Ethics and Law, and Ethics as Law: Legal Pluralism and the Normative Relationship Between the State and the Medical Profession Lee J Black Faculty of Law McGill University, Montreal May, 2017 A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Doctorate in Civil Law  Lee Black, 2017 Table of Contents ABSTRACT ....................................................................................................................... 7 ACKNOWLEDGEMENTS ............................................................................................. 9 PREFACE ........................................................................................................................ 10 CHAPTER 1: MEDICAL ETHICS, LAW AND LEGAL PLURALISM ................ 11 I. ETHICS, LAW AND LEGAL PLURALISM AS A TOPIC OF STUDY ............................... 12 II. MEDICAL ETHICS, PHYSICIANS AND THE STATE ................................................... 16 III. WHAT FOLLOWS ................................................................................................... 18 CHAPTER 2: SELF-REGULATION AND REGULATION OF THE US MEDICAL PROFESSION: A HISTORICAL PERSPECTIVE ................................ 21 I. INTRODUCTION ........................................................................................................ 22 II. THE “PRE-PROFESSION” AND THE BEGINNINGS OF ORGANIZED MEDICINE ....... 23 A. Early Nationhood Until the Mid-19th Century .................................................. 23 B. The Organizing of the First National Medical Society ..................................... 28 C. “True” Medicine and Self-Regulation .............................................................. 32 D. The Reformation of the AMA ............................................................................ 37 E. Conclusion ........................................................................................................ 40 III. THE FORMALIZATION OF STATE REGULATION OF THE MEDICAL PROFESSION AND THE REFORM OF MEDICAL EDUCATION ............................................................. 41 A. The Return of State Licensure ........................................................................... 41 B. Medical Education Reform ............................................................................... 45 C. Conclusion ........................................................................................................ 50 IV. HEALTH INSURANCE, GOVERNMENT INTERVENTION IN THE MARKETPLACE, AND THE DECLINE OF PROFESSIONAL AUTONOMY............................................................ 51 A. Early Forms of Health “Insurance” ................................................................. 51 B. Group Health Insurance ................................................................................... 54 C. Medicare, Medicaid, and Government Funded Health Care ........................... 57 D. Managed Care and Professional Autonomy ..................................................... 60 V. STATE REGULATION OF MEDICAL PRACTICE ...................................................... 64 VI. CONCLUSIONS, AND THE CURRENT STATE OF THE PROFESSION ........................ 67 2 CHAPTER 3: LEGAL PLURALISM – SOCIAL FIELDS AND LEGAL ORDERS ........................................................................................................................................... 71 I. INTRODUCTION ......................................................................................................... 72 II. WHAT IS LEGAL PLURALISM, AND WHY USE IT? ................................................. 75 A. Legal Pluralism as a Descriptive Theory of What Law Is ................................ 75 B. Why Use Legal Pluralism to Describe Medical Ethics and the Medical Profession? ............................................................................................................... 79 III. SEMI-AUTONOMOUS SOCIAL FIELDS AND THE CREATION OF LAW.................... 83 A. The Semi-Autonomous Social Field .................................................................. 83 1. The Nature of the Semi-Autonomous Social Field ....................................... 83 2. The Medical Profession as a Semi-Autonomous Social Field ...................... 87 B. What is Law? .................................................................................................... 91 1. Pluralists’ Law and Their Detractors ............................................................ 91 2. Medical Ethics as a Legal Order ................................................................. 100 C. The Helpful Theory of Professionalism .......................................................... 104 IV. THE MEDICAL PROFESSION AND MEDICAL ETHICS “AS AN APPROPRIATE SUBJECT OF STUDY” .................................................................................................. 114 CHAPTER 4: THE “LAW” OF THE MEDICAL PROFESSION ......................... 116 I. INTRODUCTION ....................................................................................................... 117 II. MEDICAL ETHICS ................................................................................................. 120 A. Oaths and Codes ............................................................................................. 