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JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES, Volume, Number Oxford University Press. . All rights reserved.For permissions, please e-mail: [email protected] doi:./jhmas/jri

The Business of Ethics: Gender,Medicine, and the ProfessionalCodification of the American

Physiotherapy Association,

BETH LINKER

ABSTRACT. The history of codes of ethics in health care has almost exclu-sively been told as a story of how medical doctors developed their own pro-fessional principles of conduct. Yet telling the history of medical ethics solelyfrom the physicians perspective neglects not only the numerous allied healthcare workers who developed their own codes of ethics in tandem with themedical profession, but also the role that gender played in the writing of suchprofessional creeds. By focusing on the predominantly female organization ofthe American Physiotherapy Association (APA) and its Code of Ethicsand 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 themale physicians of the American Medical Association (AMA) in the name ofprofessional survival. I conclude that, contrary to historians and philosopherswho contend that professional women have historically operated under agender-specific ethic of care, the physiotherapists avoided rhetoric construedas feminine and instead created a business-like creed in which they spokesolely about their relationship with physicians and remained silent on thematter of patient care. KEYWORDS: code of ethics, medicine, gender, ethics of

care, physiotherapy, allied health professions, professionalization, AmericanMedical Association, AMA Council on Physical Therapy, World War I.

The initial version of this article won the American Society for Bioethics andHumanities Student Essay Award. A later version was presented at the American MedicalAssociation, Ethics Standards Division, Chicago, Illinois, January . I wish to thank SaraTaub of the Division for arranging my visit, as well as the other members of the AMA staff fortheir helpful comments. This paper has benefited greatly from the encouragement and sug-gestions of Susan Lederer, as well as the comments of Chalmers Clark, Damon Linker,Naomi Rogers, and John Harley Warner. I would also like to thank the Yale Program in the

History of Medicine and Science and the Donaghue Initiative in Biomedical and BehavioralResearch Ethics, whose generous support made much of the research for this paper possible.


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Linker :The Business of Ethics

HE history of codes of ethics in health care in theUnited States has almost exclusively been told as a

story of how medical doctors, and more specificallyphysicians of the American Medical Association(AMA), developed their own professional principlesof conduct. Bioethicists and historians alike have

written about the monumental AMA Code of Ethicstheworlds first national code of professional ethicsthe upris-ings against that code, and the resolution put forth in the AMAsPrinciples of Medical Ethics.1To many scholars, this is the his-tory of medical ethics in Americaa narrative of how doctors codi-fied their relationships with patients and other physicians to maintaina certain standard of moral decency and honesty. Yet telling medicalethics history solely from the physicians perspective neglects thenumerous allied health care workers who developed their owncodes of ethics alongside those of the medical profession.

In , the American Physiotherapy Association (APA), a pre-dominantly female organization, passed a Code of Ethics and Disci-pline at its national convention in Atlantic City, New Jersey (see

appendix ).2At the time of its formation in , the APA was avery young group. The profession had its beginnings during WorldWar I, when the U.S. Army Surgeon Generals office recruited

. For the worlds first national code, see Robert B. Baker, Introduction, in TheAmerican Medical Ethics Revolution: How the AMAs Code of Ethics Has Transformed PhysiciansRelationships to Patients, Professionals, and Society, ed. Robert Baker (Baltimore, Md.: JohnsHopkins University Press, ), pp. xiiixxxix. For a sampling of historical treatments ofthe AMA and its codes of ethics, see Robert B. Baker, The American Medical EthicsRevolution, in Baker, American Medical Ethics Revolution, pp. ; Chester R. Burns,

Setting the Stage: Moral Philosophy, Benjamin Rush, and Medical Ethics in the UnitedStates before , in Baker,American Medical Ethics Revolution, pp. ; Susan Lederer,Medical Ethics and the Media: Oaths, Codes, and Popular Culture, in Baker, AmericanMedical Ethics Revolution, pp. ; as well as John Harley Warner, The s Rebellionagainst the AMA Code of Ethics: Scientific Democracy and the Dissolution of Ortho-doxy, in Baker, American Medical Ethics Revolution, pp. . See also Robert Veatch,Medical Codes and Oaths: History, in Encyclopedia of Bioethics, nd ed. (New York: Simonand Schuster, ), pp. ; as well as Albert Jonsen, The Birth of Bioethics(New York:Oxford University Press, ); and Albert Jonsen, A Short History of Medical Ethics(NewYork: Oxford University Press, ). For a sociological perspective on the history of theAMAs codes of ethics, see Jeffrey L. Berlant, Profession and Monopoly: A Study of Medicine inthe United States and Great Britain(Berkeley: University of California Press, ).

. Physical therapistethicist Ruth Purtilo provides a brief historical synopsis of theAPAs Code of Ethics in The American Physical Therapy Associations Code ofEthics: Its Historical Foundations, Physical Therapy, , , . Women made upover percent of the APA since its inception in . For exact membership numbers, seemember rosters published yearly in the P. T. Reviewand Physiotherapy Review.

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Journal of the History of Medicine : Vol. , July

hundreds of women to physically rehabilitate maimed soldiers, manu-ally remolding disabled male bodies through massage and exercise to

return the men to theaters of war and to the industrial workplace.3

Immediately following the war, these rehabilitation aides formed anational association and began calling themselves physiotherapists.4

Fifteen years later, many of these same women came to AtlanticCity to put their profession on firmer ground by constructing ethicalmandates that would guide their work.

The content of the APA code of ethics as well as its context arestriking. Besides the AMA, few other health care professional groupshad formal codes of ethics by the s.5 The American nursingprofession, despite the Nightingale Oath, did not have an officialcode of ethics governing its national association until .6Like-wise, other allied health professions with a similar history and gendercomposition as physical therapysuch as occupational therapy anddieteticsdid not adopt professional codes of ethics until the secondhalf of the twentieth century.7Physiotherapists were thus among thefirst women health care workers to pioneer the territory of profes-sional ethics.

. See Wendy Murphys commemorative book about the history of the American PhysicalTherapy Association, Healing the Generations: A History of Physical Therapy and the AmericanPhysical Therapy Association(Alexandria, Va.: American Physical Therapy Association, ).

. Today physiotherapists call themselves physical therapists, and in the APAbecame the American Physical Therapy Association. This transition in name and associationtitle is a complex story that is most comprehensively discussed in Glenn Gritzer and ArnoldArluke, The Making of Rehabilitation: A Political Economy of Medical Specialization, (Berkeley: University of California Press, ), esp. appendixes, pp. .

. Some obvious exceptions include dentists, pharmacists, and osteopaths. For more

about these fields and their codes of ethics, see Chester Burns, The Evolution of Profes-sional Ethics in American Dentistry, Bull. Hist. Dentistry, , , ; Robert A.Buerki, The Historical Development of an Ethic for American Pharmacy, Pharm. Hist.,, , ; and Norman Gevitz, The DOs: Osteopathic Medicine in America(Baltimore,Md.: Johns Hopkins University Press, ).

. For a history of nursing ethics and the ANA code of ethics, see Marlene Cianci, TheCode of Ethics and the Role of Nurses: An Historical Perspective, Nursing Connections,, , ; Marsha D. Fowler, The Evolution of the ANA Code of Ethics, Imprint,, , ; and Marjorie J. Stenberg, The Search for a Conceptual Framework as aPhilosophical Basis for Nursing Ethics: An Examination of Code, Contract, Context, andCovenant, Mil. Med., , , .

. The Principles of Occupational Therapy Ethics were adopted in April and revised

in April . For the revision, seeAm. J. Occ. Ther., , , . The AmericanDietetic Association, formed in , did not adopt its first code of ethics until . SeeEmma Seifrit Weigley, Professionalization and the Dietitian,J. Am. Dietetic Assoc., ,, . Also, the American Association for Social Workers did not have a formal code ofethics until . See Encyclopedia of Social Work, th ed., s.v. ethics and values.


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A common assumption made about codes of ethics (of the past orpresent) is that they are tools of moral guidance, based on unchanging

virtues of honesty, sacrifice, and selflessness. But when placed intheir appropriate context, codes of ethics are dynamic documentsthat provide a unique window into the workings of interprofessionalconflicts and negotiations. For the historian, codes of ethics are,above all, statements of distinct fears, concerns, and desires of a pro-fessional group of people in a specific time and place. Althoughsome exciting work along these lines has been conducted by medicalhistorians about codes of ethics prior to , very little attentionhas been paid to the ethics boom that took place after World War I,when hundreds of American professional groups (both related to andoutside of the medical profession) hurried to outline and secure theirown collective principles of professional conduct.8

The postWorld War I writing of codes of ethics is also importantbecause it was a time when a wide array of female health care profes-sionals first began to codify their work, much like their male counter-parts. Although historians and sociologists have long studied the rolethat gender played in the process of medical professionalization, the

same mode of analysis has not been applied to the historical interpreta-tion of codes of ethics from the past.9What, for instance, are we tomake of professional women in the twentieth century who, for thefirst time in history, engaged in what was then a male-dominatedpractice of code making? More specifically, when so few professional

. A notable exception here is Susan Lederers work on the ethics of human research aswell as popular usages of the Hippocratic Oath in the early twentieth century. See SusanLederer, Subjected to Science: Human Experimentation in America before the Second World War

(Baltimore, Md.: Johns Hopkins University Press, ); and Lederer, Medical Ethics andthe Media.

