Clinical trials and the origins of pharmaceutical fraud: Parke, Davis & Company, virtue epistemology, and the history of the fundamental antagonism

This paper describes one possible origin point for fraudulent behavior within the American pharmaceutical industry. We argue that during the late nineteenth century therapeutic reformers sought to promote both laboratory science and increasingly systematized forms of clinical experiment as a new basis for therapeutic knowledge. This process was intertwined with a transformation in the ethical framework in which medical science took place, one in which monopoly status was replaced by clinical utility as the primary arbiter of pharmaceutical legitimacy. This new framework fundamentally altered the set of epistemic virtues-a phrase we draw from the philosophical field of virtue epistemology-considered necessary to conduct reliable scientific inquiry regarding drugs. In doing so, it also made possible new forms of fraud in which newly emergent epistemic virtues were violated. To make this argument, we focus on the efforts of Francis E. Stewart and George S. Davis of Parke, Davis & Company. Therapeutic reformers within the pharmaceutical industry, such as Stewart and Davis, were an important part of the broader normative and epistemic transformation we describe in that they sought to promote laboratory science and systematized clinical trials toward the twin goals of improving pharmaceutical science and promoting their own commercial interests. Yet, as we suggest, Parke, Davis & Company also serves as an example of a company that violated the very norms that Stewart and Davis helped introduce. We thus seek to describe one possible origin point for the widespread fraudulent practices that now characterize the pharmaceutical industry. We also seek to describe an origin point for why we conceptualize such practices as fraudulent in the first place.

Community Health in Rural America During the Mid-20th Century

The Council on Rural Health (1945-1975) of the American Medical Association (AMA) collaborated with domestic health care organizations in the mid-20th century to improve access to health care in rural areas. This council promoted health and farm safety education, public health measures, insurance plans, and construction of health facilities. It also lobbied state and county medical societies to form rural health committees. AMA archive materials document these activities and demonstrate physicians' involvement and investment in the communities they served.

The Fall and Rise of Mid-Century Student Health Activism: Political Repression, McCarthyism, and the Association of Internes and Medical Students (1947-1953)

Common narratives about the mid-century American medical profession's stunning rise forget a key element: political repression. During the 1940s and 1950s, the American Medical Association (AMA) and its allies sought to eliminate those who questioned American medicine's status quo, in particular opposition to national health insurance (NHI) and condoning of racism within its ranks. One casualty was the Association for Internes and Medical Students (AIMS), which into the 1940s, was the most prominent vehicle for medical student and trainee political organizing in the United Status. This article tells the story of its rapid demise in the era of McCarthyism at the hands of an AMA campaign to besmirch AIMS's name, and in the process, destroy it.

Pharmaceutical patenting and the transformation of American medical ethics

The attitudes of physicians and drug manufacturers in the US toward patenting pharmaceuticals changed dramatically from the mid-nineteenth century to the mid-twentieth. Formerly, physicians and reputable manufacturers argued that pharmaceutical patents prioritized profit over the advancement of medical science. Reputable manufactures refused to patent their goods and most physicians shunned patented products. However, moving into the early twentieth century, physicians and drug manufacturers grew increasingly comfortable with the idea of pharmaceutical patents. In 1912, for example, the American Medical Association dropped the prohibition on physicians holding medical patents. Shifts in wider patenting cultures therefore transformed the ethical sensibilities of physicians.

