CASE AGAINST MEDICAL AND ALL OTHER OCCUPATIONAL LICENSING
by Dr. Lawrence Wilson
© August 2018, L.D. Wilson Consultants, Inc.
Table Of Contents
II. THE HISTORY OF MEDICAL LICENSING IN AMERICA
III. PROBLEMS CAUSED BY LICENSING
IV. ARROGANCE OF LICENSING
V. THE LICENSING LIES
VI. ALTERNATIVES TO LICENSING
Licensing certain occupations is often taken for granted. Licensing advocates promote it heavily as the way to avoid poor quality medical and other types of care.
However, occupational licensing does not protect the public. Standard criminal laws such as prohibitions against fraud, misrepresentation or negligence are much better for protecting the public.
In fact, licensing doctors limits competition and stifles innovation. As a result, it causes lower quality of care, less access to health care, sloppiness, protection for outdated and toxic methods, inflated prices, and arrogance.
The problems of licensing apply to all other occupations such as nutritionists, acupuncturists, attorneys, cosmetologists and dozens of others.
Milton Friedman, Nobel prize-winning economist, wrote:"... I am persuaded that licensure has reduced both the quantity and quality of medical practice...It has reduced the opportunities for people to become physicians, it has forced the public to pay more for less satisfactory service, and it has retarded technological development...I conclude that licensure should be eliminated as a requirement for the practice of medicine."(1)
George J. Stigler, Nobel Prize-winning economist at the University of Chicago, wrote: "As a rule, regulation is acquired by the industry and is designed and operated primarily for its benefit".(2)
Dr. Lori B. Andrews, Professor of Law and Norman and Edna Freehling Scholar, Chicago-Kent College of Law, wrote: "Licensing has served to channel the development of health care services by granting an exclusive privilege and high status to practitioners relying on a particular approach to health care, a disease-oriented intrusive approach rather than a preventive approach....By granting a monopoly to a particular approach to health care, the licensing laws may serve to assure an ineffective health care system."(3)
Ron Paul, MD, an obstetrician and a Congressman from Texas, wrote: “Let us allow physicians, hospitals and schools to spring up where they're needed, abolish the restrictive licensure laws, and simply invoke the laws against fraud to insure honesty among all providers of health care...That will make health care affordable for everyone..."(4).
The idea of stopping licensing of health and other practitioners may seem extreme. Let us examine why it is not as radical as it may sound.
II. HISTORY OF MEDICAL LICENSING IN AMERICA
Many people take health care and other occupational licensing for granted. However, for her first 140 years, America had essentially a free market in health care services. Few licensing laws or other barriers to entry into the healing arts existed.(5)
The American founders opposed licensing, a common practice in England. They believed in 1) a right to work, 2) a right to freedom of choice for practitioners and consumers and 3) the government as a neutral party to protect those rights.
Herbalists, nature cure therapists, hydrotherapists, osteopaths, allopaths, homeopaths and eclectic practitioners offered services. Many types of healing schools and clinics operated without government interference.
At this time, America was among the healthiest nations. Competition between practitioners and healing modalities kept prices down. Low costs made health care widely accessible.
The government kept hands off except that laws against fraud and negligence protected the consumer. No healing modality or group of healers had a legal advantage over the others. Whoever helped people the most prospered.
There was no need for insurance. Organizations similar to Consumers Union sprung up to inform people about the best doctors and the best methods of treatments. Certifying groups set standards for quality and training.
Private health care. In America until the mid-20th century, a lot of people used private doctors. There were many choices and insurance was not needed.
The lodge doctors. Some people joined associations such as the Lions Club or the Elks Lodge. Members paid annual dues and the lodges hired doctors to care for the members and their families if they became ill or unable to work. The lodge system worked very well. However, government welfare programs of the 20th century drove these societies out of business by competing with them.
Community health associations. Others in early America formed community health associations. They were similar to HMOs except owned by their members. Their incentives were to offer the best care at the best prices. They were cooperatives that hired doctors to take care of their members. If members were unsatisfied with the doctors, they hired others. If one did not like one’s community health association, one could join another or form a new one.
