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The Role of the Medical Profession in the Formulation and Execution of Public Policy*

Published online by Cambridge University Press:  07 November 2014

Malcolm G. Taylor
Malcolm G. Taylor*
Affiliation:
University of Toronto
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Extract

The role of “interest” or “pressure” groups in the United States congressional system has been subjected to analysis by American political scientists for at least three decades, but it is only in the last four or five years that studies have appeared of their role in the British cabinet system, and only one major study of an interest group has appeared in Canada. This disparity in interest is the result no doubt of the more vocal and widespread manifestation of the influence of pressure groups in the wide-open congressional system, but one has the uncomfortable feeling that their less obtrusive role in the cabinet system has been equated with a lesser importance in the political process.

Like the sociologist, the political scientist may be interested in groups as organizational or power systems, in the sense that they are private governments, or he may extend or even limit his interest to the relations of these private governments with each other and with public governments, particularly in the manner and extent of their influence on public policy. For the political scientist concerned with public administration, interest will be extended to the role, if any, played by groups in the execution of public policy. From all three aspects, the medical profession as an interest group is a happy choice for examination, for not only does it provide insights into private government, and have a major influence on public policy, but it seems safe to state that in Canada, at least, no other private group is as deeply involved in public administration, and this despite the fundamental antipathy between the healing arts and bureaucracy.

Type
Articles
Information
Canadian Journal of Economics and Political Science/Revue canadienne de economiques et science politique , Volume 26 , Issue 1 , February 1960 , pp. 108 - 127
Copyright
Copyright © Canadian Political Science Association 1960

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Footnotes

*

A paper presented at the annual meeting of the Canadian Political Science Association in Saskatoon, June 5, 1959.

The author wishes to acknowledge the generous assistance of the federal and provincial deputy ministers of health and the executive secretaries of the Canadian Medical Association and its provincial divisions in making material available and reading and checking the manuscript.

References

1 The first significant book emphasizing the role of groups was Bentley's, A. F. The Process of Government (Chicago, 1908)Google Scholar, but it did not gain full appreciation until after Herring's, Pendleton Group Representation before Congress (Baltimore, 1929).Google Scholar The most recent comprehensive study is Truman's, David B. The Governmental Process (New York, 1951)Google Scholar, in which he acknowledges his debt to Bentley.

2 On British interest groups see: Beer, S. H., “Pressure Groups and Parties in Great Britain,” American Political Science Review, L, no. 1, 03, 1956, 1–23 CrossRefGoogle Scholar; Stewart, J. D., British Pressure Groups (Oxford, 1958)Google Scholar; and Finer, S. E., Anonymous Empire (London, 1958).Google Scholar

3 Clark, S. D., The Canadian Manufacturers' Association (Toronto, 1939).Google Scholar

4 Merriam, Charles E., Public and Private Government (New Haven, 1944)Google Scholar, and McConnell, Grant, “The Spirit of Private Government,” American Politicai Science Review, LII, no. 3, Sept., 1958, 754–71.CrossRefGoogle Scholar

5 Key, V. O., Politics, Parties and Pressure Groups (4th ed., New York, 1958).Google Scholar

6 Herring, E. Pendleton, Public Administration and Public Interest (New York, 1936)Google Scholar; Truman, The Governmental Process.

7 Hall, Oswald, “Half Medical Man, Half Administrator: An Occupational Dilemma,” Canadian Public Administration, II, no. 4, Dec., 1959, 185–94.CrossRefGoogle Scholar

8 Grant, J. A. C., “The Guild Returns to America,” Journal of Politics, Aug., 1942, 303–36.CrossRefGoogle Scholar

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10 Sigerist, H. E., “A History of Medical Licensure,” Journal of the American Medical Association, CIV, 03 30, 1935, 1057–60CrossRefGoogle Scholar; Frederick, W. L., “The History and Philosophy of Occupational Licensing Legislation in the United States,” Journal of the American Dental Association, LVIII, no. 3, 03, 1959, 18–28.CrossRefGoogle Scholar

11 MacDermot, H. E., The History of the Canadian Medical Association (Toronto, 1935), 1.Google Scholar

12 Ibid., 11

13 Ibid., 11.

14 Ibid., 12

15 R.S.O. 1952, c. 228, s. 3(c).

16 MacDermot, , History of the C.M.A., 11.Google Scholar

17 1–2 Geo. V, c. 16; R.S.C. 1952, c. 27.