. The most explicit discussion of the role that gender has played in the formation of thehealth care professions can be found in the histories written about women physicians andnurses. See Susan Reverby, Ordered to Care: The Dilemma of American Nursing, (Cambridge: Cambridge University Press, ); Joan I. Roberts and Thetis M. Group,Feminism and Nursing: An Historical Perspective of Power, Status, and Political Activism in theNursing Profession (Westport, Conn.: Praeger, ); Barbara Melosh, The PhysiciansHand: Work, Culture, and Conflict in American Nursing(Philadelphia: Temple UniversityPress, ); Regina Morantz-Sanchez, Sympathy and Science: Women Physicians in AmericanMedicine(Oxford: Oxford University Press, ); and Ellen S. More, Restoring the Balance:Women Physicians and the Profession of Medicine, (Cambridge, Mass.: Harvard

University Press, ). For a more general historical overview of women and professional-ization, see Anne Firor Scott, Natural Allies: Womens Associations in American History(Urbana: University of Illinois Press, ). For a sociological perspective on the medicalprofession and its exclusion of women, see Anne Witz, Professions and Patriarchy(London:Routledge, ).


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groups had a code of ethics, why did physiotherapists feel the need todevelop one in ? What did ethics mean to this fledgling group of

professional women trying to make it in the medical world?Several factors made the profession of physiotherapy in the s ands a unique occupation in terms of both gender and healing practice.Whereas other female healers, such as nurses and occupational therapists,primarily treated patients at the bedside, physiotherapists worked ingyms, at times leading group exercises and at other times hovering overpatients on plinths (treatment tables), arduously stretching injured backsand limbs. When creating their identity as an ancillary medical profes-sion, APA therapists resisted the Victorian image of women as caregiv-ers, healers by nature.10Unlike nurses and occupational therapists whoheld on to their Victorian roots well into the twentieth century, physio-therapists believed that their work required a unique combination ofbrains and brawn, thereby challenging the nineteenth-century view thatwomen were the weaker yet more nurturing sex.11

Looking at the APAs Code of Ethics against the backdropof the larger medical arena and economic downturn that the UnitedStates experienced during the Great Depression, it becomes clear

that the APA therapists codified their profession to secure their placein the medical marketplace. But the Code of Ethics revealsmore than this. Behind the scenes, leading physiotherapists struggledwith the rhetoric, content, and style of their professional creed.When wording their code, they invoked the vocabulary of medicalprofessionalism as it was understood and used by the AMA; they alsotook great care to avoid any images of Victorian womanhood, whichprized a womans ability for caring and sympathy.

Indeed, although virtually every other health carerelated profes-sional code up to the s included some sort of statement aboutthe importance of honesty and concern for the patients well-being,the physiotherapists made no mention of the therapistpatient rela-tionship and instead composed a code that spoke almost exclusivelyto the physiotherapistphysician relationship. As this article will

. For a useful definition of ancillary professions, see Walter I. Wardwell, Chiropractic:A History and Evolution of a New Profession(St. Louis: Mosby Year Book, ).

. The argument that physiotherapists created a post-Victorian identity comes fromBeth Linker, Strength and Science: Gender, Physiotherapy, and Medicine in the UnitedStates, ,J. Womens Hist., forthcoming.


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demonstrate, this silence amid a continuous discourse on patientcare spoke a thousand words.

PROFESSIONAL BEGINNINGS : THEMILITARYETHIC

Most of the women who signed up to become physiotherapy recon-struction aides to rehabilitate the countys injured soldiers during WorldWar I had little previous experience working in the medical field. Over percent of the women came from schools of physical education,where they were groomed to become gym teachers at all-womensschools.12When the U.S. Medical Department began to actively recruitthese physical educators to become physiotherapy reconstructionaides, over women jumped at the chance to become women warworkers. The wartime effort to reconstruct maimed soldiers providedthese women with a unique chance to move from an exclusively femalesphere of educating other women and children to a medical arena wherethey largely interacted with men as both their superiors and patients.13

Before they could so much as place a finger on a soldiers body,physiotherapy recruits had to pass a three-month War EmergencyCourse set up by the Army Medical Department. By April , six

womens physical education schools offered their facilities to theMedical Department: Reed College in Oregon, Battle Creek NormalSchool of Physical Education in Michigan, New Haven NormalSchool of Gymnastics in Connecticut, and the remaining threeAmerican School of Physical Education, Boston School of PhysicalEducation, and Prose Normal School of Gymnasticsin Boston.14

The War Emergency Courses existed as a virtual boot camp in thelanguage and practice of medicine. In addition to classes in the basic

. For the number of physical education graduates, see Frank Granger, The Developmentof Physiotherapy, P. T. Rev., , , .

. For more on gender segregation within the field of physical education, see MarthaVerbrugge,Able-Bodied Womanhood: Personal Health and Social Change in Nineteenth-CenturyBoston(Oxford: Oxford University Press, ); and Verbrugge, Knowledge and Power:Health and Physical Education for Women in America, in Women, Health, and Medicine inAmerica: A Historical Handbook, ed. Rima D. Apple (New Brunswick, N.J.: Rutgers Uni-versity Press, ), pp. . See also Paul Atkinson, The Feminist Physique: PhysicalEducation and the Medicalization of Womens Education, in From Fair Sex to Feminism:Sport and the Socialization of Women in the Industrial and Post-Industrial Eras, ed. J. A. Manganand Roberta J. Park (London: Frank Cass, ), pp. . Also, in this the same volume,

see Patricia Vertinsky, Body Shapes: The Role of the Medical Establishment in InformingFemale Exercise and Physical Education in Nineteenth-Century North America, pp. .

. See Emma Vogel, Physical Therapists before World War II, inArmy Medical SpecialistCorps, ed. Robert S. Anderson, Harriet S. Lee, and Myra L. McDaniel (Washington D.C.:Office of the Surgeon General, ), pp. .


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sciences, including laboratories in cadaver dissection, physiotherapyrecruits took courses in physiology and learned how to treat simple

and compound fractures, ankylosing joints, motor and nervousdisorders, as well as how to manage amputation care.15The War Emergency Course instituted at Reed College became

the largest program of its kind, enrolling and producing the highestnumber of wartime physiotherapy reconstruction aides.16 Not everywoman, though, would have been accepted into Reeds program.Along with age restrictions (recruits had to be between to yearsold) and physical fitness requirements, the army mandated that potentialfemale recruits be of good characteror as Surgeon General WilliamGorgas put it, they had to possess powers of personal subordination,demonstrate team play, and exhibit morale of the highest order.17

The personal stories conveyed by Reed College physiotherapystudents indicate that although the army rigorously enforced its stan-dards of physical and mental health, moral fitness trumped all. Malephysicians who commanded the Reed College courses took respon-sibility for keeping the women in shape, both physically and morally.One physician in particular, named Dr. Beach, gained a reputation

for not only demanding tough daily workouts of running laps andperforming military style chin-ups but also insisting on unwaveringmoral fortitude in his recruits.18 The physiotherapists view ofDr. Beach is best exemplified in a military squad song, Do or Die,that they composed and sang in his honor:

Yes, Im ready to do or die, Dr. Beach, Im ready to do or die,You may make me chin beyond my reach or springboard ten feet high,My chest is the frontest [sic] part of my frame, my tummy is flat and low,

And when I jump and kick myself, I always land on my toe.Im willing to do or die, Dr. Beach, Im willing to do or die,Ill cut up frogs and cadavers too, and the hour law defy,Ill dress my hair in minutes two, and dress in moments five,With any old meals Ill gladly do, as sure as Im alive.

. Murphy, Healing the Generations, p. .. Lettie Gavin,American Women in World War I: They Also Served(Boulder: University

Press of Colorado, ), pp. . See also Harvard Medical School PhysiotherapyCourse, , Courtesy American Physical Therapy Association Archives (APTA),

Alexandria, Va., box , file .. As quoted in Gavin,American Women in World War I, p. .. Doris Ball Crawford, Recollections and Reminiscences from Former Reconstruc-

tion Aides, Phys. Ther., , , . See also Marguerite Irvine, Recollections andReminiscences from Former Reconstruction Aides, Phys. Ther., , , .


