconstitutional to obligate all citizens to participate in a health plan, either directly or through a mandate, that safeguards the right of people to efficacious health care regardless of their financial circumstances, their employment status, and their preexisting medical conditions?  What is it about the term “mandate” that is constitutionally questionable?  When you buy a house in this country, you pay local property taxes that support the local public schools.  (If you’re a renter, your landlord pays your share of the tax out of your rent.)  The property tax functions like the mandate:  It has a differential financial impact on people depending on whether they directly benefit from the system sustained by the tax.  To wit, you pay the tax whether or not you choose to send your children to the public schools, indeed, whether or not you have children.  You are obligated to subsidize the public education of children other than your own because public education, for all its failings, has been declared a public good by the polity of which you are a part.

It is inconceivable that the founding fathers would have found unconstitutional a law that extended life-promoting health care to the roughly 50 million Americans who lack health insurance.  The founding fathers declared that citizens – well, white, propertied males, at least – were entitled to life consistent with the demands and entitlements of representative democracy; their pledge, their Declaration, was not in support of a compromised life that limited the ability to fulfill those demands and enjoy those entitlements.

Of course, adult citizens may repudiate mainstream health care on the basis of their own philosophical or religious  predilections.  Fine.  Americans who wish to pursue health outside the medical mainstream or, in the manner of medieval Christians, to disavow corporeal well-being altogether, are free to do so.  But they should not be allowed to undermine social and political arrangements, codified in law, that support everyone else’s right to pursue life and happiness through twenty-first century medicine.

The concept of medical freedom dominated the antebellum period and resurfaced during the early twentieth century, when compulsory childhood vaccination and Oklahoma Senator Robert Owen’s proposed legislation to create a federal department of public health spurred the formation of the Anti-Vaccination League of America, the American Medical Liberty League, and the National League for Medical Freedom.   According to these groups, medical freedom was incompatible not only with compulsory vaccination, but also with the medical examination of school children, premarital syphilis tests, and municipal campaigns against diphtheria.  In the 1910s, failure to detect and treat contagious bacterial disease was a small price to pay for freedom from what medical libertarians derided as “allopathic knowledge.”   These last gasps of the Jacksonian impulse were gone by 1930, by which time it was universally accepted that scientific medicine was, well, scientific, and, as such, something more than one medical sect among many.

After World War II,  when the American Medical Association mounted its holy crusade against President Harry Truman’s proposal for national health care, “medical liberty” came into vogue once more, though its meaning had changed.  In antebellum American and again in the 1910s, it signified freedom to cast off the oppressive weight of “regular” medicine and pick and choose among the many alternative sects.  In the late 1940s, it signified freedom from federally funded health care, which would contaminate the sacrosanct doctor-patient relationship.  For the underserved, such freedom safeguarded the right to remain untreated.  The AMA’s legerdemain elicited ridicule by many, the prominent journalist Milton Mayer among them.  “Millions of Americans,” Mayer wrote in Harper’s in 1949, “geographically or economically isolated, now have access to one doctor or none.  The AMA would preserve their present freedom of choice.”  In 1960, the medical reporter Selig Greenberg mocked  medical free choice as a “hoary slogan” based on “the fatuous assumption that shopping around for a doctor without competent guidance and paying him on a piecemeal basis somehow guarantees a close relationship and high-quality medical care.”[1]

Now the very notion of medical freedom has an archaic ring.  We no longer seek freedom from the clutches of mainstream medicine; now we seek  freedom to avail ourselves of what mainstream medicine has to offer.  At this singular moment in history, in a fractionated society represented by a bitterly divided Congress, access to health care will be expanded and safeguarded, however imperfectly, by the Affordable Health Care Act.  Those who opt out of the Act should pay a price, because they remain part of a society committed to health as a superordinate value without which liberty and the pursuit of happiness are enfeebled.  To argue on about whether the price of nonparticipatory citizenship in the matter of health care can be a tax but not a mandate is obfuscating wordplay.  And the health and well-being of we the people should not be a matter of wordplay.


[1] Milton Mayer, “The Dogged Retreat of the Doctors,” Harper’s Magazine, 199:25-37, 1949, quoted at pp. 32, 35; Silas Greenberg, “The Decline of the Healing Art,” Harper’s Magazine, 221:132-137, 1960, quoted at p. 134.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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“Socialized Medicine,” anyone?

The primary season is upon us, which means it’s time for Republicans to remind us of the grave perils of “socialized medicine.”  One-time candidate Michele Bachmann accuses Mitt Romney  of “put[ting] into place socialized medicine” when governor of Massachusetts.  Newt Gingrich, rejecting Romney’s defense of the Massachusetts law as something other than socialist, declares that  “Individual and employer mandates are bad policy leading down the road to socialized medicine, whether the mandates are adopted at the federal level or the state level.”  Ron Paul, not to be outdone, derides our health care system as “overly corporate and not much better than a socialized health care system.”  Rick Santorum mournfully announces that socialized medicine is “exactly where we’re headed.”  And then of course there is that noncandidate and subtle political thinker Sarah Palin, who apparently tolerated Canadian single-payer health care well enough when it was available to her and her family members, but never fails to lambast the health care reform bill of 2010 (“Obamacare”) as the great evil, the capitulation to socialist medicine that will lead us straight into the bowels of socialist hell.