18 E.g., R.S.O. 1952, c. 228, s. 24.

19 Ibid., s. 3.

20 Canadian constitutional theory does not, as does the American, raise the issue whether participation by a regulated group in the selection of the personnel of its governing body is an unconstitutional invasion of the executive's appointing authority. See, in this connection, Lancaster, L. W., “The Legal Status of Private Organizations Exercising Governmental Powers,” Southwestern Social Science Quarterly, XV, no. 4, 03, 1935, 325–36.Google Scholar

21 College of Physicians and Surgeons of Ontario, Annual Report, 1957–1958, 11–16.Google Scholar

22 R.S.O. 1952, c. 228, s. 36.

23 “The Guild Returns to America,” 324.

24 The reasons for the exception are noted below; see p. 112.

25 Toronto Globe and Mail, Nov. 20 and 22, 1950.

26 Regine Leader Post, Nov. 30, 1946; Jan. 15, 1947; Feb. 2, 1947; Feb. 28, 1947; April 1, 1947.

27 S.C. 1909, c. 62, An Act to Incorporate the Canadian Medical Association.

28 Canadian Medical Association, By-Laws.

29 In all the provinces except Saskatchewan, and to some extent Alberta, the Association's functions can be distinguished from those of the licensing authority. In Saskatchewan, as a result of the dual role of the College, the anomaly occurs of the government's negotiating on economic matters with an agency of its own creation established to perform a governmental licensing function. In Alberta, where the two agencies exist, some of what seem to be “political” functions, for example negotiations of the Economics Committee, are conducted by the College.

30 These activities are reported in C.M.A., Transactions, 89th, 90th, and 91st annual meetings.

31 The C.C.H.A. is the successor in Canada to the Joint Commission (of the U.S.A. and Canada) on Hospital Accreditation. In addition to the C.M.A. contribution, $12,500 is contributed by the Canadian Hospital Association, $5,000 by the Royal College of Physicians and Surgeons, and $2,500 by the Association des Médecins de Langue Française du Canada.

32 See in this connection, Stern, Bernard J., Society and Medical Progress (Princeton, 1941).Google Scholar

33 Munro, A. R. Dr., Canadian Medical Association Journal, 1914, IV, 1112.Google Scholar

34 C.M.A., Committee on Economics, Report on Medical Economics, 1934.

35 C.M.A., Transactions, 74th annual meeting, 1943, 6.

36 Ibid., 75th annual meeting, 1944, 33.

37 Ibid., 80th annual meeting, 1949, 23–4.

38 Ibid., 88th annual meeting, 1955, 34.

39 O.M.A., Report to Council, 1959.

40 C.M.A., Principles Relating to Health Insurance, 1934, 1942, 1955. This latter principle is not observed in all the prepayment plans sponsored by the provincial divisions. “The lay members on the board of governors of pre-paid plans should be appointed for the business benefit they would impart to the board” (O.M.A., “Report or the Board of Directors, 1958,” Ontario Medical Review, Sept., 1958, 15 Google Scholar). The lay members are appointed not elected, and are in no sense to be considered representatives.

41 Garceau, Oliver, The Political Life of the American Medical Association (Cambridge, Mass., 1941)Google Scholar; Means, J. H., Doctors, People and Government (Boston, 1953)Google Scholar; Carter, Richard, The Doctor Business (New York, 1958).Google Scholar

42 See, e.g.: C.M.A., Submission to the Royal Commission on Dominion-Provincial Relations, 1938, and Submission to the Select Special Committee on Social Security, 1943; O.M.A., Submission to the Health Committee of the Ontario Legislative Assembly, 1956.