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Im ready to do or die, Dr. Beach, Im going to do not die,Ill promise that Ill not flirt at all, or even wink my eye,

My relationship shall be business-like, the officers Ill not see,And Ill look down so modest like, when a sergeant looks at me.19

With this squad song, the first generation of physiotherapists tookthe first step toward shaping its professional identity as one thatwould be inextricably linked to a well-defined military ethos.According to the military ethic of World War I, women war work-ers were to become defeminized not only in their appearance butalso in their social interactions. As we can see from the song lyrics,

the ideal body type of a physiotherapy recruit was one of plumb-lineverticality.20 It was also expected that a womans body languagewould work in accordance with the militarys corporeal ideal. Thephysiotherapists gestures were to be muted, her gaze turned everdownward. She was to exhibit full bodily control, restraining notonly the swing in her step but also the lilt in her voice.21

The most formal statement, however, of ethical physiotherapypractice came in the form of an oath called Loyalty to Country.Before being assigned to duty, each Reed College graduate recitedthe Loyalty to Country oath, pledging her allegiance to the countryand to the U.S. military. Similar to the patriotic sentimentsexpressed in their squad songs, the therapists taking this loyalty oathpromised to give their property, service, and life to defend theUnited States (see appendix ).22

The sacrificial language found in the Reed College oath was acommon form of expression among other female health care provid-ers of the early twentieth century. By the s, nurses graduating

from professional training schools across the United States recitedthe Nightingale Pledge, in which, among other things, they

. These are just two of the verses of a seven-verse song that the Reed College gradu-ates composed. See APTA, box , file .

. The military ideal of a svelte body coincides with the new slimming trend amongAmerican middle-class women in the s and s. See Joan Jacobs Brumberg, TheBody Project: An Intimate History of American Girls(New York: Random House, ).

. One reason the military wanted to keep the physiotherapists from flirting (as thesong puts it) with patients was to control malefemale fraternization, especially among sol-

diers and health care workers. Making the healerpatient interaction business-like was acornerstone of the militarys World War I campaign against venereal disease. See AllanBrandt, No Magic Bullet: A Social History of Venereal Disease in the United States since , nded. (Oxford: Oxford University Press, ).

. APTA, box , file .


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pledged to cure the sick, even if it meant risking their own lives. Inthe Nightingale Pledge, a nurse also promised to aid the physician

in his work, giving herself over to his orders.23

As well as nurses,occupational therapistsa group of health practitioners with thesame gender make-up and wartime professional beginnings as phys-iotherapistsdevised their own creed several years after their serviceduring World War I. In their oath, occupational therapists pledgedtheir whole-hearted service in aiding those crippled in mind andbody.24 In a similar vein, dental hygienists, another new femaleallied health profession in the early twentieth century, created acode of ethics in in which a practitioner of dental hygiene wasto be ever ready to respond to the wants of her patrons.25As theseexamples demonstrate, women health care providers of the earlytwentieth century tended to write patient-centered oaths, professingto sacrifice themselves on the altar of caring for others.

The physiotherapists, by contrast, composed a highly state-oriented code of ethics, promising alliance to the U.S. government,not to their patients. Although the notion of the common good is ashared element among the Nightingale Oath, the Occupational

Therapy Pledge, and the Reed College oath, the definition of thegood differs in crucial ways. Whereas physiotherapists dedicatedtheir lives and skills to the betterment of their country, nurses andoccupational therapists geared their efforts toward a more universalgoal of improved health. The peculiarity of the Reed College oathis compounded by the fact that both the Nightingale Pledge and theoccupational therapy oath required that their adherents have Chris-tian reverence for their work. In the case of nurses, they were to

solemnly pledge [themselves] before God, serving as His hand-maiden to nurture the ill back to health. Even in , when theAmerican Nurses Association published a suggested code of ethics (asuggestion that did not come to fruition until ), the nursing

. For a reprint of the Nightingale Pledge, see Fowler, Evolution of the ANA Code ofEthics, p. .

. Mary Binderman, MLS, director of Information Resources at the American Occupa-tional Therapy Foundation, was kind enough to send me a photocopy of the original post-card-sized Pledge and Creed for Occupational Therapists. For a reprint of the pledge, see

William R. Dunton, ed., Occupational Therapy and Rehabilitation, vol. (Baltimore, Md.:Williams and Wilkins, ), p. .

. Wilma E. Motley, History of the American Dental Hygienists Association, (Chicago: American Dental Hygienists Association, ). For a reprint of the ADHAsfirst code, see pp. .


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profession continued to use language with a Christian appeal: Themost precious possession of this profession is . . . to meet the need of

the world for skilled and tender care in illness and for wise guidancein attaining and maintaining health.26Similarly, occupational thera-pists concluded their creed with the promise that they would prayfor patience, kindliness and strength in the holy ministry to brokenminds and bodies (see appendix ).27Whereas physiotherapists iden-tified with a highly secular goal of committing themselves to the U.S.military forces, nurses and occupational therapists portrayed them-selves as part of Gods universal army, soldiering against ill health.

One way to account for the difference between physiotherapists,on one hand, and occupational therapists and professional nurses, onthe other, is that although the practice of physiotherapy was a reac-tion against nineteenth-century ideals of womanhood, the latter twoprofessions maintained deep roots in Americas Victorian past.Despite the growing professionalization of the field in the earlytwentieth century, nursing still involved the more customary dutiesof female bedside nurturing; Nurses fed, bathed, and cheered recu-perating patients. Similarly, occupational therapy began as a field

that aimed to nurture nervous patients back to health throughsimple forms of manual labor, such as beadwork, basket weaving,and woodworking. The manual labor of occupational therapy wasnot intended to be physically taxingindeed, during World War Imost soldiers received occupational therapy in bed or in theirwheelchairs. Occupational therapists engaged patients in easilyaccomplished work goals that would preoccupy the mind so as tobring about psychic well-being.28

When shaping their own professional identity, physiotherapistsresisted the Victorian assumption that softness and the ability tonurture were biologically determined traits. Instead of emphasizingtheir ability to sympathize with patients, physiotherapists promotedtheir career as one that required athleticism and physical strength.The very fact that physiotherapists consistently elicited pain in thetreatment of their patients meant that they could not be nurturers in

. A Suggested Code: A Code of Ethics Presented for the Consideration of the Amer-ican Nurses Association,Am. J. Nurs., , , .

. Dunton, Occupational Therapy and Rehabilitation, p. .. Virginia A. M. Quiroga, Occupational Therapy: The First Thirty Years,

(Bethesda, Md.: American Occupational Therapy Association, ).


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the traditional sense of the term. In many ways, physiotherapistsresembled drill sergeants more than bedside nurturers, commanders

more than those who were ordered to care. One physiotherapistworking during and after the war described her occupation ashefty work and wrote that many of her male patients would ask ifshe found her job to be too much of a strain.29

As health care practitioners who challenged the Victorian ideal ofwoman as caregiver, physiotherapists did not automatically create aprofessional identity that centered on the patient. During WorldWar I, they defined themselves as citizens first and caregivers sec-ond. They did not discuss the treatment of patients in their oath, norin their eventual professional code of ethics, the first officialstatement in which they codified their work. Instead, they focusedtheir efforts on relations with other health care workers, construct-ing an identity that was more in keeping with an early twentieth-century ethic of nationalism and professionalism than with an ethicof care.

THEETHICOFMEDICALPROFESSIONALISM

Once World War I came to an end, the physiotherapists had littleuse for the Reed College loyalty to country oath; not only werethere no occasions to recite such a pledge publicly, but promisingones life to the nation had little meaning during times of peace.Although the practice of reciting the oath died along with the war,the physiotherapists interest in working according to a set of ethicalmandates did not. Postwar physiotherapists thus shifted their think-ing away from the common good of the state and focused more on

the common good of the profession as a whole. Historian Robert A.Nye describes a similar transition among French physicians at theturn of the twentieth century. According to Nye, elite early twenti-eth-century physicians in France relied on the military honor codesof the nineteenth century to promote cohesiveness among distinctoccupational groups, getting members to think less in terms of

. This discussion about physiotherapy comes from Linker, Strength and Science. Forthe direct quotation and an account of the labor required to perform physiotherapy, see IdaMay Hazenhyer, A History of the American Physiotherapy Association, Physiother. Rev.,, , , continued in Physiother. Rev., , , , with the final entry in Phys-iother. Rev., , , .