Charity. For the poor, a variety of church and community-supported private charities served those in America who were unable to pay for health care.
This is a very brief picture of a health care system based upon freedom of choice among therapies and among providers.
Serious efforts to change the situation began in 1847 with the formation of the American Medical Association or AMA. The AMA said they wanted to protect the public against 'quacks'.
The prime objective, however, was to increase the income of its members, the drug doctors or allopaths. A report submitted at the AMA convention in 1847 was unusually candid:
"...The very large number of physicians in the United States has frequently been the subject of remark...No wonder that the merest pittance in the way of remuneration is scantily doled out even to the most industrious in our ranks ...".(6)
THE FLEXNER REPORT
The method adopted by the AMA to increase their members’ incomes was to eliminate the competition by passing licensing laws. Virtually every law restricting the practice of medicine in America has been enacted not on the crest of public demand, but due to intense pressure from the political representatives of physicians.
The AMA's efforts culminated in 1910 when Abraham Flexner, a former school director and not a physician, was commissioned by the Carnegie Foundation to evaluate medical schools. He was the brother of Simon Flexner, head of the Rockefeller Institute for Medical Research. Working closely with the AMA, he completed a survey of medical schools that was practically a carbon copy of a report the AMA had prepared several years before. The report found all but the drug medicine schools "substandard".(7)
With plenty of financial backing, the Carnegie Foundation and AMA lobbied state legislatures to pass licensing laws ‘to improve health care’. The government, they suggested, should also subsidize the new pharmaceutical industry and drug research.
Their efforts succeeded and by 1920 most states had licensing laws. The number of healing schools fell from 140 in 1900 to 77 in 1940.(8) Many schools failed because their graduates could no longer practice. All schools that accepted women were closed, as were all but two that trained African Americans. Only drug medicine schools remained.
Today's situation. Licensing remains the basis for virtually total AMA monopoly union control of medical education, hospitals, clinics and laboratories. In recent years, chiropractors, physical therapists, psychologists, cosmetologists, naturopaths and others have pushed through their own licensing laws in some or all states.
Instead of getting rid of the system that shut them out for years, they have joined it, increasing its power and prestige. Many states now have 30 or more licensing boards.
Medical licensing laws restrict trade and impair the right to contract. The U.S. Constitution, Article I, Section 10, states: "No state shall ... pass any ... law impairing the obligation of contracts." Visiting a health practitioner is a contract.
The American founders believed in a right to work. Licensing changes this right into a government privilege.
Such laws also interfere with an individual's right to protect his property. What more personal and intimate property does one have than the body?
The Ninth Amendment to the Constitution states that "The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people." The right to offer and to seek health care services of one's choice was not guaranteed in the U.S. Constitution. However, this does not mean the right does not exist or was given away.
The police powers doctrine. The legal defense of occupational licensing is the police powers doctrine. This anti-American doctrine arose in the 1800s and effectively negates the Constitution.
It states that to preserve health and safety, the government may essentially do anything it pleases. The same doctrine is the basis for unconstitutional “emergency powers acts” that have been passed in America and elsewhere. These were used to suspend basic rights during the Wuhan flu situation in 2020 and 2021.
III. PROBLEMS CAUSED BY LICENSING
THE QUALITY OF CARE
Any possible benefits of licensing must be weighed against the following problems of licensing:
1. Licensing restricts healing. Healing is a gift and an art. Many gifted individuals cannot, for various reasons, complete the 6 to 12 years of schooling necessary to obtain a medical license. Licensing deprives the population of the skills and art of these individuals, and prevents many gifted individuals from sharing their skills.
The public is forced to patronize only those who can 'hack' the medical courses and exams, regardless of whether they are the most gifted healers.
2. Licensing interferes with the doctor-patient relationship. A licensed physician is no longer responsible just to his patient. His loyalty is divided between satisfying his licensing board and satisfying the patient. The licensing board comes first if he wants to stay in practice. Anything that comes between doctor and patient tends to lower the quality of care.
3. Licensing stifles innovation, both in education and research. Licensing requirements control what is taught in medical schools. In addition, many government and university research positions require medical degrees and medical licenses.
