by Barry Edington
University of Winnipeg
Manitoba History, Number 13, Spring 1987
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Canadian Medicine: A Study in Restricted Entry. Ronald Hamowy. Toronto: The Fraser Institute, 1984. 394 pp. ISBN 0-88975-062-9.
Canadian Medicine details “the historical development of legal restrictions on entry into medical practice in Canada” from 1840 to 1920. This book is a well-researched description of the organization and development of boundaries to the entrance to the medical profession. It is a text that will be of value to medical historians and sociologists studying the development of medical certification and licensing in Canada. In Canadian Medicine, Hamowy provides a 27 page statistical appendix to demonstrate how the historical processes he describes affect the employment, income and education of the medical profession into the 1980s.
In Hamowy’s attempt to blend his documentation with an implicit sociological theory of professionalization he supports the idea expressed in the preface that a more “competitive system of medical certification” would be better for the health consumer. Because he is attempting to understand the roots of our present medical monopoly his work may be used to provide evidence for a particular political policy.
My major reservation goes beyond the materials of the text. I found it hard to read Canadian Medicine without being influenced by the publisher, The Fraser Institute, and by the preface by Walter Block. Both of these place the study within a particular ideological context where Hamowy’s work becomes a rationale for a more competitive, de-certified system of medicine. I do not wish to launch into a critique of The Fraser Institute but I would urge readers to cover the book in brown paper and skip the preface and the introduction. My reason for this recommendation is that the context of the initial remarks reduces the impact of the substantive chapters.
The conclusion reached by Hamowy’s analysis, or so we are led to believe by the preface and introduction, is that the market, free of restrictions to entry, should determine the social and economic position of physicians and the quality of health care of the population. The implicit assumption in this work is that with increasing demand for medical services the social status and income of the physicians would fall if supply restrictions on the number of physicians were eliminated. This argument is situated in the general theoretical bias of the Fraser Institute for a more competitive health care market. [1]
The purpose of the text is to counter the traditional, “meliorist” or “whig,” interpretations of history which abound in Canadian medical history — Hamowy has over ninety pages of criticisms. Unfortunately, in attempting to escape traditional medical historiography, Hamowy falls back on a well-worn reductionist methodology. His analysis shows that the inordinate amount of prestige, status and income granted to the medical profession in recent years derives from the interests of allopathic medical practitioners during the late nineteenth and early twentieth centuries. Attempts to restrict entry to medical practice, according to Hamowy, were due more to elaborate backroom planning by physicians than to an outright concern to reduce “quackery” for the health of the population. His argument, put simply, is that medical professionals have historically been self-serving and their motives in restricting entry to the profession, through licensing and certification, were oriented to creating a medical monopoly.
I have some reservations about the all-encompassing way a select group of individuals is supposedly able to organize an elaborate structure of certification without internal opposition or external assistance. Also, social class and political affiliation, important factors in separating legitimate medicine from quackery, are not discussed. Hamowy would have us believe that little outside the motives of those dominant individuals associated with the drive for allopathic superiority had an affect on the social and economic position of the profession today.
In Hamowy’s analysis of professionalization there is no mention of differences of opinion or conflicts between members of the profession. There are many examples of how political decisions, internal and external to the profession, affected the social position of the present medical practice. For example, I am surprised Hamowy makes little reference to the battles between Dr. John Rolph (Reformer) and Bishop Strachan (Tory) and their political and medical supporters in connection with the attempts to link medical education to universities in Upper Canada, especially Trinity, from 1850 to 1871. Also, there is no discussion of the ensuing fights between physicians associated with the rival Upper Canadian medical schools over the use of hospitals for teaching their students.
I enjoyed reading this work and have no doubt that it will be useful to those working in this field. Canadian Medicine stands on its own without the obvious ideological baggage which precedes it.
1. For a detailed analysis of the economics of Canadian health care see R. Evans, Strained Mercy (Toronto: Butterworths, 1985).