43 O.M.A., Committee on Public Relations, “Report to Council, 1958,” O.M. Review, XXV, no. 9, Sept., 1958, 67 (italics mine).Google Scholar

44 At the present time, medical members in Canadian legislatures are as follows: Senate, 7; House of Commons, 7; British Columbia, none; Alberta, 2; Saskatchewan, none; Manitoba, 1; Ontario, 2; Quebec, 4; New Brunswick, 1; Nova Scotia, 6; Prince Edward Island, 1; Newfoundland, 1.

45 C.M.A., Transactions, 91st annual meeting, 1958, 35.Google Scholar

46 From 1921 to 1935 the ministers of health in Ottawa were medical men, but since then laymen have held the post. There were also medically qualified ministers of health in the following provinces for the following years: Alberta, 1935–59; Saskatchewan, 1922–44; Manitoba, 1927–32, 1958–9; Ontario, 1923–37, 1943–5, 1950–9; Quebec, 1936–9, 1944–59; New Brunswick, 1917–40, 1944–59; Nova Scotia, 1930–45; Prince Edward Island, 1927–35, 1955–9; Newfoundland, 1956–9. The appointment of medically qualified ministers of health is an interesting variation from the British principle of operating a cabinet, whereby the minister stands in relation to the permanent, official deputy as amateur to expert.

47 Manitoba, 1930–6. Dr. F. W. Jackson continued as Deputy Minister, and gained international recognition as a public health leader.

48 It has already been mentioned that three federal officials are members of the General Council of the C.M.A.

49 In probably no other governmental department is the distinction between the “officer-élite” and the non-professional official so clearly delineated, as is illustrated by the constantly recurring reference to “non-medical” and “lay” personnel.

50 Transactions, 86th annual meeting, 1953, 13.Google Scholar

51 In the cabinet system, it does not appear that prior consultation provides in every instance for the free and frank interchange of views (with resulting modifications) desired. In 1953, for example, the Advisory Committee was called in by the Minister of National Health and Welfare. The members of the committee were informed that the information to be divulged to them about the forthcoming national health grants was confidential and could not be discussed by them with their parent body until the legislation had been introduced in Parliament. The Committee was reluctant to accept a situation which appeared to it as a fait accompli. It remained, however, and later restated its views in a letter to the Minister. The net effect of the interchange appears to have been negligible. See the report of discussion of this episode in ibid., 11–13.

52 S.A. 1955, c. 27, An Act to Amend the Hospitalization and Treatment Services Act, ss. 5–6.

53 Ontario Legislative Assembly, Report of the Meetings of the Standing Committee on Health, 1956, 100.Google Scholar

54 As the Committee on Economics reported in 1954, “Already the public is coming to understand that there is an alternative to government-run health insurance. [The medical plans] as the creature of organized medicine [have] had some part to play in the increasing recognition of the public in the value of a voluntary approach to meet the costs of personal health services.” C.M.A., Transactions, 87th annual meeting, 1954, 21.Google Scholar

55 Ontario Chamber of Commerce, Submission to the Government of Ontario on National Health Insurance (undated).

56 Canada, House of Commons, Select Special Committee on Social Security, Report of the Advisory Committee on Health Insurance, 69.

57 Ibid., 70.

58 Transactions, 73rd annual meeting, 06, 1942, 5.Google Scholar

59 Ibid., 7.

60 Established by Order in Council, P.C. 836, Feb. 5, 1942.

61 House of Commons, Special Committee on Social Security, Minutes of Proceedings and Evidence, no. 13, July 27, 1944.

62 Ibid., A Draft for a Health Insurance Act, s. 19 (2).

63 Ibid., no. 4, March 30, 1943, 112–13.

64 Ibid., no. 7, April 26, 1944, App. “A,” Memorandum of the Canadian Congress of Labour; and ibid., no. 11, May 18, 1943, testimony of Mr. P. Bengough, 331.

65 Ibid., no. 10, May 14, 1943, 287–8.

66 For an analysis of the health survey reports, see Taylor, M. G., “Government Planning: The Federal-Provincial Health Survey Reports,” this Journal, XIX, no. 4, Nov., 1953, 501–10.Google Scholar

67 Hospital association representatives on the committees favoured the same policy.

68 S.C., 5–6 Eliz. II, c. 28, An Act to Authorize Contributions by Canada in respect of Programmes Administered by the Provinces, Providing Hospital Insurance and Laboratory and Other Services in Aid of Diagnosis.