120 B. Other Sources of Medical Ethics .................................................................... 129 C. Concluding Thoughts on Ethics and the Law of the Profession ..................... 134 III. CODES OF ETHICS AS PROFESSIONALLY-SOURCED LAW .................................. 137 A. Introduction .................................................................................................... 137 B. Methods ........................................................................................................... 138 C. Results ............................................................................................................. 139 1. General ........................................................................................................ 139 2. Enforcement of Conduct ............................................................................. 140 D. Discussion ....................................................................................................... 141 1. Prominence of Ethics .................................................................................. 141 2. Ethics and Normativity: The Importance of Words .................................... 145 3. Assessing Normativity: Enforcement and “Law” ....................................... 151 3 E. Limitations ...................................................................................................... 157 IV. CONCLUSIONS ..................................................................................................... 158 TABLE 1. STATE AND SPECIALTY MEDICAL SOCIETIES ........................................ 162 CHAPTER 5: THE LAW OF THE STATE.............................................................. 165 I. INTRODUCTION ....................................................................................................... 166 II. WHO CAN BE A DOCTOR? ................................................................................... 168 A. Introduction .................................................................................................... 168 B. Physician Licensure and Discipline ............................................................... 169 1. Medical Licensing Acts .............................................................................. 169 2. Medical Board Disciplinary Action ............................................................ 173 a. What constitutes grounds for action? .......................................................... 173 b. How are physicians disciplined? ................................................................. 179 III. THE WIDE WORLD OF HEALTH LAW................................................................. 183 A. Introduction .................................................................................................... 183 B. State and Federal Health Care Programs and Provision of Care ................. 184 C. Medical Emergencies and Active Labor ......................................................... 187 D. Fraud and Conflicts of Interest ....................................................................... 189 E. Privacy and Confidentiality ............................................................................ 191 F. Contract Law and Insurance Regulation ........................................................ 192 IV. AN EXTENSIVELY REGULATED PROFESSION ..................................................... 195 TABLE 2. STATE MEDICAL LICENSING DISCIPLINARY PROVISIONS—UNETHICAL OR UNPROFESSIONAL CONDUCT SPECIFIED AS ACTIONABLE BY MEDICAL BOARD 198 CHAPTER 6: POLITICS, MORALITY, MEDICAL ETHICS AND LAW ......... 203 I. INTRODUCTION ...................................................................................................... 204 II. THE IMPACT OF POLITICS ON MEDICAL ETHICS ............................................... 206 A. Ethics in the Shadow of Politics ..................................................................... 206 B. Abortion .......................................................................................................... 208 1. Introduction ................................................................................................. 208 2. Abortion as a Medical Procedure ................................................................ 209 3. Planned Parenthood v Casey and the New Informed Consent................... 213 4. Gonzales v Carhart, Medical Procedures and Medical Necessity .............. 220 a. Partial-Birth Abortion ................................................................................. 220 4 b. Mandatory Ultrasound ................................................................................ 223 5. Abortion and a Growing Distrust Between the State and Profession ......... 230 C. Gun Safety Speech Laws ................................................................................. 231 III. “PROTECTING THE INTEGRITY AND ETHICS OF THE MEDICAL PROFESSION,” SOMETIMES ................................................................................................................ 241 A. Introduction .................................................................................................... 241 B. Physician-Assisted Suicide ............................................................................. 241 C. Physicians’ Role in Capital Punishment ........................................................ 