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economic self-interest and more in terms of solidarity throughoutthe profession.30

By the end of World War I, there were an estimated physio-therapists scattered across the country in military hospitals from SanFrancisco to New York City.31Without structured military connec-tions and communications, the postwar physiotherapy reconstruc-tion aides sought out a new medium through which they couldkeep up professional and personal ties with one another. In ,under the direction of Reed College physiotherapy instructor MaryMcMillan, the America Womens Physical Therapeutic Associationwas formed with approximately members (including male ther-apists and physicians) on the roster. Less than a year later, the mem-bers of this organization decided to change the name of theirprofessional society to a more gender-neutral American Physiother-apy Association, partly to entice more AMA physicians to join.32

Lacking a military structure that would define the purpose ofphysiotherapy work, APA therapists turned to the AMA to fill thestructural gap that the military left behind. In doing so, APA thera-pists fastened onto the AMAs notion of professionalism above all

else. For instance, McMillan, the APAs first president, set the prece-dent of scheduling her associations national conferences at the sametime and place as the AMAs, arguing that such an arrangementwould not only enable them to secure cheaper rail tickets and moreprominent speakers, but, more important, that it would be anovert indication of the therapists intent to become professionals inthe medical field, of lining up the APA with the AMA.33

In addition, the APA drafted an organizational constitution

within its first year of existence, much as the AMA had done in. In this document, APA therapists made their allegiance to themedical profession explicit. Indeed, according to Article II of theAPA constitution, the primary purpose of the association was

. Robert A. Nye, Honor Codes and Medical Ethics in Modern France, Bull. Hist.Med., , , . Nyes article is one of the few accounts of the role that gender, andmore specifically maleness, played in the construction of twentieth-century medicalcodes of ethics.

. Murphy, Healing the Generations, p. .

. For discussion about the change of name, see the associations first meeting notesfrom January , titled Preliminary Meeting of the A.W.P.T.A. reprinted in the P.T. Rev., , , . See also, American Womens Physical Therapy Association Consti-tution, P. T. Rev., , , .

. Presidential Messages: The First Fifty Years, Phys. Ther., , , .


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to make available efficiently trained women to the medical profes-sion. In other parts of the constitution, APA therapists used the

rhetoric of the new medical sciences to indicate their loyalty tothe medical profession. At a time when the AMA espoused greatenthusiasm for the new laboratory approach to medicine, the APAconstitutionally declared itself to be an organization that wouldestablish and maintain a professional and scientific standard ofphysical therapy practice.34

Although the APA therapists often invoked general terms, such asthe medical profession, to refer to their relationship with doctors,they had the AMA specifically in mind. They admitted as much intheir constitutional bylaws, which stated that physicians would begranted membership only if they were graduates of MedicalSchools conforming to the standard of the American Medical Asso-ciation.35 With this one statement, APA therapists made a veryimportant step in defining themselves as part of the regular medicalestablishment. In essence, their organization supported the findingsof the Flexner Report, which had the effect of bolsteringorthodox schools of medicine and weakening sectarian schools. The

APA applied the same education standards throughout their entireorganizational structure, making even the members of its physician-runadvisory committeea board that included AMA-president RayLyman Wilburprove that they had AMA-approved educations.36

With their constitution, postwar therapists also laid claim to a newname for themselves, changing their professional title from physio-therapy reconstruction aides to physiotherapists. According toone wartime therapist, the word aidewas an insult, for the women

who worked in the Army Medical Department felt assured thatothers saw their occupation as a scientific profession affiliated withthe medical profession.37 In essence, by changing their wartimename, APA therapists hoped to avoid the perception that physio-therapy was merely an arm of the medical profession, a designa-tion that would have automatically disqualified them from beingprofessionals in their own right.

. American Womens Therapy Association, p. .

. Ibid., p. .. Ibid. Ray Lyman Wilbur served as the chair of the APAs advisory committee from

to . Wilbur was also an honorary member of the APA from to . Seemembership lists published yearly in the P. T Rev. and Physiother. Rev.

. Editorials, P. T. Rev., , , .


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One of the clearest definitions of professionalism in the earlytwentieth century, at least as it was understood by the medical pro-

fession at the time, was put forth by none other than Abraham Flexner.Five years after the Flexner Report, the New York School ofPhilanthropy invited Flexner (who then held the position of assistantsecretary to the General Education Board) to deliver a lecture inwhich, among other topics, he was to address the question Is socialwork a profession? In front of an audience of social workers andphilanthropists, Flexner not only argued against social work being aprofession but also relegated the practices of pharmacy and nursinginto the same subprofessional category as social work. Flexner ren-dered a highly conventional portrayal of professionalism using thephysician as the ideal. The physician was the supreme professional,for unlike a craftsman who relied on his hands, the educated med-ical doctor used his mind. Flexner made this case most succinctlyin his discussion of the practice of pharmacy, when he remarked thatthe physician thinks, decides, and orders, [but] the pharmacistobeys . . . and does not originate.38 Because pharmacists did notpossess decision-making powers or capabilities, they were, in Flexners

words, no more than an arm added to the medical profession.39

Trained nurses, in Flexners opinion, assumed a similar position, notonly because of their ignorance but, more important, because oftheir gender. To invoke his words: [The nurse] summons him [i.e.,the physician] like a sentinel in fresh emergencies; subordinates loy-ally her intelligence to his theory, to his policy, and . . . seconds hisefforts.40 Exhibiting a view common at his time, Flexner had ahighly gender-specific notion of professionalism. He likened the

medical profession to a brotherhood, saying that it should absorb amans life to the point where he and his family would organizearound a professional nucleus.41

APA therapists knew that it was impossible to achieve equal footingwith physicians. In addition to their practice of hands-on, manual

. Abraham Flexner, Is Social Work a Profession? Paper presented at the NationalConference on Charities and Correction, New York, May (New York: NewYork School of Philanthropy, ).

. In response to Flexners speech, the American Pharmaceutical Association drafted anew code of ethics, the Principles of Pharmaceutical Ethics in . See Buerki, Histor-ical Development of an Ethic for American Pharmacy, p. .

. Flexner, Is Social Work a Profession?. Ibid.


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therapya kind of craftsman-like molding of the disabled malebodyan overwhelming majority of APA physiotherapists were

women. Yet despite their realism, postwar physiotherapists still felt thatthey deserved to be professionals regardless of gender or their place inthe medical chain of command. Repeatedly, APA therapists pointedout that unlike unskilled nurses, who had only three years of trainingat most, they had four-year physical education degrees as well as hands-on wartime skilled training in manual therapy.42Physiotherapists envi-sioned the medical field not as a hierarchy scale but rather as a liberaldemocratic community. Reflecting on her work during the war, phys-iotherapist Ruby Decker insisted that she and her fellow therapistsworked in conjunction with the patients personal physicians.Please note the phrase: in conjunction with, Decker continued,because physical rehabilitation was a co-operative program withmutual appreciation and respect between physicians and therapists.43

The physiotherapists attempt to define themselves as medical pro-fessionals stirred up much controversy. The APAs persistent drive tolay claim to the name physiotherapy irritated physician specialistsnamely, a small group of physician-electrotherapist specialists who had

called themselves physiotherapists before the war. Almost immediatelyafter Dorothea Beck assumed her office as president of the APA insummer , she received a letter from the American Electrothera-peutic Association saying that the title of physiotherapist . . . shouldbe restricted to graduate medical men only.44The letter went on torequest that Beck and her APA therapists change the title of theirorganization to American Physiotherapy Technician Association toavoid any confusion with the public and medical profession.45

The American Electrotherapeutic Association was made up ofphysicians who specialized in administering physical agents as amethod of treatment. The association had been formed in the latenineteenth century for the specific purpose of persuading fellowmedical doctors of the benefits of electrotherapy, while combating

. Louisa Lippitt, R.N., to Dr. Frank Granger, Madison, Wisc., February ,APTA archives, Board of Directors (BOD) box , file . For Grangers response, see FrankGranger to Louisa Lippitt, R.N., Boston, February , APTA archives, BOD , file .

. Ruby Decker, A Hard Look, presented at the rd annual conference of theAPTA, July , APTA archives, box , file .

. American Electrotherapeutic Association to APA, New York, December ,APTA archives, BOD , file .

. Ibid.


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the unorthodox electrotherapeutic practices of the homeopathicallybased National Society of Electrotherapeutics.46However, despite

the fact that a handful of its members were also members of theAMA, the Electrotherapeutic Association fell short of accomplishingits goal of changing the attitude of regular physicians toward electro-therapy. By the turn of the century, approximately ,physicianshad electrical devices of some sort in their offices, but most medicaldoctors were reluctant to recognize their use as a legitimate thera-peutic practice.47 Feeling as if they were fighting a losing battle,electrotherapists began to incorporate other therapies into theirbase, including thermotherapy, hydrotherapy, psychotherapy, photo-therapy, mechanical vibration therapy, climatology, exercise, anddietetics. Capitalizing on their new, more broadly appealing image,Dr. William B. Snow, editor of the Electrotherapeutic Associations

journal and member of its board of trustees, coined a new phrasethat would more accurately describe their work:physical therapy.48

The Electrotherapeutic Associations demand that the APAchange its name was not simply an issue of semantics; it was alsoabout ownership of a new field that had gained considerable credi-

bility as a result of World War I. For the electrotherapists, whothroughout the s and s were struggling to become anAMA-approved specialty (approval that they did not receive until, when the AMA instituted the American Board of PhysicalMedicine and Rehabilitation), credibility was something that theybadly needed.49 Even though by the s some of them hadadopted the title of physical therapy physicians, electrotherapistsstill had an image problem. Morris Fishbein (editor of theJournal of

the American Medical Association and Hygeia) constantly denouncedelectrotherapy as a form of quackery and cultism.50With its capacity

. Gritzer and Arluke, Making of Rehabilitation, pp. . See also A. B. Hirsch toDorothea Beck, New York, February , APTA archives, BOD , file .