Yet innovations in every field often come from people in other fields who do not possess advanced degrees and licenses. Morbidity and mortality resulting from restriction of innovation due to licensing laws is incalculable. Dangerous older methods are used while alternatives are forbidden or receive little attention.
4. Licensing protects incompetence and outdated, dangerous drugs and procedures. Licensing laws protect "accepted practice" methods. These include many questionable and dangerous therapies and procedures.
Many physicians are hesitant to deviate from the accepted methods, for fear of losing their licenses. Also, it is harder to sue for malpractice when an accepted, but dangerous procedure goes wrong.
Furthermore, doctors are much less likely to speak out and testify against other doctors, as they risk censure by their licensing board. Original AMA guidelines discouraged quality comparisons between doctors.
5. The shield of the license results in sloppier practices. Licenses gives doctors and hospitals an aura of respectability and often arrogance that results in mistakes and shoddy work. A recent article in the Journal of the AMA(9) revealed that medical mistakes are now the third leading cause of death in America.
THE COST OF HEALTH CARE
Licensing contributes to higher costs because:
1) Stifling innovation raises costs dramatically.
2) Reduced competition among doctors and clinics increases the cost of services.
3) Poorer quality of care and a sicker population raises health care costs.
4) Increased litigation due to sloppiness and false expectations raise costs. Litigation is an important cost factor in medicine today. Among other things, it causes physicians to practice 'defensive medicine'. This is the use of medically unnecessary tests and procedures in order to satisfy attorneys and protect oneself against lawsuits. It raises the cost of health care, at times a lot.
5) Complying with licensing requirements, many of which have little to do with patient care, greatly increases the cost of services. Hospitals in some states have to answer to 20 or more types of state and federal licensing agencies.
ACCESS TO CARE
Licensing decreases access to care because:
1) Fewer practitioners are available and
2) Artificially-created practitioner shortages due to licensing inflate prices that limit many people's access to care.
OTHER PROBLEMS WITH LICENSING
If medical and economic reasons are not enough to question licensing, other problems with licensing include:
1. Licensing criminalizes the population. Medical practice acts convert thousands of citizens into criminals, although they have done no harm. In most states it is a criminal offense to "diagnose, prescribe, or treat anything, mental or physical, real or imaginary" (quoted from the Arizona Medical Practice Act). Heavy-handed tactics including raids by armed SWAT teams have been used to enforce licensing laws and terrorize innocent people.
2. Control is tyrannical. Licensing boards possess police power. However, their members are not elected by the public. Boards are mainly composed of members of the profession. Ordinary citizens have little or no representation, but must abide by decisions of the licensing board. This amounts to tyranny.
3. Licensing greatly expands the power of the government. Licensing shifts responsibility and power from the consumer to government agencies. It is not a coincidence that all modern dictators have advocated government control of health care. It is an excellent way to subdue dissent in the population.
If one does not go along with official doctrines, one may lose one’s health care benefits or be imprisoned as mentally ill. Private certification, the alternatives to licensing, does not increase the power of the government.
4. Licensing debates waste legislators’ time. An Arizona state legislator told me the legislature spends up to 25% of its time resolving turf conflicts between licensed groups. The time could be far better spent.
5. It increases unemployment. Licensing keeps many potential healers out of the job market.
6. Licensing severely distorts the health care marketplace. Licensing amounts to a huge government subsidy of certain groups and healing arts, and the suppression of others. Such distortion has decidedly negative effects upon health, the economy and the quality of life in America.
7. It creates false expectations. Licensing gives the consumer of health care a false sense of security in his physician that leads to false and often unfulfilled expectations. This contributes to dependency, and later to anger and frustration. The malpractice crisis is in part due to high expectations of the public, generated in part by the licensing of physicians.
8. It is discriminatory. Licensing discriminates against the poor and less academically inclined. They have difficulty meeting licensure requirements but may be superb healers. Licensing has also been used to prevent women, African Americans and other ‘undesirables’ from entering the healing professions.
9. It tends to create a privileged class. This is accentuated in a modern welfare state. Welfare programs paid for by all citizens such as Medicare and Medicaid in America only reimburse licensed practitioners. In Arizona, registered dietitians fought hard to become licensed. There was no need except to receive insurance payments.
