The remaking of American hospitals began in the 1800s, and it was a remarkable process. Hospitals once served a very different role in society:

Medieval hospitals were conducted by religious or knightly orders and had a strong communal character; those who worked there were also bound together in a common identity and belonged to a common household. “Even when hospitals were taken over from the ecclesiastical authorities by municipalities in the later Middle Ages,” writes George Rosen, “they were not secularized. Essentially, the hospital was a religious house in which the nursing personnel had united as a vocational community under a religious rule.” In a different way, the almshouses of colonial America, which were the first institutions to care for the sick, retained a communal character. The colonial almshouse, David Rothman writes, provided a “substitute household: for people without a home who were poor or sick. “The residents were a family, not inmates.” Even the architecture of the colonial almshouse, which resembled an ordinary residence, reflected its conception as a household.

A key phrase above is “for people without a home.” For those who had family or were otherwise part of a community, care was provided in the home. Even the indigent poor were generally cared for in homes, until the government had a better idea:

In the colonial period, the almshouse was a secondary response to poverty and illness. As I indicated earlier, the colonists preferred to provide relief to the poor in their own homes, or to pay neighbors for taking care of them. But after about 1828, there was a shift in policy as states abolished home relief. By making the almshouse the only source of governmental aid to the poor, legislatures hoped to restrict expenditures for public assistance.

Eventually hospitals took over the role of taking in those of need of help and performing a sort of triage:

The contagiously ill they sent to the pesthouse, and the incurable and chronically ill, as well as those whom they thought wicked and undeserving, they sent to the almshouse. Such exclusions enabled the hospitals to restrict the number of patients they admitted and to keep down the reported mortality rates, since the hopelessly ill could be directed or transferred elsewhere before they became a blot on the hospital’s good name. This practice was encouraged by the medical staff, since the hospital would be less useful as a source of instruction to students if it filled up with chronic cases.

As industrialization progressed, the need for hospitals increased:

[Until 1870] hospitals had been formed mainly to take care of people who did not fit into they system of family care. The earliest hospitals were built chiefly in ports or river towns—Philadelphia, New York, Boston, New Orleans, Louisville—centers of commerce where strangers were likely to be stranded sick or where people were likely to be found working and living alone. Institutioinal charters and appeals for funds alluded to the needs of such people. In 1810, when Doctors James Jackson and John C. Warren circulated a letter to some of the “wealthiest and most influential citizens” of Boston to interest them in a hospital, they mentioned, as cases in need, journeymen mechanics living in boarding houses, widowed or abandoned women, servants, and others who had no adequate housing or kin to care for them.

As with other social institutions originally established to care for the needy, such as public schools and Sunday schools, those who were able to provide for their own needs in this area began to see the convenience of paying someone else to provide that care, thereby freeing them from the burden of family obligations. It wasn’t long before hospital care had become respectable, with middle-class families first offloading the care of relatives, then eventually turning to hospitals for their own care.

An interesting side note: American hospitals are apparently unusual in that a patient usually remains under the care of his own physician while in the hospital. In other countries the hospital takes full responsibility for the patient from his physician once he enters their care.


7 thoughts on “Hospitals

  1. Sadly, the Church has abrogated many of our respsonsibilities (read ‘duties’), finding it easier to have someone else (the government) do it.

    Regardless of the political arguments I have against them, the government welfare programmes in the United States should not exist–because we Christians should be seeing to those needs.

  2. Thanks for posting these very interesting quotes, Rick. I think its important to see that sharing one another’s burdens is not fulfilled by simply paying one anothers’ hospital bills, because in a sense many hospital bills represent an abdication of that very duty. So we don’t want to be “enablers”. We also want to encourage each other to actually take care of the sick and dying. What an interesting catch-22 the modern world has created, where you need a job to have health insurance – which institutionalises the problem that insurance supposedly was created to help.

    But a lone fish swimming upstream has a hard go of it on this issue.

  3. Chad,

    sharing one another’s burdens is not fulfilled by simply paying one anothers’ hospital bills

    Agreed. In fact, it makes things worse by feeding the beast, when I think we ought to be about the business of helping our neighbors stay out of its clutches entirely by finding (recovering?) non-institutional approaches to keeping our community healthy.

  4. On the other hand, I think surgery and hospital treatment has three times saved the lives of my family members. I am not sure how in home care could have taken care of the Equuschick’s recent lacerated pancreas when her horse kicked her.

    But on the other, other hand- institutional care has gotten so, well, institutionalized, that we thought it best, in each of the three instances where major surgery in a hospital saved my family member’s lives, they also benefited by having some of us with them 24 and 7, keeping an eye on them, helping them with tasks they could not do, and so forth.

  5. DeputyHeadmistress,

    I think it is surgery that tips the balance towards hospitals, since (a) they can provide an aseptic operating environment more easily than the home can, and (b) most surgeries require such specialized skills that it is unreasonable to expect a surgeon to make a home visit.

    But I do wonder if, after we decided that there is a role for hospitals, we didn’t proceed to expand their role way beyond what is necessary. Much of what happens only in hospitals these days mostly happens there for the convenience and profitability of the medical profession. How different could things be if we were adamant about only turning over as much health care to hospitals and medical professionals as is absolutely necessary?

  6. On the other hand, lets not forget that doctors and hospitals not only save lives, but take them tragically and unecessarily at times as well. Is it a matter of taking a utilitarian ethic and weighing lives saved against lives lost? I don’t think so. The fact that someone was saved in a hospital is not the ultimate trump card. No slight intended to DHM of course, not at all.

    But the thing with utilitarianism is that we have to assume that the means we employ are accomplishing what we think they are, and discounting the possibility of God working through other means. Had we not gone the route of industrialised medicine, we just might have a network of holistic physicians that could provide us with even better care. It seems counter-intuitive, but its definitely possible. The “opportunity cost” of throwing all our resources into the hospital model of care is the stifling of alternative research and methods.

  7. How different could things be if we were adamant about only turning over as much health care to hospitals and medical professionals as is absolutely necessary?

    Great point. Not too long ago, our son needed major surgery. The surgeon was superb and did an excellent job. In the end, all came out well. But – recovery was another story. The quality of nursing care while my son recovered in the hospital was very close to non-existent. Basic tasks such as bathing, emptying the catheter bag, even monitoring nutrition were not being performed to any degree of adequacy. The surgeon’s daily orders for the staff were not being carried out. This took place in a hospital with a stellar reputation; one of the best in the state. We quickly realized that we needed to be present 24/7 in order for my son to receive adequate care. We ended up taking care of him in the hospital, but could have given him much better care at home – certainly better care than was being performed by the hospital staff. (Since then we’ve had similar experiences while caring for friends and neighbors. The experience with our son is not an isolated incident.)

    Our society has been so conditioned to specialization and reliance on “experts” that we’ve lost our ability and confidence for action. We don’t know what is “absolutely necessary” so we just let them do everything – due to our ignorance, and our fear that “something might go wrong” if we rely on ourselves.

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