247 IV. MEDICAL ETHICS, POLITICS, MORALITY AND LAW .......................................... 260 CHAPTER 7: THE WEAKNESS OF PROFESSIONAL ETHICS ........................ 265 I. CONFLICTS OF INTEREST: WHAT, ME WORRY? ................................................. 266 II. REGULATION OF CONFLICTS OF INTEREST: WHO’S THE LEADER AND WHO’S THE FOLLOWER? ............................................................................................................... 268 A. Conflicts of Interest: Endemic in Medicine .................................................... 268 B. Fee Splitting, Fraud and Kickbacks ............................................................... 271 1. The Problem ................................................................................................ 271 2. The Profession’s Legal Order ..................................................................... 276 3. The State’s Legal Order .............................................................................. 277 C. Physician Self-Referral ................................................................................... 281 1. The Problem ................................................................................................ 281 2. The Profession’s Legal Order ..................................................................... 290 3. The State’s Legal Order .............................................................................. 294 D. Physician-Industry Relationships ................................................................... 298 1. The Problem ................................................................................................ 298 2. The Profession’s Legal Order ..................................................................... 305 3. The State’s Legal Order .............................................................................. 310 III. CONFLICTS OF INTEREST: THE LIMITS OF SELF-REGULATION AND ETHICS? 313 CHAPTER 8: LEGAL PLURALISM – A FRAMEWORK FOR THE PAST AND FUTURE OF NORMATIVE ETHICS AND THE PROFESSION-STATE RELATIONSHIP .......................................................................................................... 320 I. LEGAL PLURALISM AND MEDICAL ETHICS ........................................................... 321 II. THE NATURE OF HEALTH CARE AND MEDICAL ETHICS: NECESSITATING COLLABORATION ....................................................................................................... 325 A. Introduction .................................................................................................... 325 5 B. External Impacts of Medical Ethics ................................................................ 326 C. The Economic and Social Uniqueness of Health Care ................................... 328 III. LEGAL PLURALISM: IMPERFECT, BUT A BETTER WAY .................................... 330 A. Imperfect ......................................................................................................... 330 B. A Better Way ................................................................................................... 332 IV. ETHICS AS CRUCIAL LAW FOR THE MEDICAL PROFESSION .............................. 338 BIBLIOGRAPHY ......................................................................................................... 344 6 ABSTRACT Medical ethics is a critical component of physician identity and professional self- regulation, and has been since the mid-19th century and the establishment of the American Medical Association (AMA) as the preeminent national medical society, and its Code of Medical Ethics as the preeminent set of ethics norms in the United States. Ethics, though, is not the only source of norms for physicians and the medical profession. Since the late 19th century, the State has taken a greater role in regulating both physicians and health care, starting with public health measures and professional licensing and eventually extending into most corners of medical practice. Despite the growth of State regulation, though, the profession continues to revise and enact ethics norms for members of the profession, and today medical ethics remains a cornerstone of medical practice. The concurrent—although not always congruent—regulation of physicians by the State and the medical profession raises serious questions of authority and what, exactly, physicians are bound to follow. Traditional theories that attempt to explain the relationship between the medical profession, State and medical ethics, such as professionalism, generally place the profession’s authority as subsidiary to the State’s. This assigns medical ethics a precarious position, making its relevance subject to changes in State law that could contradict ethics norms and therefore jeopardize its efficacy within the profession. This Thesis seeks out other sources of authority for the medical profession and medical ethics, independent of the State and reflective of the traditional authority of the profession and ethics as the profession developed into its modern form. The theory of legal pluralism will be used here as the framework through which to explore the role of ethics and the relationship between the medical profession and the State, providing a different perspective on these