The Social Transformation of American Medicine

INTRODUCTION

The Social Origins of Professional Sovereignty

THE DREAM of reason did not take power into account.

The dream was that reason, in the form of the arts and sciences, would liberate humanity from scarcity and the caprices of nature, ignorance and superstition, tyranny, and not least of all, the diseases of the body and the spirit. But reason is no abstract force pushing inexorably toward greater freedom at the end of history. Its forms and uses are determined by the narrower purposes of men and women; their interests and ideals shape even what counts as knowledge. Though the works of reason have lifted innumerable burdens of hunger and sorrow, they have also cast up a new world of power. In that world, some people stand above others in knowledge and authority and in control of the vast institutions that have arisen to manage and finance the rationalized forms of human labor.

Modern medicine is one of those extraordinary works of reason: an elaborate system of specialized knowledge, technical procedures, and rules of behavior. By no means are these all purely rational: Our conceptions of disease and responses to it unquestionably show the imprint of our particular culture, especially its individualist and activist therapeutic mentality. Yet, whatever its biases and probably because of them, modern science has succeeded in liberating humanity from much of the burden of disease. Few cultural relativists, suffering from a bad fever or a broken arm, would go so far to prove a point as to trade a modern physician for a traditional healer. They recognize, in behavior if not always in argument, that in medicine the dream of reason has partially come true.

But medicine is also, unmistakably, a world of power where some are more likely to receive the rewards of reason than are others. From a relatively weak, traditional profession of minor economic significance, medicine has become a sprawling system of hospitals, clinics, health plans, insurance companies, and myriad other organizations employing a vast labor force. This transformation has not been propelled solely by the advance of science and the satisfaction of human needs. The history of medicine has been written as an epic of progress, but it is also a tale of social and economic conflict over the emergence of new hierarchies of power and authority, new markets, and new conditions of belief and experience. In America, no one group has held so dominant a position in this new world of rationality and power as has the medical profession. Its rise to sovereignty in the late nineteenth and early twentieth centuries is the first part of the story I have to relate; the emergence in our own time of a bureaucratic and corporate regime is the second.

Power, at the most rudimentary personal level, originates in dependence, and the power of the professions primarily originates in dependence upon their knowledge and competence. In some cases, this dependence may be entirely subjective, but no matter: Psychological dependence is as real in its consequences as any other kind. Indeed, what makes dependence on the professions so distinctive today is that their interpretations often govern our understanding of the world and our own experience. To most of us, this power seems legitimate: When professionals claim to be authoritative about the nature of reality, whether it is the structure of the atom, the ego, or the universe, we generally defer to their judgment.

The medical profession has had an especially persuasive claim to authority. Unlike the law and the clergy, it enjoys close bonds with modern science, and at least for most of the last century, scientific knowledge has held a privileged status in the hierarchy of belief. Even among the sciences, medicine occupies a special position. Its practitioners come into direct and intimate contact with people in their daily lives; they are present at the critical transitional moments of existence. They serve as intermediaries between science and private experience, interpreting personal troubles in the abstract language of scientific knowledge. For many people, they are the only contact with a world that otherwise stands at a forbidding distance. Physicians offer a kind of individualized objectivity, a personal relationship as well as authoritative counsel. The very circumstances of sickness promote acceptance of their judgment. Often in pain, fearful of death, the sick have a special thirst for reassurance and vulnerability to belief. The therapeutic definition of the profession's role also encourages its acceptance: Its power is avowedly enlisted solely in the interests of health—a value of usually unambiguous importance to its clients and society. On this basis, physicians exercise authority over patients, their fellow workers in health care, and even the public at large in matters within, and sometimes outside, their jurisdiction.

In clinical relations, this authority is often essential for the therapeutic process. The sick are ordinarily not the best judge of their own needs, nor are those who are emotionally close to them. Quite aside from specialized knowledge, professionals possess an advantage in judgment. Furthermore, effective therapeutic measures frequently require not only difficult and even repellent tasks, such as violating the integrity of the body, but also rechanneling the unconscious urges of some patients to be sick and to be cared for. Their families often cannot handle, indeed may be responsible for such urges—hence the need for some outside party to mediate recovery. Professionals are ideally suited for this role because they can refuse to indulge such tendencies in patients without threatening their relationships with them. And so professional authority facilitates cooperation in recovery besides compensating for the often impaired and inadequate judgment of the sick.

The dominance of the medical profession, however, goes considerably beyond this rational foundation. Its authority spills over its clinical boundaries into arenas of moral and political action for which medical judgment is only partially relevant and often incompletely equipped. Moreover, the profession has been able to turn its authority into social privilege, economic power, and political influence. In the distribution of rewards from medicine, the medical profession, as the highest-paid occupation in our society, receives a radically disproportionate share. Until recently, it has exercised dominant control over the markets and organizations in medicine that affect its interests. And over the politics, policies, and programs that govern the system, the profession's interests have also tended to prevail. At all these levels, from individual relations to the state, the pattern has been one of professional sovereignty.

