The Foibles of Flexner

Perhaps the AAMC and AMA should stop apologizing for Flexner and start apologizing to Flexner

Abraham Flexner’s legacy is problematic—not so much because his words are so distant from the present-day principles of the Association of American Medical Colleges (AAMC) and American Medical Association (AMA), but rather because his thinking was so close to that of today’s AAMC and AMA. 

Flexner, 1910

Conventional Complaints

In 2020, the AAMC dropped Flexner from its pantheon, encouraged by the AMA, which commissioned his 1910 Flexner Report. The AAMC accused Flexner of “racist and sexist ideas”and blamed him for shuttering five of the then-extant African American medical schools. (Meaculpa: I used to make the same argument against Flexner.) But, on closer inspection, his racial and sexual notions are ambiguous.  He may deserve credit for saving two Black medical schools. His “The Medical Education of the Negro” and “The Medical Education of Women” sound dreadful today, but their condescending tone may have been essential to overcoming the  AMA’s and AAMC’s bigotry. 

My substack, Bastiat’s Window, explores the fever swamps in those years: Mathematical statistics was created largely to validate eugenics. Woodrow Wilson dismissed African Americans from federal employment.  Virginia justified purging African Americans from voter rolls on progressive grounds. The Carnegie Institute suggested euthanasia for socially inadequate people. Public health sired the Tuskegee Study. Eugenics was taught in medical schools, while the writer G.K. Chesterton stood nearly alone in opposing it.

The AAMC and AMA were indisputably racist and sexist. Flexner’s message to them was: 

The practice of the negro physician will be limited to his own race … But the physical well-being of the negro is not only moment to the negro himself. … Not only does the negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors, precisely as the ignorant and unfortunate white contaminates him. …The negro must be educated not only for his sake, but for ours. 

Paraphrasing Flexner, his missive to the AMA was: Black doctors won’t be treating you or supervising your doctor. They’re important to white people’s health because they’ll slow the spread of diseases originating in Black communities. Flexner may well have used such language because otherwise, the AAMC and AMA would have terminated all Black medical education. And on the other hand, he made a point of noting that an African American “has his rights and due and value as an individual …” One might ask why Flexner felt compelled to inform the AMA and AAMC of that last fact. 

For 62 years, the AAMC’s highest honor was the Abraham Flexner Award. But in 2020, the AAMC, “as part of its commitment to becoming an anti-racist, diverse, equitable, and inclusive organization,” rechristened it the “AAMC Award for Excellence in Medical Education.” Given the AAMC’s record on race, this is arguably akin to changing a hypothetical “Jefferson Davis Award” to “the Confederate Army Award.” And it’s probably unfair to equate Flexner with Davis. Flexner proposed, but the AAMC disposed. He contributed words and advice, but it was the AAMC that meticulously took his advice and made of it what they wished..

Legitimate Complaint against Flexner

A more legitimate concern with Flexner is that he laid the foundation for the illiberal tendencies of the AAMC and AMA in 2023. 

Pre-Flexner, American medicine was a chaotic stew of allopathy, osteopathy, homeopathy, chiropractic, naturopathy, eclecticism, etc. with many schools lacking even a modicum of scientific rigor. After Flexner, American doctors were all allopaths, trained in standardized medical schools, well-versed in science, and bound by its strictures. What followed was history’s greatest period of medical innovation. (Note: Osteopathic medicine eventually gained acceptance by the AMA and other allopathic institutions, but only many decades after Flexner.)

But devotion to science can have a dark side. In Flexner’s time, medical schools and public health endorsed eugenics and tolerated little dissent. Economic historian Thomas C. Leonard wrote that, “Until the late 1920s, American geneticists supported eugenics or kept their reservations private while welcoming the funding and publicity eugenics generated.” Medical science was complicit in barring immigrants, prohibiting interracial marriage, and sterilizing 70,000 Americans. Later in the century, the same brutal orthodoxy disparaged path breaking discoveries as heresies (e.g., the neurological basis for autism, h. pylori’s role in ulcers, prions as pathogens). Throughout COVID-19, those who questioned public health orthodoxies were branded “anti-science” and worse.

Flexner was clearly enthralled by the Progressive Era’s enthusiasm for social engineering by credentialed elites—an attitude shared by eugenicists and by today’s AAMC and AMA. One of the hallmarks of all three was a fervent belief that doctors should shift away from their traditional focus on individual patients and toward pursuit of social activism—effectively, medicine becoming an adjunct of public health. Consider the following three quotes:

In his 1910 report, Flexner wrote: 

“[T]he physician's function is fast becoming social and preventive, rather than individual and curative.”

Two years later, in 1912, Harvey Jordan, future dean of medicine at the University of Virginia, addressed the First International Eugenics Congress in similar terms: 

“Medicine is fast becoming a science of the prevention of weakness and morbidity; their permanent not temporary cure, their racial eradication rather than their personal palliation.”

In 2021, the AAMC and AMA released a 54-page ideology-laden speech code titled Advancing Health Equity: A Guide to Language, Narrative and Concepts. In it, doctors were implored to:

“shift the narrative … from the traditional biomedical focus on the individual and their behavior to a health equity focus on the well-being of communities.”

In 2021, I explored the present-day politicization of public health and of medicine. Discussion within the AMA and AAMC includes racial prioritization of life-saving drugs, racial reparations, mandatory diversity statements by medical school faculty and med school applicants. As medical researchers were forced into silence about eugenics a century ago, so today’s find it hard to question these new orthodoxies, are intimidated into silence, and must swear fealty to ideological mandates. 

None of this, by the way, negates the very real disparities in health status and in the makeup of the healthcare workforce. I was raised in the 1950s and 1960s in the Jim Crow South, and in my hometown, one can still see and feel the detritus of that legacy. Vaccine hesitancy among African Americans during COVID is partially attributable to memories of the Tuskegee Study. The Supreme Court ended “separate, but equal” a few months after my birth in 1954, but, as noted in the AAMC’s journal, “another 15 years would pass before the AAMC committed itself fully to ensuring African Americans, and all minority students, have equal and meaningful access to medical schools.” The result, the article said, was that “the proportion of African American physicians to African Americans in the U.S. population” was lower in 2010 than it was in 1910. (Overall, the proportion of doctors to U.S. population roughly doubled over that period.)

In 1910, Flexner sought to end unsafe, unscientific medicine by pleading for homogeneous medical school applicants, curriculum, and pedagogy. While his proposals preceded a period of unparalleled innovation, they also paved the way for troubles in our own time. Rigidly standardized medical education, centralized medical licensure, and boundless concessions to dubious expertise enable the stifling of dissent and insistence on ideological conformity. 

The case against Flexner in these areas is far clearer than the charge that he was racist or sexist. 

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Robert F. Graboyes publishes Bastiat’s Window, a Substack journal of economics, science, and culture—with an emphasis on healthcare. He is a health economist, journalist, and musician in Alexandria, Virginia, and holds five degrees, including a PhD in economics from Columbia University. In 2014, he received the Reason Foundation’s Bastiat Prize for Journalism. His music compositions are at YouTube.com/@RFGraboyes/videos.