. Gritzer and Arluke, Making of Rehabilitation, p. .. Ibid., p. . See also American Electrotherapeutic Association to APA, New York,

December , APTA archives, BOD , file .. For more on the specialty status of the electrotherapists (who eventually became

known as physiatrists), see Rosemary Stevens,American Medicine and the Public Interest, nd

ed. (Berkeley: University of California Press, ).. Morris Fishbein, The Medical Follies: An Analysis of the Foibles of Some Healing Cults,

Including Osteopathy, Homeopathy, Chiropractic, and the Electronic Reactions of Abrams, withEssays on the Antivivisectionists, Health Legislation, Physical Culture, Birth Control, and Rejuve-nation(New York: Boni and Liveright, ), p. .


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to act on nerves and on muscles, producing visible motive effects,electrotherapy worked only through the power of persuasion. Electro-

therapy could dupe people into believing that something therapeuticwas happening, when, according to scientific measures, it was not.51The physicians of the American Electrotherapeutic Association

were, for the most part, sympathetic to Fishbeins criticisms. Work-ing in the field themselves, they knew all too well how deregulatedand widespread the practice of electrotherapy had become amongnonmedical healers and salesmen. Indeed, it was deregulation andlay competition that led the electrotherapists to attempt to staketheir claim on physiotherapy and benefit from its good name.

When Beck published the letter addressed to her by the Electro-therapeutic Association in the P.T. Review, physiotherapists fromacross the country voiced a uniform resistance to the suggestion thattheir name be changed from physiotherapist to physiotherapytechnician. Echoing Flexners assumptions about professionalism,APA members argued that by using the term technicianthe Electro-therapeutic Association insinuated that APA therapists were merecraftswomen, lacking any professional training. Jessie Wright, a

physiotherapist from Pennsylvania, argued that the word technicianimplied mechanically following set technique, which was incontradistinction to the intelligent work required of a physiother-apist. Each individual case, continued Wright, offers differentproblems, and as a result physiotherapists had to use thought,observation and judgment in treatments.52In other words, physio-therapists saw themselves as originators of a kind of specializedmedical knowledge, much like physicians.

Emboldened by the cause to retain their name, the editorial boardof the P.T. Reviewdecided in to change the title of their journalto the Physiotherapy Review. We are a bit sorry to see the old initialsP.T. . . . go, wrote the editors, but for the wider good of the Asso-ciation and for the profession we feel that Physiotherapy Reviewholds identity with dignity and professional feeling.53Before leaving

. Morris Fishbein, The New Medical Follies: An Encyclopedia of Cultism and Quackery inThese United States, with Essays on the Cult of Beauty, the Craze for Reduction, Rejuvenation,

Eclecticism, Bread and Dietary Fads, Physical Therapy, and a Forecast as to the Physician of theFuture(New York: Boni and Liveright, ), p. .

. Jessie Wright to Dorothea Beck, Leetsdale, Penn., April , APTA archives,BOD , file .

. Editorials, Physiother. Rev., , , .


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her presidential post in , Beck responded to the New Yorkbasedelectrotherapist-physicians, telling them that by unanimous vote the

members of the APA had decided to keep their professional title asphysiotherapists.54To Beck and her colleagues at the APA, the matterof their professional name had been settled by virtue of democraticrule and by proof that physiotherapy, despite it being manual therapypracticed by nonphysician women, required a degree of intelligenceand esoteric knowledge that many physicians did not possess.

THEAMACOUNCILONPHYSICALTHERAPY

ANDBUSINESSETHICS

In addition to her correspondence with the men of the Electro-therapeutic Association, Beck also sent a letter in January tothe newly formed AMA Council on Physical Therapy, making acase as to why the APA should be able to retain the title of phys-iotherapy. Her strategy of going above the heads of the electro-therapists to men high in the medical profession ultimatelyfailed, for the AMA had already began to equate physiotherapywith the practice of pharmacy, an arm of the medical profession

that was to be supervised and controlled by the brains of eliteAMA physicians. Indeed, according to the minutes of the firstmeeting of the Council on Physical Therapy held in Chicago onOctober , presiding chairs Drs. Olin West (then secretaryand general manager of the AMA) and Fishbein encouraged theother members of the council to replicate the structure and goalsof the AMA Council on Pharmacy and Chemistry.55Westand Fishbein invited Dr. W. A. Puckner, then secretary of the

Council on Pharmacy and Chemistry, to attend the meeting andto instruct the newly initiated members on how to maintain sci-entific standards in physical therapy, keeping the practice out ofthe hands of undesirable and unqualified impostors to the field,much the same way that pharmaceuticals were kept from unethical

. Dorothea Beck to Electrotherapeutic Association, New Jersey, June , APTAarchives, BOD , file .

. Meeting of the Council on Physical Therapy, American Medical Association Head-

quarters, Chicago, Illinois, October , Courtesy AMA Archives, Chicago, Ill., verticalfile. The other members of the Council on Physical Therapy included W. T. Bovie (Boston),Arthur Compton (Chicago), Ralph Pemberton (Philadelphia), Harry Mock (Chicago), WalterB. Cannon (Boston), A. S. Warthin (Ann Arbor), Francis Carter Wood (New York City),George Miller MacKee (New York City), and A. U. Desjardins (Rochester, Minnesota).


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druggists who sold unregulated nostrums to an unsuspectingpublic.56

Like the Council on Pharmacy and its regulatory control overmedicinal remedies, the primary purpose of the Council on PhysicalTherapys was to collect variously produced electrical apparatusessold as physical therapy devicesequipment that included ultravi-olet lights, diathermy, and roentgen-ray therapy machinestestthem, and determine which devices produced therapeutic resultsand which did not. And also like the Council on Pharmacy andChemistry, the Council on Physical Therapy made an agreementwith the Cooperative Medical Advertising Bureau that only coun-cil-endorsed electrical devices would be advertised in the pages ofthe AMAs professional and popular journals. At the encouragementof Fishbein, the council resolved to publish its physical therapyreports not only in theJournal of the American Medical AssociationandHygeia but also in city newspapers to influence the public onmatters [of physical therapy].57

Although the council said little to nothing about the APA or itstherapists during the meeting in , the councils members still

aimed to define professionalism in physiotherapy, much like theAPA therapists did. But the way these two groups approached thetask of defining professionalism differed substantially. Whereas APAtherapists adopted a more conventional definition of professionalismas thought work as opposed to mere craftwork, the men of theAMA Council on Physical Therapy had internalized a more mod-ern, postWorld War I view of professionalism, making distinctionsbased not only on education but also on utilitarian calculations of

the public good. In a special issue of theAnnals of the AmericanAcademy of Political and Social Sciencedevoted to ethics in the profes-sions, architect Robert D. Kohn attributed the wellspring of ethicalconcern among the professions to the war effort, for it created auniversal desire for service, [to] sacrifice ones private interests to

. Ibid. I thank Laura Carroll, archivist at the AMA, for providing me with Dr. Pucknersfull name and biography. Quotations from Resolution Providing the Establishment of a

Council on Physical Therapy, AMA House of Delegates Proceedings, Chicago, Ill., May , APTA archives, box , file .

. Ibid. See also Resolution Providing the Establishment of a Council on PhysicalTherapy, AMA House of Delegates Proceedings, Chicago, Ill., May , APTAarchives, box , file .


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the common good, and to lay aside the money-making motive.58

This new outlook of equating the service motive with ethical

practice and the money-making motive with unethical behaviormade it possible for businessmen to be ethical professionals as well.Edward A. Filene, then president of William Filenes Sons, proposeda simple two-pronged code of business ethics whereby a businesshad to serve the community as well as produce merchandise of reli-able quality for the lowest practically possible price.59Not surpris-ingly, this formula of business ethics worked to benefit largemanufacturers while penalizing small, independent businessmen.

In this postWorld War I milieu, in which businessmen could beethical professionals too, the AMA Council on Physical Therapyfollowed in step, basing the distinction between professional andnonprofessional practices as much on education as economics.When the Council on Physical Therapy published its first officialreport in October , it highlighted the difference between thenonprofessional salesmen, who emphasized the money makingpowers of physiotherapy devices, and the professional large manu-facturers, such as General Electric, who aimed to benefit the patient

therapeutically.60 To the council, the unethical businessman whosold his physical therapy wares solely for the purpose of financialgain was more of a threat than an uneducated manual healer was.61

The council concluded its report by asserting that an independentsalesmans dishonesty and naked self-interest should disgust allconscientious practitioners of medicine.62

With this one report, the council effectively established the termsof ethical practice in physical therapy for many years to come.