questions. It will enlighten the relationships shaped by medical ethics and law, and medical ethics as law. **** L’éthique médicale est un élément crucial de l’identité des médecins et de l’autorégulation professionnelle. C’est le cas depuis le milieu du 19ème siècle, époque de la création de l’Association Médicale Américaine (AMA), et de l’établissement de son Code d’Éthique Médicale comme l’ensemble prééminent de normes éthiques aux États-Unis. L’éthique, en revanche, n’est pas la seule source de normes pour les médecins et la profession médicale. Depuis la fin du 19ème siècle, l’État a progressivement joué un rôle grandissant dans la régulation des médecins ainsi que de la santé publique, en commençant par des mesures de protection de la santé des populations, l’établissement de licences professionnelles, jusqu’à son implication dans l’ensemble de la pratique médicale. Malgré l’accroissement de la 7 régulation par l’État, la profession médicale continue de mettre à jour et d’établir de nouvelles normes éthiques s’appliquant à ses membres, et l’éthique médicale est encore aujourd’hui une pierre angulaire de la pratique médicale. La cohabitation parfois conflictuelle de normes de régulation provenant de l’État avec celles provenant de la profession médicale pose de sérieuses questions quant à l’autorité relative de chacune de ces sources, et quant ce qui régit l’activité des médecins. Les théories traditionnelles qui tentent d’expliquer les relations entre la profession médicale, l’État et l’éthique médicale, comme par exemple le professionnalisme, considèrent généralement l’autorité de la profession comme subsidiaire à celle de l’État. Cela assigne par conséquent une place précaire à l’éthique médicale, et soumet sa pertinence à l’évolution des lois étatiques, qui peuvent contredire les normes éthiques, et nuire à son efficacité au sein de la profession. La présente Thèse cherche à trouver d’autres sources d’autorité pour la profession médicale et l’éthique médicale, qui soient indépendantes de l’État, et reflètent l’autorité traditionnelle de la profession et l’éthique en suivant les évolutions modernes de la profession. La théorie du pluralisme juridique sera utilisée ici comme cadre conceptuel à travers lequel nous explorerons le rôle de l’éthique, et la relation entre la profession et l’État, ce qui donnera une perspective renouvelée de ces questions. Nous éclairerons notamment les relations modelées par l’éthique médicale et la loi, et par l’éthique médicale en tant que loi. 8 ACKNOWLEDGEMENTS I would like to thank the individuals and organizations that assisted me in the gathering of information for the development of the concepts contained in this Thesis and its drafting. First and foremost, the American Medical Association (AMA) and the American College of Surgeons for allowing me to access their archives. I would like to especially acknowledge Amber Dushman at the AMA Archives, who provided invaluable assistance while I sifted through AMA historical documents, and Bette Crigger, Director of Ethics at the AMA, who lent a sympathetic ear and gave additional context to many of the issues I explore in this Thesis. For the French translation of the Abstract, I thank Gabrielle Bertier, doctoral student and member at the Centre of Genomics and Policy at McGill University. I would also like to thank the members of my Advisory Committee, Professor Lara Khoury and Professor Daniel Weinstock. They continually reminded me to see the forest instead of all the trees, to keep focused on my goals and not get too bogged down in the minutiae (although this was often quite interesting). Finally, I would like to thank my doctoral supervisor, Professor Daniel Jutras. He guided me in the exploration of legal theories, pushed me to think critically about ethics and its normativity, and questioned many of my writing choices, leading to what is hopefully to him a satisfactory result. My family also deserves a great deal of thanks and appreciation. To my partner in all things, Heather, thank you for allowing me years of student-hood and supporting me through the highs and lows of reading, writing and mental states. To my children, Declan and Lennox, thank you for trying to type on the keyboard. Unfortunately, I did not retain your work in the final version of this Thesis. To my mother and sister, Toby and Sandy, thank you for observing from afar, and giving me a place to go when I needed to escape my computer. Other than those individuals and organizations named above, I did not receive any assistance in the development and drafting of this Thesis. 9 PREFACE Medical ethics is not a new or unique topic. There are also many, many examples in the medical, ethics, sociology, anthropological and legal literature that examine the history and normativity of medical ethics and the authority of the medical profession. Many of these discussion and debates appear as part of this Thesis, but the work contained within extends traditional concepts of ethics, professionalism and law in a new direction, using the theory of legal pluralism. Legal pluralism is not a new theory either, but neither has it been applied to the contexts of medical ethics and the medical profession. The application of legal pluralism to these contexts is what I consider original scholarship and a distinct contribution to knowledge. 10