As a historian of ideas, I am confused.  What exactly do these Republicans mean by “socialized medicine” and, more generally, by “socialism”?  Are they referring to the utopian socialism of the early nineteenth century that arose in the wake of the French Revolution, the socialism of Charles Fourier, Henri Saint-Simon, and Joseph Le Maistre?  Are they referring to Marxist socialism and, if so, which variant?  The socialism of the early Marx, the Marx of the  economic and philosophical manuscripts of 1844 and The German Ideology or the socialism of the late Marx, the Marx of Das Kapital?  It is difficult to imagine the candidates rejecting the conservative socialism of Otto Bismarck, the German Iron Chancellor who, during the 1870s and 1880s, wed social reform to a conservative vision of society.  But then again they might:  Bismarck’s reforms, which included old-age pensions, accident insurance, medical care, and unemployment insurance, paved the way for the triumph, despite Bismarck’s own antisocialist laws, of Germany’s Social Democratic Party in the early twentieth century.

Perhaps the Republicans mean to impugn a broader swath of post-Marxist reformist socialism (also termed “democratic socialism”).  Does their antipathy take in the British liberal welfare reforms of David Lloyd George that from  around 1880 to 1910 constructed Britain’s social welfare state?  After all, Britain’s National Insurance Act of 1911 provided for health insurance, and many of Lloyd George’s  acts aimed at the health and well-being of British children.  Child labor laws, medical inspection of schools, and medical care for school children via free school clinics were among them.  Certainly all the candidates would repudiate FDR’s New Deal.  Depression or no, it was a medley of socialist programs that culminated in a social security program that workers could not opt out of.  But then again, perhaps the candidates do not understand socialism as the cumulative protections of democratic socialism.  Maybe the socialism they impugn is only hard-core late Marxism and its transmogrification after 1917 into Soviet Marxism-Leninism, both of which now slumber peacefully in the dustbin of history.  I don’t know.  Does anyone?  Maybe some of these candidates only see red when contemplating employment of physicians by the state.

When it comes to “socialized medicine,” just how far do the Republicans seek to turn back the clock?   Does more than a century of social welfare reform have to go?  Certainly they must repudiate Medicare and Medicaid, whose passage in 1965 was, with respect to the elderly and indigent, socialism pure and simple; for the AMA these programs sounded the death knell of democracy.  But why stop there?  If they really want to root out medical socialism, they can hardly condone Medicare’s precursor, the Kerr-Mill Act of 1960 that made federal matching funds available to states that underwrote the costs of health care for their indigent elderly.

And what of the FDA, that competition-draining, creativity-stifling offspring of Rooseveltian socialist thinking.  Who is the government to tell medical equipment manufacturers which devices they may sell to doctors and the public?  The 1976 Medical Devices Amendments to the Federal Food, Drug and Cosmetic Act of 1938 would have to go.  The more than 700 deaths and 10,000 injuries attributed to defective cardiac pacemakers and leaky artificial heart valves by the Cooper Commission in 1970, not to mention the 8,000 women injured (some left sterile) by their faulty contraceptive Dalkon Shields – this was a small price to pay for an open marketplace that encouraged and rewarded innovation.  The 1962 Kefauver–Harris Amendments to the Federal Food, Drug and Cosmetic Act of 1938, which arose in the wake of the thalidomide tragedy of 1961, would probably fare no better.  After all, these amendments dramatically expanded the FDA’s authority over prescription drugs by requiring drug companies to conduct preclinical trials of toxicity and then present the FDA with adequate and well controlled studies of drug effectiveness  before receiving regulatory approval.  I wonder if principled antisocialists can even abide the FDA-enforced distinction between prescription-only and nonprescription drugs, as codified in the 1951 Durham-Humphrey Amendment to the 1938 Act.  Before then, Americans did just fine self-medicating without government interference.  Sure they did.  Citizens of the late 30s could be relied on to decide when to take the toxic sulfonamides (which depressed white cell counts and led to anemias), just as citizens of the late 40s knew enough pharmacology and bacteriology to decide when and in what dosages to use the potent antibiotic “wonder drugs,” all of which could be obtained over-the-counter or directly from pharmacists until the 1951 Act.

But why stop there?  Perhaps Republican political philosophy obliges the candidates to repudiate the Federal Food, Drug and Cosmetic Act in toto.  After all, it authorized the FDA, a federal agency, to review the safety and composition of new drugs before authorizing their release.  Yes, the legislation arose in the wake of 106 deaths the preceding year – many children among them – from sales of the Tennessee drug firm S. E. Massengill’s Elixir Sulfanilamide.  The Elixir was a sweet-tasting liquid sulfa drug that – unbeknown to anyone outside the company — used toxic diethylene glycol (a component of brake fluid and antifreeze) as solvent.  But, hey, this was free-market capitalism in action.  Sure, hundreds more would have died if all 239 FDA inspectors hadn’t tracked down 234 of the 240 gallons of the stuff already on the market.  But is this really any worse than having 10,000 or so European and Japanese kids grow up with flippers instead of arms and hands because their pregnant mothers, let down by the regulatory bodies of their own countries, ingested Chemie Grünenthal’s sedative thalidomide to control first-trimester morning sickness?  A free medical marketplace has its costs, dead kids, deformed kids, and sterile women among them.  Perhaps, in the Republican vision of American health care, this marketplace had every right to bestow on Americans their own generation of thalidomide babies, not just the small number whose mothers received the drug as part of the American licensee’s advance distribution of samples to 1,267 physicians.