Although it heralded the importance of physiotherapy as a practicenecessary to medicine, it condemned APA therapists to a subordi-nate position in the medical hierarchy and, in a less obvious way,questioned their status as professionals. The AMA concluded that

. Robert D. Kohn, The Significance of the Professional Ideal: Professional Ethics andthe Public Interest,Ann. Am. Acad. Pol. Soc. Sci., , , no. , .

. Edward A. Filene, A Simple Code of Business Ethics, Ann. Am. Acad. Pol. Soc.Sci., , , no. , .

. Report of Committee on Present Status of Physical Therapy, J. Am. Med. Assoc.,

, , . For the committees discussion of General Electric, see Meeting of theCouncil on Physical Therapy, American Medical Association Headquarters, Chicago,Illinois, October , Courtesy AMA Archives, vertical file.

. Report of Committee on Present Status of Physical Therapy, p. .. Ibid, p. .


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physical therapy could become a legitimate practice only if it werecontrolled by graduate physicians, who prescribed therapy after

careful physical and laboratory examinations.63

More important,the council referred to APA therapists as therapist technicians,despite the associations repeated protests against the use of such ter-minology, which they believed implicitly questioned their status asprofessionals.64

The AMA councils report came as a severe blow to theAPA therapists who fought for the right to call themselves physio-therapists. In a private letter responding to the councils report,newly elected APA president Gertrude Beard despondently wrote toformer president Beck, It looks like our name is fated.65Knowingthat the AMA held a great deal of power over defining professional-ism in medicine, Beck advised Beard to maintain a congenial rela-tionship with the medical profession, writing, the closer personaltouch you can establish with the AMA and particularly with Councilon Physiotherapy, the better. Trueif sadwe need a pull whichis quite self-evident.66Not wanting to concede their name but feel-ing forced to accept the medical professions decree, the physiother-

apists campaign to be seen as professionals shifted from an optimisticand ambitious effort to save their professional title to a more sober andself-conscious movement for professional recognition.

UNSENTIMENTALHEALERS

For almost ten years following the AMA Council on PhysicalTherapy report, the APA suffered continual interpractitioner territo-rial battles and grave financial losses, primarily as a result of market-

place competition coupled with a declining economy. As APAtherapists moved from positions secured by the war machine to theprivate sphere over the course of the s, they encountered a medicalmarketplace crowded with osteopaths, chiropractors, and nursesall of whom claimed to practice physiotherapy. The therapists

. Ibid.. Ibid.. Gertrude Beard to Dorothea Beck, Chicago, December , APTA archives,

BOD , file . Although the AMA and the Electrotherapeutic Association allowed thePhysiotherapy Association to keep its professional title, they still called individual physio-therapists technicians.

. Dorothea Beck to Gertrude Beard, New Jersey, October , APTA archives,BOD , file .


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occupational insecurity worsened with the onset of the GreatDepression. According to an APA survey conducted in , thera-

pist salaries across the country had been cut drastically, and up to athird of all private practices had been closed as a result of the coun-trys economic downturn.67 In addition, APA membership plum-meted, despite the temporary moratorium on membership fees.68

Dispirited and financially strapped, APA physiotherapists had littlefervor to lobby for state medical legislation that would secure theirname and legally exclude others from practicing their trade. By themid-s, APA president Margaret Campbell, along with manyother leading therapists, agreed that the APA had to make its coop-eration and alignment with the medical profession more overtor,as Campbell put it, therapists needed to work quietly and ethicallywith the medical profession.69If the AMA saw the APA therapistsas ethical professionals, Campbell reasoned, then the physiotherapistscould win the medical professions unconditional allegiance.

To express their desire to work ethically with the AMA in themost forthright way, the APA took on the task of composing a pro-fessional code of ethics. At the annual convention, APA leaders

instituted a special committee on ethics, demanding that its mem-bers compose a written code of ethics that would conform to theAMAs code. When constructing the code, the APA ethics commit-tee did not refer to the Reed College oath, and with good reason.As philosopher Robert M. Veatch points out, oaths and codes ofethics are two very distinct forms of ethical pronouncements thatserve different functions. Of the two, codes of ethics are more mod-ern, a by-product of a highly bureaucratic society. As such, they

provide a complex set of rules and comprehensive standards toguide the practicing health practitioner, patient, or other decisionmakers in their attempts to negotiate the murky waters of special-ized health care and individual interests.70Oaths, on the other hand,

. Margaret Campbell to Catherine Worthingham, February , APTA archives,BOD , file . See also Editorials, Physiother. Rev., , , .

. See Chapter News, Physiother. Rev., , , ; and Chapter News, Physiother.Rev., , , , , . For the membership fee moratorium, see Physiother. Rev.,, , .

. Emphasis added. Chapter News, Physiother. Rev., , , ; Chapter News,Physiother. Rev., , , . Therapists also talked about transferring the publicitycampaign initiative to the medical profession. For more on this, see Chapter News,Physiother. Rev., , , ; and again in Chapter News, Physiother. Rev., , , .

. Veatch, Medical Codes and Oaths: History, pp. .


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have a long history of functioning as simple moral statementsexpected to be recited in a group setting. Whereas oaths are more

general in intent, codes of ethicswritten documents that are sup-posed to be read, not recitedoutline details of interprofessionalrelationships, providing a comprehensive list of rules that can bestudied and cited by other professional groups.

The women who drafted the APA Code of Ethics did notthink of themselves as moral philosophers; instead, they consideredthemselves to be the guardians of a new professional field thatneeded to be put on firmer ground.71When thinking about the con-tent of their Code of Ethics, the physiotherapists reacted to a specificset of problems pertaining to their own professional survival in themedical world of the mid-s. Leading up to the implementationof the Code of Ethics, the editors of the Physiotherapy Reviewoffered explicit guidelines to be followed in the creation of theirprofessions creed. From the editorial, it is clear that the APA thera-pists had studied the Council on Physical Therapys report veryclosely. The editors emphasized that APA therapists should distin-guish themselves from trade workerswho kept one eye on the

clock and the other on the unionand from businessmen whohad one eye on the work and the other on the balance sheet. 72Inkeeping with the spirit of the councils report, the editorsclaimed that as professionals, the APA therapists were beyond thepurely selfish motivation of profit, claiming that physical therapyshould be performed for its own sake, regardless of financialreturns.73

In addition, the editors urged its fellow APA members to down-

play the gender make-up of their field, advising the ethics commit-tee to adopt a more masculinized rhetoric of medicalprofessionalism. Most striking, the editors felt that it was of utmostimportance to avoid any hint of sentimentalism in the organiza-tions creed.74 By the early twentieth century, sentimentality hadbecome a gender-laden term in medical circles. The medical profes-sions resistance to sentimentalism was in part a reaction against

. Buerki, Historical Development of an Ethic for American Pharmacy, p. . Buerki makesthe same point about the pharmacists who drafted the Code of Ethics for Pharmacists.

. Our Profession, Physiother. Rev., , , .. Ibid.. Ibid.


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Victorian medicine, perceived, at least, as an era of stoicism and gen-tility. As historian Regina Morantz-Sanchez demonstrates, it was

during the Victorian period that the American public reveredwomen physicians, for they alone had the unique ability to com-bine sympathy and sciencethe hard and soft sides of medicalpractice.75But during the rise of the new laboratory medicine atthe turn of the twentieth century, the organized medical professionbegan to resist the soft side of medicine, conflating it with senti-mentality, sympathy, caring, and all-around irrational femininebehavior. Sentimentality hindered the practice of hard science, forit undermined the possibility of creating a clear separation betweensubject and object, healer and patient.76

To a great extent, the AMA Council on Physical Therapy fueledthe APA therapists fear of waxing sentimental. In , Dr. HowardA. Carter, member of the Council on Physical Therapy, wrote anarticle for the Physiotherapy Reviewcomplaining that there was toomuch poetry in [the physiotherapists] so-called scientific papers.77

He urged them to cease their armchair philosophizing and wishfulthinking and stick to data and scientific findings instead.78From the

time that the therapists started their own journal in , theyindeed devoted many pages to humor columns, marriage and birthannouncements, as well as to articles geared toward morale boosting.But over the course of the s and s, APA therapists shed thefeminine characteristics of their journal, transforming it into a morestreamlined, professionalized publication that aimed at objectivityrather than subjectivity. By adhering to the rhetorical and aestheticrules woven into the male-dominated medical profession, APA

therapists implicitly sided with antifeminine tenets of medicalprofessionalism.

. Morantz-Sanchez, Sympathy and Science, p. .. For a more comprehensive treatment of the relationship between gender, medical

professionalism, and science, see Ellen Singer More and Maureen A. Milligan, eds., TheEmpathic Practitioner: Empathy, Gender and Medicine(New Brunswick, N.J.: Rutgers Univer-sity Press, ). The articles of particular relevance are: Susan Lederer, Gender, AnimalExperimentation, and the Doctor-Patient Relationship, pp. ; Ellen S. More,

Empathy Enters the Profession of Medicine, pp. ; and Regina Morantz-Sanchez,How Women Physicians Became More Empathic than Men, pp. . See alsoMorantz-Sanchez, Sympathy and Science.