Back to the future: The AMA and religion, 1961-1974

U.S. medical scholarship and education regarding religion and spirituality has been growing rapidly in recent years. This rising interest, however, is not new; it is a renewal of significant interweavings that date back to the mid-20th century. In this Perspective, the authors draw attention to the little-known history of organized medicine's engagement with religion from 1961 to 1974. Relying on primary source documents, they recount the dramatic rise and fall of the Committee on Medicine and Religion (CMR) at the American Medical Association (AMA). At its height, there were state-level committees on medicine and religion in 49 states, the District of Columbia, and Puerto Rico, and there were county-level committees in over 800 county medical societies. Thousands of physicians attended annual conferences for clinicians and clergy, and direct outreach to patients included a film viewed by millions. The CMR arose in the context of rapid medical advances, the growth of professional chaplaincy, and concern for declining "humanism" in medicine-conditions with parallels in medicine today. The CMR was brought to a puzzling end in 1972 by the AMA's Board of Trustees. The authors argue that this termination was linked to the AMA's long and contentious debate on abortion. They conclude with the story's significance for today's explorations of the intersection of spirituality, religion, and medicine, focusing on the need for mutual respect, transparency, and dialogue around the needs of patients and physicians.

The Rashomon effect: another view of medicine, religion, and the American Medical Association

What is the story of medicine and religion at the American Medical Association (AMA)? Where did the Department of Medicine and Religion originate? What did the program accomplish? Why was it all but completely discontinued after scarcely a decade? The surviving records support more than one interpretation. Exploring the broader organizational context helps tell a richer story.In this issue of Academic Medicine, Daniel Kim and colleagues open a window on a fascinating bit of history: that of the AMA's formal experience with religion and medicine during the 1960s and early 1970s; however, reconstructing the story of a program from documentary records is always something of an uncertain proposition. Equally important is taking account of such factors as the role of the AMA's House of Delegates in policy making, of state and county medical societies in carrying out program activities, and of the influence of charismatic individuals on decisions regarding programs and activities. Before the medical community decides what lesson(s) to draw from the story of the AMA's Department of Medicine and Religion, it should try to understand that story as completely as possible.As Kim et al note, the available materials leave out much that historians might wish to know. Records preserve the substance of decisions taken, but are largely silent about the reasoning behind those decisions. Relevant information is scattered through multiple record systems, making it difficult to find. Inevitably, historians have to read between the lines.

Revisiting black medical school extinctions in the Flexner era

Abraham Flexner's 1910 exposé on medical education recommended that only two of the seven extant medical schools for blacks be preserved and that they should train their students to "serve their people humbly" as "sanitarians." Addressing charges of racism, this article traces the roots of the recommendation that blacks serve a limited professional role to the schools themselves and presents evidence that, in endorsing the continuance of Howard's and Meharry's medical programs, Flexner exhibited greater leniency than he had toward comparable schools for white students. Whether his recommendations to eliminate the other five schools were key factors in their extinction is addressed here by examining 1901-30 enrollment patterns. Those patterns suggest that actions of the American Medical Association and state licensing boards, combined with the broader problem of limited premedical educational opportunities for blacks, were more consequential than was the Flexner report both for the extinction of the schools and for the curtailed production of black doctors.

Only for "purely scientific" institutions: the Medical Library Association's Exchange, 1898-1950s

OBJECTIVE

Centralized exchanges of scientific materials existed by the late nineteenth century, but they did not include medical publications. North American medical leaders therefore formed an association of institutions to run their own exchange: the Medical Library Association (MLA). After providing background to the exchange concept and the importance of institutional members for MLA, this article examines archival MLA correspondence to consider the role of its Exchange in the association's professional development before the 1950s.

RESULTS

MLA's membership policy admitted only libraries open to the medical profession with a large number of volumes. But the correspondence of the MLA Executive Committee reveals that the committee constantly adjusted the definition of library membership: personal, public, sectarian, commercial, allied science, and the then-termed "colored" medical school libraries all were denied membership.

CONCLUSION

Study of these decisions, using commercial and sectarian libraries as a focus, uncovers the primary justification for membership exclusions: a goal of operating a scientific exchange. Also, it shows that in this way, MLA shadowed policies and actions of the American Medical Association. Finally, the study suggests that the medical profession enforced its policies of exclusion through MLA, despite a proclaimed altruistic sharing of medical literature.

