Editor’s Note: Today’s post comes from contributing editor Brooks Hudson, a PhD student in history at Southern Illinois University.
Whenever Prohibition reenters the zeitgeist through pop culture like the recent cable TV series Boardwalk Empire or through a historical anniversary, it seems inevitable that someone will produce an “isn’t this ridiculous” style article about the “bizarre” practice of prescribing medicinal alcohol. On the surface, the entire debate about prescription alcohol often seems illegitimate and merely a loophole that doctors and patients used to skirt enforcement of the Volstead Act.
As medical historians have pointed out, though, prescription alcohol is not merely arcane trivia. It represented an early skirmish between an aggressive government and the collective efforts of the American Medical Association to assert its rights to distance medicine from politics.
In reality, the status of medicinal alcohol resulted from negotiations between the state and organized medicine over the power to prescribe. Medicine already had enough prestige to weaponize laws against rival professions. Even critics of the AMA like pharmacist Henry Rowland Strong understood that it was seen “as a graceless and indelicate thing to criticize the medical profession,” and, he argued, the “political schemers in the high places of organized medicine” were always “quick to take advantage of this sentiment.” Strong feared that medicine would overtake pharmacy, and he warned:
“No sooner is [the doctor] attacked for his greed for power and his unscrupulous methods of attaining it than he hastens to hide behind the skirts of the profession at large—the sentimental and picturesque ideal of the profession that the public cherishes in its heart—waxing eloquent about the sacredness of the calling, reciting its long list of honorable men and achievements, and setting forth its noble and disinterested aims.”
Critics feared that giving organized medicine the power to decide what medicines people could use would, in the words of Strong, “be tantamount to the establishment of a State system of medicine.”
“In medicine, as in religion,” he wrote, “very little is definitely settled, and the laws of progress require that the State leave all questions pertaining to either subject open for discussion and experimentation, giving everyone the right to believe and practice any system or none. Once grant this Medical Trust the power it seeks, and there would be no limit to its aggression.” State medicine in this case it is not socialized, but rather a coercive private use of state power for private gain. Prescription drug laws are a part of that story, and prohibition provided an opportunity for organized medicine to claim its right as an autonomous actor, independent of the state.
Alcohol (Not) Medicine Yet
In 1916, the Pharmacopeia of the United States of America removed brandy and whisky from its list of scientifically approved medicines. At the AMA’s annual meeting in June 1917, the organization concluded that “alcohol is detrimental to the human economy,” and its “use in therapeutics as a tonic or stimulant or for food has no scientific value.” Therefore, it concluded, “the American Medical Association is opposed to the use of alcohol as a beverage,” and “the use of alcohol as a therapeutic agent should be further discouraged.”
Once Prohibition began in 1920, however, there was an incredible amount of money to be made in prescribing medicinal alcohol. The science had not changed, but both the AMA (and the Pharmacopeia) reversed course. It seems that the potential profits from writing alcohol prescriptions had clarified their thinking. Money, rather than medicine, may explain the organization’s change of heart.
Many believed that prescription alcohol was exactly what it appeared to be: extra income for physicians in exchange for writing prescriptions for people with no medical ailment or need for medicinal alcohol. When speaking anonymously in newspapers or medical journals, many physicians were much more candid about medicinal alcohol than when they testified before Congress or appeared in a public setting.
Aaron Hardy Ulm, reporting for the New York Times, led his story “Flood of Liquor Sold By Order of Doctors,” by writing:
“There is in a certain city of the East a physician of scholarly attainments and reputable standing in his profession, but lacking in those attributes making for a successful private practice. For years he has given the bulk of his time to research work. For this, he is paid on a modest scale by a commercial establishment which makes his work available to the medical profession as a whole. His earnings have been supplemented by meager returns from a small private practice.
However, until within the last year or two, he earned scarcely enough to meet living expenses. Now, he pays his bills promptly and puts by a small sum monthly as insurance against old age and rainy days. For his earning have been increased to the extent of about $100 a month [about $1,500 today] by the Volstead Act. To an entirely new group of ‘patients,’ he disposes of his quarterly allotment of 100 liquor prescription blanks at $3 each.”
In an AMA survey on attitudes of the medical community, an anonymous doctor from Montana described his feelings:
“The whole thing is beyond me. Out here if they don’t get medicinal liquor they get moonshine. I tried to get along without a permit, but in case of sickness some of my patients thought they ought to have liquor and I would have to send them to my competitor to get their prescription. In a way the prescription work as a nice graft. It allows me to have an assistant. Two books a quarter for a year is 800 prescriptions, which at $2 each equals $1,600 nearly enough to pay his salary and allowing me to take postgraduate work, attend medical meetings, and have more time for the enjoyment of the good things in life.”