. Howard A. Carter, The Council on Physical Therapy, Physiother. Rev., , , .. Ibid.


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CONTRACTING WITHTHEAMA: THEAPA

CODEOFETHICS

Despite the APAs push to create a professional image sanitized ofmotherly sentimentality and selfish greed, certain AMA physiciansstill remained wary of the new occupation. Throughout the earlys, the APA headquarters received a stream of complaints fromphysicians who accused APA therapists of practicing without adoctors prescription.79These accusations reached their peak in theearly s, when private-practice physicians lost percent of theirpre-Depression income.80This was a time before widespread health

insurance and managed care, when most patients paid for medicalcare out of pocket and weighed the need to pay the doctor a visitagainst a widening range of more appealing spending options, suchas movies, food, shows, and transportation.81With money tight andcompetition stiff, some physicians went so far as to argue that thephysiotherapists should be eliminated completely. As one CaliforniaAPA therapist reported in , many doctors with whom sheworked felt that physiotherapy should only be done by a physi-

cian, because APA members were taking a good deal of businessaway from them.82In response, the APA created a Committee on Publicity to target

physicians and laymen alike, assuring them that APA therapists werepart of the medical establishment and willing to adhere to its man-dates of professionalism, including the rule that physiotherapistsshould only treat with a physicians prescription. The APA took tothe radio waves, and in a public announcement PresidentCampbell clearly defined physical therapy as a treatment that mustbe directed by a physician.83In addition to taking advantage of thenew advertising technologies, the Publicity Committee urged APA

. See, for example, APA to Catherine Worthingham, December , Chicago,Ill., APTA archives, BOD , file ; and Dr. Harold Behneman to APA, February ,San Francisco, Calif., APTA archives, BOD , file .

. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profes-sion and the Making of a Vast Industry(New York: Basic Books, ).

. Nancy Tomes, Merchants of Health: Medicine and Consumer Culture in theUnited States, ,J. Am. Hist., , , . For direct quotation, see p. .

Tomes estimates that during the s and s, percent of health care spending camedirectly from patients.

. Catherine Worthingham to APA, November , San Jose, Calif., APTAarchives, BOD , file .

. Radio Talk by Our President, Physiother. Rev., , , , emphasis added.


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members to take a more grassroots approach to educating doctorsabout their profession. Chairman of the committee Margaret Wallace

wrote that calling up doctors in the community and saying to them,You know, we do not accept any cases without orders is anexcellent type of publicity. Tell them, she instructed, that an APAtherapist is just like an ethical druggist who does not give out spe-cial medicines without orders.84 The APA therapists hoped itwould be to their advantage to be seen akin to pharmacists, who hadalso agreed to be ethical practitioners, administering drugs onlywith written prescriptions from doctors.85

But Campbell and other leading APA therapists had no groundson which to take disciplinary action against those therapists whomight stray from the rules of medical professionalism. Althoughconfirming the importance of cooperating with the medical profes-sion, the APAs original constitution remained a toothless doc-ument. Nothing in the constitution, that is, allowed APA presidentsto bar members who conducted physiotherapy without a doctorsprescription.86

With their Code of Ethics, however, the APA made official

its intent to rely exclusively on a physicians prescription and to rep-rimand members who refused to abide by these rules of referral.APA therapists made their aims clear in the title for the creed, callingit a Code of Ethics and Discipline. Time and again throughout theirvery brief code, the APA therapists made reference to the impor-tance of deferring to physicians as the overseers of physiotherapy.The code opens with a pithy two-sentence rule that in many waysencapsulates the driving assumption behind the document: Diag-

nosing, stating the prognosis of a case, and prescribing treatmentshall be entirely the responsibility of the physician. Any assumptionof this responsibility by one of our members shall be consideredunethical.87Again, under the section titled Professional Practice

. Margaret Wallace, Editorial, Physiother. Rev., , , .. For the established relationship between pharmacists and the AMA, see Chapter III,

section of the AMAs Principles of Medical Ethics (), in Baker, ed., AmericanMedical Ethics Revolution, p. .

. One APA member, Margaret Cleveland, explicitly expressed concerns about theAPAs inability to police its members. See Margaret Cleveland to Gertrude Beard, January, Cleveland, Ohio, APTA archives, BOD , file .

. See Code of Ethics and Discipline, Physiother. Rev., , , . The code hasalso been reprinted in appendix I.


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and Behavior, the code states that a physiotherapist shall notattempt to criticize the physician or dictate technique or proce-

dure.88

Finally, under the section Advertising, the code mandatesthat physiotherapy advertisements should include a statement thatthe work is medically supervised.89

Aside from making its dependence on the medical professionexplicit, the executive officers of the APA armed themselves with acreed that they could use to police delinquent members. The finalsection of the code, titled Discipline, gave the APA president thepower to punish members who did not adhere to the code of eth-ics.90At this point in the organizations development, the only realtool of punishment was revoking memberships. As the reasoningwent, if a therapist did not have her name on the APA membershiproster, she would squander a steady supply of patients that normallycame from physician referrals and therefore lose her practice.

Although the code was a way to demonstrate loyalty to the medi-cal profession, it was also a means for APA therapists to uphold theiridentity as professionals and, in turn, to prevent further subordina-tion in the medical chain of command. For instance, although APA

therapists agreed freely to give up the ability to diagnose and pre-scribe treatments, they rejected the physicians requests that theyrelinquish their private practices. Ever since , when the Councilon Physical Therapy recommended that technicians should be dis-couraged from establishing individual [private practices], APAtherapists resisted the effort.91With one-third of its therapists operat-ing their own private practices and another third working in thenations school systems, the APA refused to acquiesce to the physi-

cians demands.92

Initially, the APA tried to combat the medical professions

squeeze on their private practices by trying to demonstrate thatindependently practicing physiotherapists would diminish medicalmarketplace competition. Playing into the medical professions hotlycontested debates over physician specialists, APA president Hazel

. Ibid.. Ibid.

. Ibid.. Report of Committee on Present Status of Physical Therapy, J. Am. Med. Assoc.,

, , .. Editorial, Physiother. Rev., , , . APA to Catherine Worthingham,

February , Chicago, Ill., APTA archives, BOD , file .


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Furscott wrote a letter to the Council on Physical Therapy in arguing that if a general practitioner sends his patient to another

physician who is practicing the technique of physical therapy, heturns his case over . . . and may lose his patient. But, she continued,if he refers the case to an ethical technician, he may supervise anddirect the treatment at will.93In other words, if the treatment ofphysical therapy fell solely into the hands of a physician who woulddevelop his practice around delivering physical therapy, the compe-tition for patients would increase. At least with APA ethical tech-nicians at the disposal of physicians, Furscott reasoned, a generalpractitioner could continue to procure fees from initial patient eval-uations as well as subsequent follow-up visits.

In addition to appealing to arguments of marketplace economics,Furscott also made the claim that physiotherapists were in manyways analogous to pharmacists, who also had their own private prac-tices. In her letter to the AMA, she contended that physicians shouldbe taught techniques in physiotherapy just as they learned their mate-ria medica.94 The doctor, according to Furscott, should write his[physical therapy] prescription in dose form as he does a prescription

of medicine, and he should direct and supervise the application ofthe agencies of Physical Therapy as he does the procedures in Medi-cal Therapy.95And like the pharmacist who had his own place ofbusiness where he administered medications, physiotherapists,Furscott argued, should have their own private practices where thephysical therapy prescription shall be filled.96 The APAs argu-ment was perfectly logical: Physicians had private offices, druggistshad private offices, and so, too, should physiotherapists. For it to be

otherwise was nothing less than the AMA failing to recognize thatthe members of the APA were ethical professionals, too.97

With their Code of Ethics, physiotherapists tried to make one laststand to keep their private practices, for as professionals, they feltentitled to the privilege of maintaining private offices. Under ArticleI of their code, Professional Practice, the APA claimed that whena therapist treated a patient under a doctors orders, the patient shall

. APA to AMA Council on Physical Therapy, August , Chicago, Ill., APTA

archives, Box , file .. Ibid.. Ibid.. Ibid.. Ibid.


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be referred back to the physician for periodical examinations.98

Such a statement of practice would have been unnecessary if the

APA assumed that all physical therapy treatments were going to takeplace under the same roof as a prescribing physician, that is, under adoctors directsupervision. In other words, a formal system of patientreferral would have been pointless if physicians were working nextto a physiotherapist with the ability to monitor the patients progressthemselves.

