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How doctors became powerful – Arguments from Paul Starr’s ‘The Social Transformation of American Medicine’ – Part 1

[Part 2 is here]

Sociologist Paul Starr’s book ‘The Social Transformation of American Medicine’ is among the most important expositions of the evolution of medical practice and the biomedical profession in the USA. It was published in 1982 and won the 1984 Pulitzer Prize in General Nonfiction. It is quite a thick book and contains several crucial arguments about the history and sociology of the medical profession (and of medicine in general) in the US. The arguments are of relevance for other societies too. Here I try to organize those in what I hope to be an easily readable and understandable format.

In this post (Part 1) I will summarize the general sociological arguments using which Starr (and other sociologists) explains the power of the medical profession. In Part 2, I summarize the historical events and processes that Starr argues culminated in the profession becoming socially and economically powerful.

The first crucial concept that Paul Starr brings in is the ‘authority’ of doctors. Only when this authority grew did the medical profession begin to gain social and economic power. He explains the theory behind this: “Authority 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. While authority may be generally said to have reserves of both persuasion and force, the reserve strength of professional authority—when separate from bureaucratic office—consists primarily of persuasion.

“Most conceptions of authority emphasize the regulation of action. In the classic definition of Max Weber, for example, Herrschaft (variously translated as authority or domination) is the probability that people will obey a command recognized as legitimate according to the prevailing rules in their society. But authority involves more than the giving of commands. A scientific treatise, a sacred text, and even a book of grammar embody authority. Institutions like the church make authoritative judgments about the nature of the world. In modern societies, such judgments become increasingly specialized, as different professional communities become sovereign over different aspects of reality. Authority, then, also refers to the probability that particular definitions of reality and judgments of meaning and value will prevail as valid and true. I will call this form of authority cultural authority to distinguish it from the social authority that Weber had in mind.

“Cultural authority entails the construction of reality through definitions of fact and value. Authority, in this particular form, may be used without being exercised; typically, it is consulted, often in the hope of resolving ambiguities. The authority that physicians exercise over nurses, technicians, and other subordinates in the medical hierarchy is primarily social authority; physicians aim to regulate their actions. Insofar as doctors give patients instructions or advice, they are also exercising social authority. But prior to making any recommendations, physicians have to define and evaluate their patients’ condition. Patients consult physicians not just for advice, but first of all to find out whether they are ‘really’ sick and what their symptoms mean. Cultural authority, in this context, is antecedent to action. The authority to interpret signs and symptoms, to diagnose health or illness, to name diseases, and to offer prognoses is the foundation of any social authority the physician can assume. By shaping the patients’ understanding of their own experience, physicians create the conditions under which their advice seems appropriate.

“Of course, not all patients who accept doctors’ judgments as authoritative also take their advice. A doctor may tell a patient that if [s]he does not stop smoking and lose weight, [s]he will not have long to live. The patient may very well take this as an authoritative judgment of the facts but decline to follow the advice. Here the physician’s cultural authority exceeds [her] social authority; this is quite commonly the case. Physicians generally do not have the coercive powers of the state to enforce either their definitions of reality or their instructions. Judges rule; physicians usually advise. But the authority of the doctor is very much like the definition that the German historian Mommsen once gave of authority in general: ‘more than advice and less than a command, an advice which one may not safely ignore.’ One may not safely ignore medical advice, not usually because of any threat of force by the physician, but because of the consequences that the doctor predicts will ensue if the advice is rejected.

“There is, however, an entire class of functions carried out by physicians in which patients are more or less forced to accept the doctors’ cultural authority. For purposes of certification, patients often have no choice but to submit to professional examination. In their capacity as cultural authorities, doctors make authoritative judgments of what constitutes illness or insanity, evaluate the fitness of persons for jobs, assess the disability of the injured, pronounce death, and even assess, after people have died, whether they were competent at the time they wrote their wills. These professional judgments carry implications for courts, employers, and other social authorities. In such situations, the physician is supposed to give the facts alone; others will decide what to do about them.

“The kind of authority claimed by the professions, then, involves not only skill in performing a service, but also the capacity to judge the experience and needs of clients. The legitimation of professional authority involves three distinctive claims: first, that the knowledge and competence of the professional have been validated by a community of his or her peers; second, that this consensually validated knowledge and competence rest on rational, scientific grounds; and third, that the professional’s judgment and advice are oriented toward a set of substantive values, such as health. These aspects of legitimacy correspond to the kinds of attributes—collegial, cognitive, and moral—usually cited in definitions of the term ‘profession.’ A profession, sociologists have suggested, is an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than profit orientation, enshrined in its code of ethics.”

Historians have shown that the medical profession in the US, and elsewhere, had not always commanded the cultural and social authority it began to wield since the early 1900s. It is conventionally argued that this new power of the profession emanated from the rise of scientific knowledge and technological innovations during this period (bacteriology, antiseptic surgery, X-rays, etc.) Starr explains that science is only part of the explanation for the power of the medical profession: “The advance of science and technology did not necessarily guarantee that physicians would remain in control. Quite the opposite result might have occurred: The growth of science might have reduced professional autonomy by making doctors dependent upon [corporate] organizations. Modern medical practice requires access to hospitals and medical technology, and hence medicine, unlike many other professions, requires huge capital investments. Because medical technology demands such large investments, it makes the medical profession vulnerable to control by whoever supplies the capital.”

Indeed these changes did occur eventually, and doctors began to lose power since the middle of the 20th century – although only in small parts. But in the early 1900s the medical profession in America famously thrived at a time when many other occupations were surrendering to the onslaught of corporate control. In Part 2 we will look at how this came to happen.

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