The AMA Asserts its Power
In 1921, Congress introduced the Willis-Campbell Act to tighten regulations on physician prescribing and to exclude beer from the category of medicinal alcohol. Immediately, the AMA asserted government overreach for allowing politicians without sufficient expertise to dictate standards for the medical profession. While public comments come across as sanctimonious, the negative response to limiting certain prescribing patterns should not have come as a surprise, as some doctors openly admitted that prescription alcohol was indistinguishable from garden-variety self-medication.
In the Journal of American Medicine, for example, a doctor from New York City grudgingly admitted, “I have written more prescriptions for whisky since Prohibition than during my twenty years of practice. I have used two books of blanks and I feel that not one of that number of patients was legitimately entitled or needed a prescription for whisky. I am sure they exaggerated their cases,” he said, “and if their sufferings were as stated we have other remedies which would have relieved them. But such is the case in a large general practice in a great city.”
This was not unusual. Some strict prohibitionists who believed in a uniform alcohol ban decried his colleagues as “prescription peddlers.”
The debate in the country’s newspapers about the proper alcohol restrictions was quite different from what doctors openly said in their own journals. The New York Times, for instance, wrote that the Willis-Campbell legislation was really about the “right of the physician to select his remedies and to decide what doses of these remedies each patient requires.” Furthermore, “aside from the insult to a great and noble profession, this Federal prescription of prescription will force conscientious physicians who believe in the therapeutic use of alcohol to break the law. The health, the life, of their patients will necessarily outweigh in their minds the ignorant interference of fanatical or fanatic-frightened laymen with medical practice.” Similarly, the Chicago Daily Tribune argued that doctors were “entitled to decide how much the patient needs and not to be told by law.”
Few considered the possibility that patients, themselves, could or should make decisions about their preferred medicines—without the coercion of governmental or medical regulations.
Inequities of the Prescription Model: Profits Over (Poor) Patients
In 1933, in the last months before the end of Prohibition, Congress debated one final bill about doctors’ ability to prescribe medicinal alcohol. House Member Thomas L. Blanton, a Democrat and Prohibitionist from Texas, favored easing regulations to make it easier for patients. Primarily, he complained, the medical model effectively provided whisky to the rich while denying it to the poor.
As Blanton pointed out, the popular press seemed not to debate the real prescription alcohol system that had developed. The federal mandate that required paying a doctor for prescriptions constrained patients’ access to alcohol by their wealth, race, and class. The prescription system only served patients who could afford to see a doctor, afford the cost of the prescription fee, and afford the cost of the prescribed alcohol. In short, the prescription model rewarded wealth and punished poverty.
Blanton was, he said, against the “bill in its entirety.” He claimed that the “idle rich, with more money than brains… [can] get all the liquor they want, simply by paying an unscrupulous doctor… for all they want. But the poor man, who is not able to pay the $3 for his prescription, will not be able to get any liquor at all. Of course, he will be better off without it. But he should have equal rights with the rich, so far as Congress-made laws are concerned.”
The Meaning of Prescription Alcohol
Blanton argued that prescription alcohol was class legislation simply masquerading as humane public policy while hiding the profit-making that motivated it. Congress had implemented an arbitrary system for prescription alcohol. The law required, for instance, that a doctor specify a specific “ailment” on the prescription form, but the regulations did not clarify what constituted an “ailment.” Was it physical or mental? A disease? An illness? A disorder?
Doctors often simply wrote the nearly meaningless term “debility” for the ailment. Other conditions that merited medical alcohol prescriptions included “pneumonia, influenza, difficulties of old age, diabetes, heart failure, shock, anemia, asthma, catarrh, cancer, poisoning, colds, dyspepsia, dysmenorrhea, neuritis, rheumatism, snake bite, heart disease, blood pressure disturbances, alcoholism, and insomnia.” Alcohol cures none of these conditions, and, in fact, alcohol worsens some of them.
The debate really hinged on medicine and well-being. Alcohol could temporarily improve a patient’s subjective mental state. It made people more upbeat, happy, or sleepy but that is different from using alcohol to cure a specific health problem. And this was implicit in Representative Blanton’s debate in Congress. If the system was not based on medical need but instead on a patient’s ability to pay, everyone, critics argued, should have the same ability to purchase medicine. Customers would be free to seek the advice of a doctor if they desired, but they should not be penalized for not paying a physician. The solution was simple to reformers like Blanton: politicians should not be physicians and physicians should not dictate what medicines patients take.
The story of medicinal alcohol has echoes in contemporary policies that can provide differential access to certain drugs based on a patient’s ability to secure a prescription. The line between legal “medicines” and illegal “drugs,” has long been subject to contentious debates, and, as Representative Blanton reminded us drug policy makers often fail to “give the same rights and privileges to the poor that [they] hand over on a silver platter to the rich.”