Public efforts to regulate the health professions, especially by imposing restrictions on those who shall be allowed to practice them, go back to the Babylonian emperor Hammurabi (d. 1750 b.c.e.). Rules for medical practice existed in ancient Greece and tenth-century Baghdad. By the Middle Ages in Europe, it was customary for civil powers to demand a university education, examination, and experience as conditions for permission to practice medicine. In this period the first professional societies were founded, modeled on the merchant guilds (Gross). University and guild combined to link education to licensing—government permission to practice.
The first licensing statutes were passed in the American colonies in the seventeenth century, although not until the eighteenth century did the statutes seek to restrict practice. According to Eliot Freidson (1970), medicine did not emerge as a consulting, as opposed to a teaching, practice until the late nineteenth and early twentieth centuries. Throughout the two millennia since the time of the Greek physician Hippocrates (c. 460—c. 377 b.c.e.), the medical elite created by education and licensed by the state was supplemented by a vast number of unlicensed healers, mostly women (generally barred from medicine), who treated the common folk.
The trend to state regulation, endorsement, and protection of the health professions suffered a brief hiatus in the nineteenth century in the United States, when there arose a deliberate experiment in egalitarian deregulation following from a democratic belief that the common folk were as good as the educated elite in most matters. The experiment was abandoned later in the century, as Texas passed a medical practice act in 1873 and California followed suit two years later; by 1905, thirty-nine states licensed physicians (CSG). Nurses formed a national professional association in 1896; by 1926 forty states required licenses of nurses.
The trend is not, however, universal. Professional recruitment, standard setting, and discipline can be carried out by professional groups and associations without the protection of the state. Typically, groups of serious practitioners band together, agree to set standards, and develop informal review procedures for adherence to standards—for members only. Professional ethics and oaths, including professional standards of education and compensation, can be enforced by the professional association alone, and in some cases (various psychological and holistic health professions, for example) the process goes no further. In several healing professions, there is no regulation beyond that of the voluntary association; the only penalty for professional wrongdoing, if it is discovered, is loss of membership in that association.
Regulation tends to be reserved for those health professions that are widely perceived to have powers the abuse of which can lead to public injury. At one time, only the profession of medicine was included in that category; now it has extended through dentistry, nursing, pharmacy, and others (close to fifty, on one count; CSG/CLEAR), on a state-by-state basis (naturopathy, for instance, is regulated in some states but not in others). Licensure varies in kind as well as in range: As of 1973, nine states still had permissive licensing for nurses—an unlicensed nurse could practice without hindrance as long as she did not claim to be licensed. Scope-of-practice statutes ordinarily accompany licensure, defining the procedures for which the practitioner is licensed.
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