If we’re going to turn back the clock and recreate a Jacksonian medical universe free of intrusive, expensive, innovation-stifling, rights-abrogating big government, let’s go the full nine yards.  Let’s repudiate the Pure Food and Drugs Act of 1906, which compelled drug companies to list the ingredients of drugs on the drug labels.  Sure, prior to the act most remedies aimed at children were laced with alcohol, cocaine, opium, and/or heroin, but was this so bad?  At least these tonics, unlike Elixir Sulfanilamide, didn’t kill the kids, and the 1906 Act did put us on the path to government overregulation.  And, anyway, it’s up to parents, not the federal government, to figure out what their kids ingest.  Let them do their own chemical analyses (or better yet, contract unregulated for-profit labs to do the analyses for them) and slug it out with the drug companies.

And, while we’re at it, let’s roll back the establishment in 1902 of the brazenly socialistic Public Health and Marine Hospital Service, with its “big government” division of pathology and bacteriology.  Okay, it did a few things Republican candidates would likely applaud, like preventing incoming immigrants from coming ashore with infectious diseases like cholera, yellow fever, and bubonic plague.  But the Service couldn’t leave well enough alone. With its federal budget and laboratory of government employees, it went on to identify infectious diseases like typhoid fever, tularemia, and undulant fever.  Then, during World War I, after its name had been shortened to the Public Health Service, it isolated the organisms responsible for epidemic meningitis and developed tetanus antitoxin and antityphoid vaccine.  But, hey, private enterprise of the time would have addressed these issues better and more cost effectively, right?  And it wouldn’t have placed us on the road to socialist perdition.

Compulsory vaccination for smallpox and diphtheria?  State laws that beginning in 1893 required public schools to exclude from enrollment any student who could not present proof of vaccination?  Forget it.  States and municipalities had no right forcibly to intrude into the lives of children with their public health inspectors, followed by school physicians with their vials of toxin-antitoxin.  What was this if not socialist medicine, with the state abrogating the rights of parents and school principals alike – the former with the right to keep their children unvaccinated, that they might contract infection and pass it on to classmates and family members; the latter with the right to keep school enrollment as high as possible without government interference.

Here’s the point of this exercise in conjecture:  If we’re going to have a national debate about health care, then our candidates must cease and desist from using evocative words that incite fear and loathing but mean nothing because they mean anything and everything.  You can’t have a debate without people capable of debate, which is to say, people who grasp ideas as something other than sound bites that mobilize primitive emotions.  Debaters make arguments and cite evidence that support them; they don’t throw out words and wait for a primal scream.

It would be nice if we had presidential candidates willing and able to explain their take on specific ideas and then wrestle with the applicability of those ideas to the real-life problems of specific groups of Americans.  It would be nicer still if all this explaining and wrestling and applying were informed by the lessons of history.  I believe we will have such debates shortly after hell freezes over.  Therefore, I offer my own ideational stimulus package to inch us toward this goal.  I propose an Act of Congress that proscribes the use of certain words and phrases among all presidential candidates.  Each time a candidate uses a proscribed word or phrase in a campaign speech, a TV commercial,  or an internet posting, he or she, if nominated, forfeits one electoral vote earned in the general election.  In the realm of health care, “socialism,” “socialist medicine,’’ “big government,” “death panels,” “overregulation,”  “the people,” and “the American way” would top the list.  Such terms cannot be part of a national debate because they do not promote reasoned exchange.  They have emotional resonance but nothing else.  In fact, they preclude debate by allowing the word or phrase in question to carry an implicit meaning that reaches consciousness only as a gut-churning abstraction.  Gut-churning abstractions, be it noted, tend to be historically naïve and empirically empty.

So I end where I began:  What exactly do our Republican candidates mean by “socialized medicine” other than a global repudiation of the health care reform bill of 2010?  Do they mean that medicine was just socialist enough before the bill passed, but that specific components of the bill – like preventing insurers from denying coverage to people with preexisting conditions – take the country to a point of socialist excess serious enough to abrogate the new protections the bill affords uninsured and underinsured  Americans.  Or perhaps American health care, even before the legislation, was simply too socialist, so that it becomes incumbent on our elected leaders to turn back the clock, undo past legislative achievements, reverse specific governmental policies, and disembowel certain regulatory agencies.  But if the latter, exactly which laws and policies and agencies must be sacrificed on the altar of a free and open medical marketplace?   I don’t know what the Republican candidates have in mind, but I’m all ears – once they stop lobbing word grenades and actually make an argument.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.