Medical Professionalism and the Parable of the Craft Guilds

Professionalism has deep roots in Western society. In his book, Death of the Guilds, E.A. Krause (1) makes a compelling case that the medieval European craft guilds are the antecedents of today's professions. The craft guilds have not survived. As a commentary on the article by Campbell and colleagues in this issue (2), I will argue that, like the guilds, the medical profession exists in a 3-way relationship with government and business. As such, its privileged position in society is subject to changes in the balance of power. I developed some of these ideas in a recent essay (3).

The history of the guilds, which rose to power and declined over several centuries, is instructive for the professions (4). The guilds became powerful because they provided an important public service: Their members made high-quality products. The guilds were able to guarantee high quality because they limited production and because they required long apprenticeships and promoted a few apprentices to master status. Moreover, because they limited production, they could assure the public that every piece met a high standard. The local guilds paid taxes to town government and enjoyed its protection. This arrangement had downsides for the public: high prices and scarcity of goods. Eventually, the rise of capitalism led to the demise of the guilds. Businessmen employed former apprentices to make products faster and cheaper, and they paid town governments more than the guilds. The guilds went into a long, slow decline. The proximate cause was actions taken by government and business; the root cause was the guilds' insensitivity to the interests of the public and their failure to adapt to new circumstances. At their peak, guild members made a very good living working at their own pace doing something they enjoyed. In …