GUEST EDITORIAL
Orthodontics: A case study in the tension between guild
standards and capitalism
John J. Sheridan, DDS, MSDa
New Orleans, LA
O rthodontics is a guild-based profession
similar in historic construction to law, medicine, and
academics. As such, we have enjoyed decades of rela-
tive autonomy and prosperity. And then we have capi-
talism; that magnificent engine of commerce that drives
the most powerful economic system ever known to
man. Unfortunately, there’s a developing tension
between our guild-based profession and capitalism of
which we should be aware.
At this point, those elements of a guild-based pro-
fession that have served us well should be defined.
They are:
• A guild has the power to control the conditions
under which their members work.
• Guilds are comprised of participants who try to
acquire not only income and assets, but also a good
reputation, a stock of favorable impressions of one’s
self and one’s work in the minds of others, especial-
ly fellow practitioners, ie, those who are better qual-
ified than anyone else to pass judgment.
• Guilds encourage competition as well as the sharing
of knowledge, generating an ambient professional
pride that benefits all members and their patients.
Control over the workplace becomes the great pivot
on which our guild-based specialty turns. All in all, we
have managed to establish control and hold on to it
most of the time. Capitalism and the State, each with its
own distinct interests, become the two most likely
antagonists that must be held at bay if professionals are
to control their destinies.1 The transfer of control from
guild-based professionalism to a state/capitalistic force
is pathetically evident in medicine. Case in point: man-
aged care plans suffer from an inherent conflict of
interest. On the one hand, they pledge to take care of
their enrollees, but on the other, their financial success
depends on doing as little for them as possible.
This editorial was printed in The Newsletter of the Southwestern Society of
Orthodontists 26:2 Summer/Fall 1998. It is at the request of some members of
that Society that this editorial was submitted for reprinting in the AJO/DO.
Professor of Orthodontics, Louisiana State University.
Copyright © 1999 by the American Association of Orthodontists.
0889-5406/99/$8.00 + 0 8/1/97040
The loss of control of the work place in organized
medicine has led to situation comedies that are humili-
ating to witness. For instance, recently the federal gov-
ernment stepped in between feuding doctors and HMO
managers to set limits on the types of bonuses that doc-
tors could be offered for containing the cost of services
for Medicare and Medicaid patients.2 If medicine, the
most powerful and prestigious of all the professions,
can be made to scramble for control over its own work-
place, what can the future hold for our specialty? Per-
haps some promise, if we understand the gravid
strengths within our guild heritage.
As in profit-based capitalism, there is competition
among guild-based professionals in nonpecuniary
types of achievement, such as recognition, reputation,
and the technical quality of the work performed.
Instead of fleeing competition, we intensify it as a
means of encouraging individual practitioners to live
up to whatever standards of conduct and technical per-
formance may be thought important. This mutual con-
structive criticism is motivated by a tacit understanding
of the long-term interests of the profession and benefits
to the patient.
We stage competitive exercises to inure novices.
These trials do not end when students leave the class-
room and enter the world of mature practitioners.
Study group requirements, submission of cases for
membership in regional AAO components, the pro-
gressive phases of the American Board of Orthodontics
certification, and continuing education requirements
are the means by which newer professionals get a sense
of the values and habits of mind they will need
throughout their careers.
This is what enables them to hold their own and
keep their poise under criticism in what Alvin Gould-
ner called “cultures of critical discourse.”3 He had in
mind mainly the world of intellectuals and scholars, in
which the duty to criticize is probably more ingrained
than anywhere else. However, competition between
clinicians is just as robust and is nowhere more evident
than in the notorious tendency of experts to arrive at
conflicting judgments. Witness the diversity of options
15A
16A Sheridan
when a borderline extraction case is presented for treat-
ment planning among a group of seasoned clinicians.
The disagreement usually attests, not to the vacuity of
professional knowledge, but to the difficulty of the
questions experts address when they are speaking as
authoritative members of a community.
Each individual practitioner ultimately depends on
patronage of paying consumers, but patronage presup-
poses trust and, when it comes to the high stakes ques-
tions that experts have to address, trust can best be
elicited collectively by requiring all members to
encourage the critical appraisal of their peers. The
result is a profession that tends to be acutely status con-
scious, but which also tolerates greater candor and
higher levels of criticism than would be thought
acceptable in most communities.
Therefore, it compels us to calculate self-interest
twice. First, in monetary (business/capitalistic) terms,
and then in the quest for recognition and distinction
within a community of peers whose standards derive
from the work they perform. The result is subtly differ-
ent from those who mainly compete in the business
arena. But there is a more general similarity. Both the
clinician and the businessperson are aware of the situ-
ations that detract from their benefit to the community.
Opportunities to advance one’s own interests at the
expense of patients or customers who are vulnerable or
confused are always present. Unfortunately, some clin-
icians and businesspersons will succumb to temptation,
and concern for reputation will not stop them. Every
occupation has its unscrupulous opportunists and its
fools. But if orthodontists or businesspersons were not,
in the main, effectively restrained by concern for their
reputation, patients and customers would be far less
trusting than they are.
Although capitalism and professionalism put com-
American Journal of Orthodontics and Dentofacial Orthopedics
March 1999
petition to different uses, both depend on each other.
It’s a matter of balance rather than domination. Neither
could make war on the other without putting their own
fundamental commitments in peril. Orthodontics is
best construed not as an atavistic remnant from the age
of guild organization riling at the competitive spirit of
capitalism but rather as an influence whereby calcula-
tions of least cost and maximum efficiency can be tem-
pered by the classical standards of our guild-based
profession. This is not being nostalgically naive.
Recently, 16 state legislatures passed laws prohibiting
“gag rules” and reaffirming the right of doctors to
unrestricted communication with their patients; the
federal government followed suit with an order to the
same effect.4
There are rising tensions between the guild-based
professions and capitalism. However, it would not be
surprising if the historic culture of the professions were
looked to as a force that could rein in the excesses of
economic proclivities and governmental influence
while appreciating the efficiencies of a market-based
economy. Such a prospect does not depend on the Vic-
torian premise that professional people are morally
superior to business people, nor does it assume that
competition alone can be counted on to protect the
patient. It depends only on the consistent observation
that the guild-based, university-programmed profes-
sions can impose on their members a competitive disci-
pline that is more thorough, more multifaceted, and
therefore more compatible with the public interest.
References
1. Krause EA. Death of the guilds: professions, states, and the advance of capitalism,
1930 to the present. New Haven, CT: Yale University Press; 1997.
2. The New York Times. December 25, 1996, p. A1.
3. Gouldner AW. The future of the intellectuals and the rise of the new class. Continuium
1979:28-34.
4. The New York Times. September 17, 1996, p. D12.