Medical licenses also serve as ‘tickets of entry’ for thousands of government research jobs, grants and fellowships. Licensing is an integral part of a welfare system that redistributes wealth to certain privileged individuals and groups including licensed doctors.
10. It is falsely promoted. Promoters of licensing claim it protects the public. Yet almost all pressure for licensing laws comes from the professions, not due to public demand.
Basic criminal laws against fraud, negligence and misrepresentation already protect the consumer. These laws are far more stringent than the protection licensing affords. It is rare, for example, for a physician to lose his license unless he is convicted of a serious criminal offense. Licensing boards do not like to punish their own members. Repeated malpractice claims, no matter their merit, do not always result in loss of licensure.
IV. THE ARROGANCE OF LICENSING
I separate this problem of licensing from the others because it is more important, in some ways, than all the others, although all the problems are certainly significant.
A friend was just in the hospital in our town. He felt fine and asked to be discharged. The licensed physician on duty made the outrageous statement, Yyou can leave now, but if you do you will never be allowed back in this hospital.”
Those with licenses often believe they “have arrived”, they are the elite, and they are above decency and even above the law. This is sad to have to say, but I speak with many licensed doctors so I know this is true.
Licensing attracts this type of individual, and it promotes these attitudes by granting to the “chosen few” special privileges that the rest of us do not have.
Going along. Arrogance is also cowardice and silence when one should speak out and resist. This applies to all physicians, who often realize that licensing controls them in ways that harm their relationship with their patients or clients, and harms their ability to do their job. But most just go along, and this is horrible!
Sadly, even those shut out by licensing for years such as chiropractors, naturopaths, and acupuncturists in the past 50 years or so have cowered in fear and jumped on the bandwagon, rather than fight to get rid of this evil system.
Turning on their associates. Even worse, when a new group acquires its own licensing board, they may turn on their own colleagues and shut them down with their newly-acquired police power.
I watched this occur in Arizona with the chiropractors, naturopaths and acupuncturists. Excellent practitioners were forced out of business, and a school I worked at was forced to leave the state.
NOTE: Naturopaths in America are of two types today. Some naturopaths understand the problems of state licensing and prefer to remain without it. Their group, of which I am a member, is the American Naturopathic Medical Association. The other group of naturopaths love licensing. Their organization is the American Association Of Naturopathic Physicians.
Arrogance is always a blindness to reality, and a serious mental illness. Arrogance is also a tool of the dark forces that are everywhere. They use it to build pride and haughtiness in our people that spoils and eventually ruins individuals and entire industries such as medical care.
If we are not careful, arrogance eventually poisons the entire nation, and is not to be taken lightly. For more details, read Arrogance.
V. THE LICENSING LIES
1. Medical licensing was established to protect the public.
2. State medical boards are independent and autonomous. (In fact, they are controlled by a national medical board in America and in other nations).
3. You are safer visiting a licensed health practitioner, rather than an unlicensed practitioner. The malpractice insurance costs do not support this contention at all. The opposite is true.
4. You will get better care from a licensed health practitioner than from an unlicensed one.
5. Licensing may not be perfect, but we need it to prevent chaos, and there is really no alternative. Yes, there are alternatives
VI. ALTERNATIVES TO LICENSING
All societies need to asses and maintain quality products and services. The question is how best to do this. Licensing professions and occupations is one answer. However, we have shown it has many problems. Here are other methods:
1. Eliminate licensing altogether. The substitute, which already exists, is private certification of physicians and others in all areas of health care and specialization.
2. Limit licensing so that the licensing board only has jurisdiction over its licencees, not the entire population.
3. Other methods such as registration. This can be private or governmental.
Let us examine these in more detail.
ELIMINATE ALL LICENSING
One alternative is to eliminate mandatory licensing. This would mean a return to principles that worked well in America for over 100 years. Without licensing, private certifying agencies would spring up to replace state medical boards.
Many such groups already exist. One could still choose an AMA-approved, board-certified physician. However, one could also choose among a variety of alternative practitioners who are not presently permitted to practice.