Keeping modern in medicine: pharmaceutical promotion and physician education in postwar America

Recent critiques of the role of pharmaceutical promotion in medical practice invoke a nostalgic version of 1950s and 1960s medicine as representing an uncomplicated relationship between an innovative pharmaceutical industry and an idealistic and sovereign medical profession-a relationship that was later corrupted by regulatory or business practice changes in the 1980s or 1990s. However, the escalation of innovation and promotion in the pharmaceutical industry at mid-century had already provoked a broader crisis of overflow in medical education in which physicians came to use both commercial and professional sources in an attempt to "keep modern" by incorporating emerging therapeutics into their practices. This phenomenon was simultaneously a crisis for the medical profession- playing a key role in attempts to inculcate a "rational therapeutics"-and a marketing opportunity for the pharmaceutical industry, and produced the structural foundations for contemporary debates regarding the role of pharmaceutical promotion in medical practice. Tracing the issue from the advent of the wonder drugs through today's concerns regarding formal CME, we document how and why the pharmaceutical industry was allowed (and even encouraged) to develop and maintain the central role it now plays within postgraduate medical education and prescribing practice.

African American physicians and organized medicine, 1846-1968: origins of a racial divide

Like the nation as a whole, organized medicine in the United States carries a legacy of racial bias and segregation that should be understood and acknowledged. For more than 100 years, many state and local medical societies openly discriminated against black physicians, barring them from membership and from professional support and advancement. The American Medical Association was early and persistent in countenancing this racial segregation. Several key historical episodes demonstrate that many of the decisions and practices that established and maintained medical professional segregation were challenged by black and white physicians, both within and outside organized medicine. The effects of this history have been far reaching for the medical profession and, in particular, the legacy of segregation, bias, and exclusion continues to adversely affect African American physicians and the patients they serve.

The short history and tenuous future of medical professionalism: the erosion of medicine's social contract

The profession of medicine is based on a shared set of tacit and explicit agreements about what patients, doctors, and society at large should be able to expect from each other, a social contract that defines the profession. Historically, the development of this set of agreements depended upon the creation of social organizations that could speak for the entire profession. Over the last several decades, however, the perceived need for these organizations, and especially the umbrella organization for the profession, the American Medical Association, has waned. The reasons for this are complex, but the consequences are significant: an eroding social contract, fragmentation, lack of cohesion and integrity, and loss of the public's confidence. The present social contract is one-dimensional, overly simplistic, and failing to sustain the public's trust. To address these problems, a renewed social contract is necessary. Although this renewed contract should be based on foundations similar to the original, it must directly confront such contemporary challenges as resource allocation and conflicts of interest. Equally as important, to reinvigorate our social contract more physicians will need to come to grips with a basic truth: to sustain professionalism we need a strong, unified professional association.

Pharmaceutical marketing research and the prescribing physician

Surveillance of physicians' prescribing patterns and the accumulation and sale of these data for pharmaceutical marketing are currently the subjects of legislation in several states and action by state and national medical associations. Contrary to common perception, the growth of the health care information organization industry has not been limited to the past decade but has been building slowly over the past 50 years, beginning in the 1940s when growth in the prescription drug market fueled industry interest in understanding and influencing prescribing patterns. The development of this surveillance system was not simply imposed on the medical profession by the pharmaceutical industry but was developed through the interactions of pharmaceutical salesmen, pharmaceutical marketers, academic researchers, individual physicians, and physician organizations. Examination of the role of physicians and physician organizations in the development of prescriber profiling is directly relevant to the contemporary policy debate surrounding this issue.

Cancer, quackery and the vernacular meanings of hope in 1950s America

Hope was central to cancer control in twentieth-century America. Physicians placed great store in its power to persuade people to seek medical help as early as possible in the development of the disease, when it was most amenable to treatment; to maintain patients' loyalty through what could be a long, painful and uncertain course of therapy; and to encourage doubts about alternative healers. Some also argued that hope could have beneficial therapeutic and psychological effects for patients. However, we know very little about its meanings for the public. Focusing on a large collection of letters written to the Food and Drug Administration in the 1950s concerning an anti-quackery campaign, this article explores how men and women responded to the competing messages of hope promoted by orthodox cancer organizations and by alternative healers. It asks: What did hope mean to such men and women? How did they construct this meaning? How did they decide which treatments were hopeful and which were not? And, how did they use hope to imagine the social world of cancer? In short, this article explores the vernacular meanings, epistemologies, and imaginative uses of hope among Americans in the mid-twentieth century.

