A profession selling out: lamenting the paradigm shift in physician advertising.

F or generations following the first American Medical Association (AMA) Code of Ethics in 1847, the relationship between doctors and advertising remained unambiguous—advertising was forbidden. In 1975, however, the Federal Trade Commission (FTC) accused the profession of ‘‘restraint of trade’’ and legally persuaded doctors to permit advertising amongst their clan. As the 1970s witnessed the relentless burgeoning of healthcare expenditure, physicians accepted the blame for immuring themselves from the natural forces of economics. American physicians were bullied to embrace advertising under the delusion that doctoring—like any trade—would become better and cheaper if incited by competition. Today most American physicians engage in some form of paid advertising, yet it is doubtful that physician advertising has either augmented the quality or diminished the cost of health care. Advertisement has eroded medical professionalism by denying doctors the right to enforce ethical boundaries between themselves and the ‘‘let the buyer beware’’ world of business. And more is at stake than professional status, for the doctor/patient relationship, the cornerstone of medicine, is endangered as physicians continue to cast forth the self interested lure of advertisement. To assume that for over 130 years physicians anathematised advertising for purely ethical reasons would be naive. Sociologist Paul Starr explains that in the early 19th century, no group ‘‘embraced the ways of the market as actively as did popularisers, alternative healers, and quacks’’. Advertisement was perhaps the most successful implement of empirical medicine. So it is no surprise that professional licensed doctors in America grew up with a ‘‘distaste and discomfort for advertising’’. Medical advertisements were especially potent in the self reliant Jacksonian era, which touted health as a do it yourself venture commodified into tonics and one time procedures. To distinguish themselves from the circus of healthcare providers, physicians not only instituted higher educational standards and licensure but also demanded that their members refrain from advertising to the masses. Thus, the early divorce of professional medicine and advertisement may have been as much about public relations as about ethics. Nevertheless, it was significant that the members of the medical profession framed their aversion to advertising as an ethical objection. According to the first AMA Code of Ethics (1847), it was ‘‘derogatory to the dignity of the profession ...to resort to public advertisements’’. Licensed doctors took a vow not to advertise because of a collective agreement that it was ethically incompatible with patient care. To promise cures or to publish testimonials violated medicine’s commandments, resulting in strict censure and ostracism from the profession. Abstinence from advertisement thus for many decades survived as an unchallenged criterion in defining the American medical professional. Physicians guarded their profession from advertisement and their right to exert such internal control was not questioned. Before the 1960s and 70s, doctors were trusted to construct their own professional boundaries and they were relatively free from outside interference with their clinical activities. After the successful FTC suit in 1975 (Goldfarb v Virginia State Bar), the AMA removed all prohibitions to advertising, retaining only a weak restriction against false or misleading advertising. Medicine has in the past been regarded as the epitome of professions. Members of professions typically share specialised knowledge and possess certain technical expertise. Yet what separates a profession from a trade is codified ethics— professional behaviour is internally anchored by enforced ethical principles. Professionals in return procure from the public a special magnitude of trust. Professor Allen Dyer claims that identifying someone as a professional ‘‘ultimately depends on the ability to trust that individual with personal matters’’. A professional’s work is buttressed by considerable trust even during a first encounter because of the belief that this individual—by virtue of being a professional—is bound by ethical rules that prevent the exploitation of his or her knowledge and skill. A professional is one individual in society who is not trying to sell you anything; an individual who has at least sacrificed the semblance of profit making ambition in order to enjoy a private relationship with others that is free of consumer scepticism. Therefore, opening the doors to physician advertising threatens the professional status of doctoring by denying physicians as a group the right to coalesce around a set of unifying ethical beliefs. Advertising is a divisive force that pits individual against individual, weakening the common ethical calling that is intrinsic to a profession. The view that advertisement was inappropriate for professionals was not exclusive to medicine, for many other groups, including the American Bar Association, prohibited advertising in the early 20th century. Trust is indispensable to the intimacy and invasiveness of doctoring; advertising undermines the ability of physicians to welcome patients into a safe haven of trust, where respect for the patient is perpetually reaffirmed by a sotto voce approach to solicitation and compensation. Unfettering doctors to advertise with impunity has propelled the metamorphosis of the medical profession into a trade; and this was perhaps what many in the FTC had in mind back in 1975. Michael B Pertschuk, the FTC chairman during the AMA advertising suit, declared that a ‘‘way to control the seemingly uncontrollable health sector could be to treat it as a business and make it respond to the same marketplace influences as other American business and industries’’. In addition to disputing the AMA’s right to forbid advertising among physicians, the FTC at the same time challenged other ethical restrictions within the AMA, including restraints on the corporate practice of medicine and income sharing arrangements between physicians and nonphysicians. The FTC suit against the AMA thus appears to