But in focusing their efforts so singularly on fostering a solid rela-tionship with the medical profession, the APA therapists neglectedto make any mention of the therapistpatient relationship. Thisabsence is particularly noteworthy because most other medicallyrelated codes of ethics of the time devoted entire sections to discus-sions about the professional care of the patient. From its originalcode of ethics adopted in to the revised Principles of Medicinein , the AMA always mentioned honesty and the patienthealerrelationship as essential components of ethical practice. The same istrue for the American Pharmaceutical Association which, in itsrevised Principles of Pharmaceutical Ethics of , compels the

pharmacist to hold the health and safety of his patrons to be the firstconsideration of his practice.99Focused attention on the patient canalso be seen in codes of ethics that were written by other contempo-rary professional women. In , the Dental Hygienists Associa-tion adopted a patient-centered code of ethics, claiming that thedental hygienist should be ever ready to respond to the wants of herpatrons, to care for even the simplest cases, seeing every proce-dure as an operation performed on living, sensitive tissue.100The

Suggested Code of the American Nursing Association usedsimilar language of concern for the patient in that the leaders of theorganization saw themselves as satisfying a greater need of theworld for skilled and tender care in illness.101

Perhaps the APA therapists decision to remain silent about thetherapistpatient relationship was a mere oversight. More likely, theiromission was an example of shrewd decision making; it was a way, in

. Code of Ethics and Discipline, p. .

. For a reprint of the Principles of Pharmaceutical Ethics, see Annals of theAmerican Academy of Political and Social Science, pp. . For direct quotation, see p. .

. For a copy of the code of ethics, see Motley, History of the American DentalHygienists Association, pp. .

. A Suggested Code, p. .


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other words, to overcompensate for the gender make-up of theirorganization. In medical circles, the healerpatient relationship often

served as the most likely venue through which woman practitionerswould express their sentimentality for patients and their care.102Thus,by failing to comment on the healerpatient relationship, APA thera-pists maintained their gender-neutral, non-Victorian identity withgreater ease. Moreover, by , APA therapists already had a longhistory of creating a defeminized identity, beginning with their mili-tary Reed College loyalty oath, in which therapists promised tomaintain a businesslike relationship with physicians and patients.

GENDERANDCODESOFETHICS

The APAs proclamation testifies to the fact that gender playedan instrumental role in the writing of its Code of Ethics. In a veryreal sense, APA therapists used their first code of ethics as a way toovercompensate for the gender make-up of their field. They used anacceptable form of professional codification as a way to challenge theAMA legitimately, which continually refused to grant equality tomen and women alike in the newly burgeoning allied health field.

Despite the AMAs refusal to see physiotherapy along the same linesas the male-dominated practice of pharmacy, APA therapists insistedthat they were equal to pharmacists, for even the AMA, at the initi-ation of the Council on Physical Therapy in , had itself madethe argument that the two practices should be seen as analogous. Butsuch an analogy did not translate into everyday practice. Through-out the s and early s the AMA supported pharmacists whoowned private practices but refused the same arrangement to phys-

iotherapists.In short, gender remained an unstated yet important difference

between the fields of pharmacy and physiotherapy. Whereasapproximately percent of all practicing pharmacists in the earlytwentieth century were women, the opposite was true for physio-therapy, where men constituted anywhere from to percent ofthe profession up to the mid-s.103Another striking difference

. Morantz-Sanchez, How Women Physicians Became More Empathic Than Men, p. .

. On the issue of gender and pharmacy, including statistics of the number of femalepractitioners from the years , see Teresa Catherine Gallagher, From FamilyHelpmeet to Independent Professional: Women in American Pharmacy, ,Pharm. Hist., , , . For the number of physiotherapy male members, see mem-bership directories printed annually in P. T. Rev. and Physiother. Rev.


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between these two ancillary professions, both dependent on a physi-cians prescription, is the wording of their ethical codes. Unlike the

APA code, the official Principle of Pharmacy Ethics devotes anentire section to the pharmacists duties to the public, wherein itis stated that he should hold the health and safety of his patrons tobe the first consideration of his practice. Although differencesbetween the APA code and the Principle of Pharmacy Ethicsare too many and too complex to outline here, the question of whatrole, if any, gender played in the resultant differences between thetwo codes remains.

The APA Code of Ethics also complicates the notion that thereexists a predetermined gender-specific ethic of care.104Many socialscientists and philosophers have contended that women, especiallyfemale health care providers, have historically been caregivers whohave nurtured men, children, and other women at home and atwork. Most famously, Nell Noddings and Carol Gilligan have bothargued that according to their observation of womens behaviorsand experiences, women tend to put themselves at the service ofother[s], striving to find options that avoid bringing harm to any-

one.105Likewise, a similar deterministic assumption of woman ascaregiver permeates historical studies of the early twentieth-centuryprofessions in the United States. In this literature, female health-related professionals are often depicted as service-oriented, andcooperative by nature, whereas their male counterparts are usuallyprofit-seeking, competitive, and ultimately concerned about pro-tecting their occupational territory.106

If care-based, service-oriented ethics is the rule among female

health professionals, then physiotherapy is the exception to the rule.

. For a sampling of the ethics of care argument, see Carol Gilligan, In a Different Voice:Psychological Theory and Womens Development(Cambridge, Mass.: Harvard University Press,); and Nell Noddings, Caring: A Feminine Approach to Ethics and Moral Education(Berkeley:University of California Press, ). For a more recent critique of the ethics of care theory,see Helga Kuhse, Caring: Nurses, Women and Ethics(Oxford: Blackwell Publishers, ).

. Noddings, Caring, pp. , . Latter quotation comes from Gilligan found in SusanSherwin, No Longer Patient: Feminist Ethics and Health Care(Philadelphia: Temple Univer-sity Press, ), p. .

. Much of the historical literature on the Sheppard-Towner Maternity and

Infancy Act and the U.S. Childrens Bureau supports the idea that there were gender-spe-cific approaches to professionalization and the dissemination of expert knowledge in theearly twentieth century. Some of the best books on this topic include Molly Ladd-Taylor,Mother-Work: Women, Child Welfare and the State, (Urbana: University of IllinoisPress, ); Kriste Lindenmeyer, Right to Childhood: The U.S. Childrens Bureau and Child


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From their military oath to their correspondence with the AMACouncil on Physical Therapy and their Code of Ethics, APA

therapists made it clear that they thought more about the ethics ofmedical professionalisman ethic that after World War I includedbusiness ethicsthan the patient-centered ethic of care. To thetherapists themselves, the code was a supremely professional actthat had decisively set physical therapy above cult practitioners(such as chiropractors) who pursued their work without heed toethics and with little consideration of proper and adequate train-ing.107As ethical professionals, they considered themselves to bemore dignified than blue-collar workers or money-hungry salesmen.

With their Code of Ethics, APA therapists relinquished thelicense to diagnose and prescribe treatment in the name of profes-sionalism. To be sure, the Code of Ethics can be interpreted as theultimate act of self-subordination; after all, the physiotherapistseffectively gave up any chance of becoming completely autonomousprofessionals. But from the therapists perspective, the code wonthem a secure place in the medical profession. And to a certainextent, they were right. When the AMA Council on Physical Ther-

apy issued its second report in , the board of physicians statedthat although they were originally concerned about the ethicalstanding of physical therapy, they now considered it to be an upstand-ing medical practice and a permanent part of modern medicine.108

Moreover, the council fully endorsed APA physiotherapists. Thesetechnicians thoroughly imbued with medical ethics, concluded thecouncil, are logically of value to the medical profession. Indeed,by the s, many physicians blamed the prevalence of quackery

on physicians who failed to refer patients to professional physical

Welfare, (Urbana: University of Illinois Press, ); Richard A. Meckel, Save theBabies: American Public Health Reform and the Prevention of Infant Mortality, (Baltimore,Md.: Johns Hopkins University Press, ); Robyn Muncy, Creating a Female Dominion inAmerican Reform, (Oxford: Oxford University Press, ); and Sheila M.Rothman, Womans Proper Place: A History of Changing Ideals and Practices, to the Present(New York: Basic Books, ). Nancy Cott complicates the notion that there were gender-specific views of professionalization after World War I by looking at several female profes-

sional groups after enfranchisement. See Cott, The Grounding of Modern Feminism (NewHaven, Conn.: Yale University Press, ).

. Hazenhyer, History of the American Physiotherapy Association, p. .. Report of the Committee on the Present Status of Physical Therapy,J. Am. Med.

Assoc., , , , emphasis added.


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therapists.109 The AMA recommended that the medical professionsupport the APA professionals, for, as one physician-analyst argued,

increasing the use of physical therapy will do more, perhaps, thanany other thing to eradicate sectarianism.110The APA code not only helped shape the terrain of the allied

medical field, it also played a role in the way that gender entered themedical discourse on professionalism, explicitly and implicitly. Intheir code, the physiotherapists avoided the rhetoric of sentimental-ity and any discussion of the patient to establish themselves as medi-cally related professionals, a standing jeopardized not only by theirgender but also by their already subordinate position in the medicalhier

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