How the medical profession rose to this position of cultural authority, economic power, and political influence; how, together with other powerful social forces, it shaped the institutional structure of medical care; and how that system has now evolved, so as to put the profession's autonomy and dominance in jeopardy—these are the questions that this book addresses.

Some may think the sources of professional sovereignty too obvious to be worth pursuing. For haven't healers always been esteemed and powerful? And doesn't the growth of science make inevitable the high value and position attached to medicine? And isn't there something about American culture, particularly our preoccupation with health and well-being, that makes us especially inclined to give doctors a high status?

The answer to each of these questions is no.

It is simply not true, as some might have it, that physicians have always occupied positions of honor and comfort ever since the first medicine man had the good fortune to recite an incantation immediately before his patient's spontaneous recovery. There are numerous historical counter-examples. Under the Romans, physicians were primarily slaves, freedmen, and foreigners, and medicine was considered a very low-grade occupation. In eighteenth-century England, while ranking above the lowlier surgeons and apothecaries, physicians stood only at the margins of the gentry class, struggling for the patronage of the rich in the hope of acquiring enough wealth to buy an estate and a title. In nineteenth- and early twentieth-century France, doctors were mostly impecunious, and the successful among them, conscious that medicine was an inadequate claim to status, pursued an ideal of general cultivation rather than mere professional accomplishment.¹

In the world today, not all societies with scientifically advanced medical institutions have powerful medical professions. To take a conspicuous case, in the Soviet Union the average earnings of physicians are reported to be less than three-quarters of the average industrial wage. Not coincidently, 70 percent of the doctors are women.² Even in a Western society quite similar to ours, Great Britain, most general practitioners are only moderately well paid, and they work within a national health service whose budget and overall policies they do not control. In Britain and other European countries, there is a powerful upper stratum of consultants within the medical profession, but such sharp internal differences also tend to distinguish their medical professions from ours. Hardly anywhere have doctors been as successful as American physicians in resisting national insurance and maintaining a predominantly private and voluntary financing system. The growth of science, while critically important in the development of professionalism, does not assure physicians broad cultural authority, economic power, or political influence, as they have achieved in the United States.

The explanation for professional sovereignty in medicine also cannot be found in any ingrained peculiarities of American culture. Doctors in America were not always the powerful and authoritative profession that they are today. A century ago they had much less influence, income, and prestige. "In all of our American colleges," a professional journal commented bitterly in 1869, "medicine has ever been and is now, the most despised of all the professions which liberally-educated men are expected to enter."³ Although a few eminent doctors made handsome fortunes, many before 1900 could hardly scrape together a respectable living.

To be sure, many observers, beginning with de Tocqueville, have remarked that Americans are singularly concerned with their individual well-being. Since the 1830s, when de Tocqueville visited America, the United States has been swept by a series of popular movements concerned with improving health variously through diet, exercise, moral purity, positive thinking, and religious faith. Today, were a revived de Tocqueville to observe Americans jogging in parks, shopping in health food stores, talking psychobabble, and reading endless guides to keeping fit, eating right, and staying healthy, he would probably conclude that, if anything, the obsession is now more pronounced.

But a concern with health has not always produced faith in doctors. On the contrary, many of those most disposed to take health "into their own hands" are skeptical of physicians. The advocates of popular health fashions, even when they are doctors, frequently see themselves at war with the medical profession. Intensified religious feeling does not always benefit established churches; similarly, a therapeutic awakening may lead to a proliferation of health sects rather than deference to professional authority.

These plausible, yet mistaken explanations for the high status and power of physicians have the same general problems. They cannot explain comparative and historical variations in the position of the profession, and they assume that popular attitudes—whether toward healing, science, or health—translate directly into status and power. The analysis here begins with several contrary premises.

First, the problem of professional sovereignty in American medicine is historical; there is no necessary and invariant relation to social structure of a function such as caring for the sick. Social structure is the outcome of historical processes. To understand a given structural arrangement, like professional sovereignty, one has to identify the ways in which people acted, pursuing their interests and ideals under definite conditions, to bring that structure into existence. In the nineteenth century, the medical profession was generally weak, divided, insecure in its status and its income, unable to control entry into practice or to raise the standards of medical education. In the twentieth century, not only did physicians become a powerful, prestigious, and wealthy profession, but they succeeded in shaping the basic organization and financial structure of American medicine. More recently, that system has begun to slip from their control, as power has moved away from the organized profession toward complexes of medical schools and hospitals, financing and regulatory agencies, health insurance companies, prepaid health plans, and health care chains, conglomerates, holding companies, and other corporations. Understanding these changes requires an analysis that is simultaneously structural and historical: structural in its identification of the underlying patterns of social and economic relations that explain observed events; historical in its tracing of those patterns to the human actions that brought them about. I do not want to deny the value of narrative history without structural analysis, nor even of structural analysis without history (though the former is certainly more entertaining). But the two, it seems to me, go further in each other's company than either can go alone.

