Catherine Tang
Philadelphia, Pennsylvania, United States

The rise of the American federal pension system in the wake of the Civil War made doctors suddenly responsible for denying or approving veterans’ pension applications. This new legal duty sometimes strained the doctor-patient relationship. Dr. John W. Wright, an ophthalmologist in Columbus, OH, recognized that some veterans would have an incentive to not disclose certain parts of their medical history.

By the late 1880s, the number of pension seekers had risen to about 16.85% of all Union veterans, totaling nearly 245,000 pensioners.¹ Applicants claiming defects in vision represented a significant portion of the applications, with 4,672 pensions granted for eye-related disabilities between July 1886 and December 1887. The combined impact of the number of pension seekers and the General Law of 1862, which allowed multiple dependents to also receive pensions,² led to suspicions of imposters that conflicted with concerns over unjustly denied applications. This provided the basis for Wright’s calls for increased recognition of the role of ophthalmologists in deciding which applications were appropriate and which bordered on fraudulent.³ Wright appears to agree with the directive from the Commissioner of the Bureau of Pensions, who emphasized that errors were “disastrous to the pensioner. Hundreds of pensioners at the biennial examinations were subject to an unjust and unintentional reduction by the inadvertence of examining surgeons,”⁴ while also recognizing the need to “guard against imposters.”⁵

Wright himself recounted the example of Mr. B, a veteran who was nearly blind and incapable of performing manual labor, yet who refused his suggestion of an operation because he feared “it would prove so successful that he would be compelled to relinquish his pension.”⁶ Some pension applications also asked doctors to evaluate the “character of the pensioner’s disability” to ensure it was not “caused or protracted by vicious habits,”⁷ and Wright mentions a veteran whose application was repeatedly denied because his acquaintances believed he was “a malingerer.”⁸ Given the need to make such subjective assessments that may potentially harm the viability of an application, the gap between doctors and their patients widened, with suspicions fraught on both sides.

Further straining the doctor-patient relationship was the fact that medical professionals were also presented with economic incentives to conduct and process a large number of pension applications.⁹ Biennial examinations of pensioners involved a fee of “one dollar and fifty cents, [which] would be paid to the surgeon by the person examined.”¹⁰ However, given that the “fee for the examination will not be allowed until an acceptable certificate is furnished,”¹¹ there was the potential for some untruth on the part of the doctor to ensure the successful completion of certificates. For instance, in the case of of Mr. B, Dr. Wright details how, after going to a different surgeon, the “cicatrix where the incision had been made in the upper part the cornea…excited the interest of the surgeon,” who told Mr. B that his eye was “badly butchered,” leading to a “comfortable pension” even though Mr. B neglected to mention that the scarring was due to a previous operation rather than from being in the line of duty.¹² The second surgeon did not directly question Mr. B, showcasing how, in spite of the need for increased scrutiny, certain examining doctors may have felt inclined to fabricate by omission by not prying too deeply into their patients’ medical histories despite the requested details in the application form. This illustrates how the actions of doctors may have been influenced by not only a desire to promote the interests of applicants, but also by self-serving motivations.¹³

Yet despite some potential dishonesty from a subset of the population, the integration of the medical community into the pension system led to a new professional model that emphasized specialized knowledge and accreditation. The Commissioner of the Bureau of Pensions’ directive emphasized the need for examinations to be standardized and “full in medical or surgical detail…[with] a description of disease or injury, organs and structures involved, pathological lesions, [and] structural changes.”¹⁴ Wright echoed these sentiments in some of his own examinations, such as noting “there was no complication or structural disorganization of the parts, the inflammation being simply mechanical.”¹⁵ Given the stakes of a pension application, especially with the loss of sight in both eyes receiving the most severe rating, these additional expectations required surgeons to have scientifically-rooted medical expertise. This further translated to the Bureau demanding “the very best skill this country can supply”¹⁶ and employing only a small portion of the medically pluralistic community at the time. Additionally, “boards of examining surgeons and special agencies [were] established throughout the country”¹⁷ that ranged from two to five people to review applications, which may have played a role in the establishment of formal medical boards as well as the American Medical Association’s emphasis on regulated medical degrees and its local-state-national model¹⁸ later in the century.

Ultimately, the rise of the U.S. federal pension system between 1860 and 1907 had profound implications for the medical profession, as doctors were thrust into the dual roles of advocates for their patients and gatekeepers for the pension system. While the Bureau and some physicians like Dr. Wright sought to guard against fraudulent claims, the evolving system, for the most part, laid the groundwork for a more professionalized practice, more rigorous expectations of medical expertise, and a better intertwining of medicine and bureaucracy.

Bibliography

1. Theda Skocpol, “Public Aid for the Worthy Many: The Expansion of Benefits for Veterans of the Civil War,” in Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States. The Belknap Press of Harvard University of Press, 1992, 109.
2. U.S. Congress. An Act to Grant Pensions. 37th Cong., 2nd sess., 1862.
3. John W. Wright, “A Plea for the Better Recognition of the Oculist in the Service of the US Pension Department,” JAMA 11, no. 17 (1888). https://jamanetwork.com/journals/jama/issue/XI/17, 591.
4. J.H. Baker, “Instructions to Examining Surgeons for Pensions,” Department of the Interior, Pension-Office, 1872, 11.
5. Wright, “A Plea for,” 588.
6. Wright, “A Plea for,” 589.
7. Baker, “Instructions to Examining,” 4.
8. Wright, “A Plea for,” 590.
9. Skocpol, “Public Aid for,” 116.
10. An Act to Grant Pensions, 568. 
11. Baker, “Instructions to Examining,” 9.
12. Wright, “A Plea for,” 591.
13. Baker, “Instructions to Examining,” 13.
14. Wright, “A Plea for,” 589.
15. Baker, “Instructions to Examining,” 6.
16. Ibid.
17. Ibid.
18. Johnson, Andi. “Organizing the AMA” (lecture, American Health Policy, Philadelphia, PA, September 12, 2024).