69 This part of the 1949 statement of policy gained no friends in the hospital associations or Blue Cross plans, who resented “being thrown to the wolves” in order, as they saw it, to delay government medical care insurance.

70 S.C. 1957, 5–6 Eliz. II, c. 28, s. 2 (f) (iii).

71 The Ontario Health Survey Report, 1951, 67.Google Scholar

72 Ontario Legislative Assembly, Report of the Meetings of the Standing Committee on Health, 1956, 97–102.Google Scholar

73 Ibid., 102.

74 For the counter views of the Ontario Hospital Association, see ibid., 112–14, and for a statement of the views of the radiologists, pathologists, and hospitals, see the symposium by Agnew, G. H., MacNeill, D. C., and Pritzker, H. G., “Provision and Payment of Diagnostic Services,” Canadian Journal of Public Health, XLVIII, no. 10, Oct., 1957, 413–25.Google Scholar

75 C.M.A., Transactions, 91st annual meeting, 1958, 25.Google Scholar

76 The roles accorded organized medicine in the administration of public programmes are excellent illustrations of the concept of both formal and informal “co-optation.” See Selznick, Phillip, “Foundations of the Theory of Organization,” American Sociological Review, XIII, no. 1, Feb., 1948, 33–5.Google Scholar

77 Wheare, K. C., Government by Committee (Oxford, 1955)Google Scholar, is the definitive work on committees in the British constitution.

78 Most of these were set tip as sub-committees of the health survey committees; see Taylor, “Government Planning.”

79 R.S.M. 1954, c. 111, s. 6.

80 S.M. 1958, c. 24, s. 2.

81 There is reason to doubt whether such a contract can be legally binding on the members of the Association unless, as in the Alberta programme, separate agreements are signed by individual practitioners. See C.M.A., Transactions, 91st annual meeting, 1958, 24.Google Scholar In order to deal more effectively in its negotiations with government, the British Medical Association organized, in 1948, a parallel organization, the British Medical Guild. A similar increase in its relations wth government led the Canadian Medical Association, in 1957, to consider whether it, too, needed such a parallel body. It was decided, however, that with a minor amendment in the Canadian Medical Association Act, authorizing the C.M.A. “to promote the interests of the members of The Association and to act on their behalf in the promotion thereof,” the purposes of the British Medical Guild could be achieved within the C.M.A. organization.

82 For an extended analysis of these programmes, see Taylor, M. G., “Social Assistance Medical Care Plans in Canada,” American Journal of Public Health, 06, 1954, 750–9.CrossRefGoogle Scholar

83 Taylor, M. G., Administration of Health Insurance in Canada (Toronto, 1956), chap, VII, “Methods of Payment.”Google Scholar

84 Editorial, Nova Scotia Medical Bulletin, Jan., 1959, 1–2 (italics mine).Google Scholar

85 The agreement within the profession is apparently so unanimous that Michel's “iron law of oligarchy” is immediately brought into question. Would a minor change in internal opinion bring new leadership and different policies?

86 Page 37.

87 Transactions, 86th annual meeting, 1953, 13.Google Scholar

88 E.g., the Canadian Hospital Association and the Canadian Life Insurance Officers' Association.

89 Truman, David, The Governmental Process, 168.Google Scholar

90 On the difficulty of precisely defining “the public interest” see Schubert, Glendon, “The ‘Public Interest’ in Administrative Decision Making,” American Political Science Review, II, no. 2, 06, 1957, 346–69CrossRefGoogle Scholar, and on the role of the public official see Hodgetts, J. E., “The Civil Service and Policy Formation,” this Journal, XXIII, no. 4, Nov., 1957, 467–79.Google Scholar

91 Truman, , The Governmental Process, 513.Google Scholar

92 C.M.A., Transactions, 83rd annual meeting, 1934, 42.Google Scholar