My second premise is that the organization of medical care cannot be understood with reference solely to medicine, the relations between doctors and patients, or even all the various forces internal to the health care sector. The development of medical care, like other institutions, takes place within larger fields of power and social structure. These external forces are particularly visible in conflicts over the politics and economics of health and medical care. In the twentieth century, the costs of illness and medicine have become critical concerns of governments and political parties because of their implications for social welfare, overall economic efficiency, and political conflict. In the United States, private foundations play a critical role in financing medical education and research. Employers, unions, and insurance companies are centrally involved as intermediaries in the financing of services. Some of these external agents are mainly interested in profit in the narrow sense. But often, by providing medical care or paying costs associated with it, governments, political parties, foundations, employers, unions, and voluntary agencies hope to derive a different sort of benefit: good will, gratitude, loyalty, solidarity, dependence. The prospect of advantages of this kind makes medical care an especially strategic arena of political and economic conflict.

My third premise is that the problem of professional sovereignty calls for an approach that encompasses both culture and institutions. Consequently, this study goes back and forth between consciousness and organization in attempting to understand both the growth of the cultural authority of the medical profession and the conversion of that authority into the control of markets, organizations, and governmental policy. This is not to put either cultural analysis or political economy ahead of the other. For it is not possible, as I see it, to understand the origins of the power of the medical profession, in the face of all the other political and economic forces at work in health care, without reference to its cultural authority. Nor is it possible to understand the rise of its cultural authority without reference to underlying changes in material life and social organization.^*

THE ROOTS OF AUTHORITY

Dependence and Legitimacy

If, as I argue, the rise of the medical profession depended on the growth of its authority, we need to understand more precisely what authority is.

Authority, in its classical sense, signifies the possession of some status, quality, or claim that compels trust or obedience.⁴ As part of this ability to compel trust or obedience, authority signifies a potential to use force or persuasion, though paradoxically authority ends when either of these is openly employed. The use of force, as Hannah Arendt observes, signifies the failure of authority; so does resort to persuasion, which, she points out, "presupposes equality and works through a process of argumentation. Where arguments are used, authority is left in abeyance."⁵ Authority calls for voluntary obedience, but holds in reserve powers to enforce it. Behind political authority ultimately stands the threat of violence or imprisonment; behind managerial authority, the threat of dismissal from work. These reserve powers make subordinates dependent upon such authorities for their life, liberty, and livelihood; they create a strong basis for compliance, apart from any belief that subordinates may hold about the authorities' claim to obedience.

Authority, therefore, incorporates two sources of effective control: legitimacy and dependence. The former rests on the subordinates' acceptance of the claim that they should obey; the latter on their estimate of the foul consequences that will befall them if they do not.

Authority relations are not fixed and untroubled. Often they go through periods of distress, as when children fight with their parents, students disagree with their teachers, or workers protest against their employers' policies. In such periods, the legitimacy of authority may be in doubt, but the ongoing dependence of subordinates maintains authority. Conversely, when the governing authorities may, for one reason or another, be weak and incapable of carrying out their reserve threats, their legitimacy may assure continuity of control. Thus the twin supports of dependence and legitimacy introduce a stability into authority relations: When one is weak, the other may take over, and so authority, as a mode of control, is stronger and more reliable than either force or persuasion.⁶

Authority may also gain compliance from different people for different reasons. In a firm, for example, the authority of the owners and directors is likely to be followed at the highest levels because the managers accept the rights of ownership and share a commitment to the enterprise; often the workers do, too. However, in some countries with large Communist and Socialist parties, the workers may accord little legitimacy to the firm, but feel much dependence upon it for jobs. The probability of compliance with managerial authority may still be great. Similarly, the upper strata in a society may support the ruling political authority because they believe it to represent the highest values, whereas the basis of compliance among subordinate castes or classes, ethnic or religious groups may be adherence to legality or sheer dependence. From childhood they may have learned that resistance to authority brings swift reprisal. Once again, the twin supports of legitimacy and dependence add to the overall effectiveness of authority as a mode of control.

The acceptance of authority signifies "a surrender of private judgment." However, even in surrendering private judgment, one may still believe that the words of authority can be persuasively elaborated.⁷ For authority usually has a reserve of reasons as well as powers. The advantage of authority, however, is that it makes it unnecessary to elaborate the reasons for the believing subject, just as it dispenses with the use of force on the recalcitrant. This is its essentially economic value. From the viewpoint of a client independently seeking out professional advice, authority may be "a shortcut to where reason is presumed to lead,"⁸ while for the professional using authority to control an involuntary inmate, authority may be a shortcut to where coercion would be presumed to lead.