Existing laws against fraud, negligence and misrepresentation would continue to protect the public. The public would be better protected from malpractice because no physician would be shielded by his license. Physicians would be directly accountable to their patients.
Groups similar to Consumer's Union would spring up to rate practitioners, hospital costs and the effectiveness of treatments. A truly consumer-driven system would weed out the more dangerous and ineffective treatments and irresponsible practitioners far more effectively than licensing.
Similar to car care. Health care would operate in a manner similar to present-day car care. There would be many levels and types of care available. Not everyone enjoys the same level of car care, but most people receive care, innovations are permitted, and competition keeps prices in check.
I have never heard on the news about a “car care crisis”. Maybe it is because there is a free market and no licensing in this area, even though we depend for our lives on our vehicles every day.
In Oklahoma in 1994, the state legislature voted to restrict the power of the state medical board to regulating only allopathic doctors. This is quite a revolutionary idea.
It means that one can practice healing without a license as long as one does not hold oneself out as a medical doctor. In all other states, the medical board regulates everyone except those with specific exemptions to the law.
This is similar to a contractor's license. It is not mandatory and one can choose to use either a licensed or unlicensed contractor.
Minnesota and California have opened up the healing field somewhat by adding broad exemptions to their state medical practice acts. These permit some unlicensed practitioners to offer services without fearing arrest for practicing medicine without a license. However, the allopathic or drug medicine union remains firmly in control of hospitals, doctors, laboratories and other health care facilities.
Dietitians and some nurses and others are registered instead of licensed. All who meet qualifications are listed in a registry. Listing is not mandatory, but hospitals and other institutions usually require their employees to be listed in the registry.
Registration is better than licensing because it does not involve the police power of the state. However, it is somewhat like licensing when the government in any way favors registered practitioners or punishes unregistered practitioners. As the government has gotten larger and larger, it uses registration as a basis for employment. We think private certification is much better.
VII. CONCLUSIONS – THE TRUTH ABOUT LICENSING
Medical licensing prevents some abuses and it creates a more standardized form of medical care. Also, licensing of chiropractors, acupuncturists and others provides these practitioners some protection from the “big boys”, the conventional doctors and their state Board of Medical Examiners.
However, these benefits are minor in comparison with the problems with licensing detailed in this article.
Another truth is that licensing was instituted to reduce the number and variety of health practitioners, to increase the income of one group, and to control physicians and the public alike.
The negative effects of licensing include lower quality of care, reduced access to care, greatly increased costs and much poorer health of the public.
America did very well without health practitioner licensing for many years. As one looks for causes of the health care dilemmas the nation faces, licensing need to be considered. Perhaps it is time to join Milton Friedman and other prominent economists and question the blind belief in licensing.
Friedman, M., "Medical Licensure" in the Dangers
of Socialized Medicine,
ed. by Hornberger and Ebeling, Future of Freedom Foundation, Fairfax,
Va. 1994, p.68.
2. Andrews, Lori B., Dregulating Doctoring: Do Medical Licensing Laws Meet Today's Health Care Needs?, People's Medical Society, 1983, 1986.
3. Andrews, L., ibid. See also: The Shadow Health Care System: Regulation of Alternative Health Care Providers by Lori Andrews, Houston Law Review, Vol. 332, #5, 1996.
4. Paul, R., "Health Care", Health Freedom News, Monrovia, CA, Feb. 1989, P18-19.
5. Goodman, J. and Musgrave, G., Patient Power, Cato Institute, 1992, p.140.
6. "Proceeding of the National Medical Convention", NY J of Med., 9 (July 1847):115.
7. Flexner, A., Medical Education in the United States and Canada, Bulletin #4, Carnegie Foundation for the Advancement of Teaching, 1910.
8. U.S. Bureau of the Census, Historical Statistics of the United States, Colonial Times to 1970, bicentennial Edition, Part 2, Series B 275-90, pp.75-76.
9. JAMA, 284;pp.483-485, July 26, 2000.
10. Kleiner, M., Licensing Occupations” Ensuring Quality or Restricting Competition, Upjohn Institute, 2006.
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