The business of ethics: gender, medicine, and the professional codification of the American Physiotherapy Association, 1918-1935

The history of codes of ethics in health care has almost exclusively been told as a story of how medical doctors developed their own professional principles of conduct. Yet telling the history of medical ethics solely from the physicians' perspective neglects not only the numerous allied health care workers who developed their own codes of ethics in tandem with the medical profession, but also the role that gender played in the writing of such professional creeds. By focusing on the predominantly female organization of the American Physiotherapy Association (APA) and its 1935 "Code of Ethics and Discipline," I demonstrate how these women used their creed to at once curry favor from and challenge the authority of the medical profession. Through their Code, APA therapists engaged in a dynamic dialogue with the male physicians of the American Medical Association (AMA) in the name of professional survival. I conclude that, contrary to historians and philosophers who contend that professional women have historically operated under a gender-specific ethic of care, the physiotherapists avoided rhetoric construed as feminine and instead created a "business-like" creed in which they spoke solely about their relationship with physicians and remained silent on the matter of patient care.

Policing the social boundaries of the American Medical Association, 1847-70

In May 1870 the American Medical Association (AMA) voted to deny the admission of black delegates and their white colleagues to the national meeting in Washington, D.C. Historians of race and medicine have customarily viewed this decision as marking a crucial milestone in the formation of the nexus between racism and the development of the American medical profession in the era after the Civil War (1861-64). This study recasts this narrative by locating the 1870 decision in relation to the antebellum practices of the association and their social consequences for American medicine. It argues that the viability of the AMA as the national voice of the profession was critically dependent on rejecting racial equality. Indeed, at a moment when the question of the abolition of slavery polarized the nation, the AMA was founded in 1847 to create a voluntary professional organization, national in scope, dedicated to raising the standards of medical training and practice. To this end, the AMA elected presidents and selected host cities for annual meetings in the North, South, and West. Seven out of the fourteen meetings and six out of fourteen presidents were from slave and/or border states. These institutional practices together with the representation of blacks as different and enjoying an appropriate status as slaves grounded the national identity of the profession in black subordination. Similarly, the gendered discourses about healing and practices of female exclusion privileged medical authority as male by drawing on and reinforcing patriarchy. In the wake of the war, leaders hoped to restore the national character of the organization by resuming antebellum practices. In response to the new possibilities for blacks in medicine--as represented by the biracial National Medical Society--the AMA took steps to vigorously police the racial boundaries of the national profession. As this study will show, the 1870 decision reflected the logic of the racial politics at the heart of the association's antebellum past and would loom large in its future.

The Secret Kappa Lambda Society of Hippocrates (and the Origin of the American Medical Association's Principles of Medical Ethics)

This paper relates the neglected history of an idealistic, secret medical fraternity which existed briefly in Lexington, Kentucky, during the first half of the 19th century. It was created for students in the Medical Department at Transylvania University, the fifth US medical school, founded in 1799. One goal of the fraternity was to counter the widespread dissension and often violent quarrels among doctors that characterized American medicine of that period. And to that end, it was among the first to promote Thomas Percival's code of medical ethics in this country. Branches of the fraternity were established in Philadelphia and New York City, where members became influential in local medical politics but in time encountered hostility from rival physicians. The secret character of the fraternity branches was publicized and maligned during an anti-Masonic movement in this country in the 1830s, which soon led to the demise of the Philadelphia group. The New York branch remained active through the 1860s. Members of both branches were among those who in 1847 established the American Medical Association and devised its Principles of Medical Ethics.