During most of human history, medicine has seemed a very minor factor in social life. For millennia, great minds analyzed and speculated on the interrelations of society and government, law, religion, and other institutions; no comparable thought was devoted to the inter-relations of society and medicine.

This was still true when sociology came into being as a modern discipline. In their voluminous and now-classic works examining many of society's basic structures and processes, the founders of sociology scarcely so much as mentioned medicine. This omission becomes all the more striking when we recall that they gave major attention to other professions, and to the role of experts generally—and still more so when we recall how central to their work was the recognition of science and technology as driving forces in the modern world.

Within the last fifty years the situation has changed drastically. In all Western societies, medicine itself has emerged as a force to be reckoned with, encompassing a powerful profession and a great network of facilities and organizations, and it constitutes as well a social “problem.” Moreover, where only yesterday medicine was ignored by social scientists, today it is the primary concern of a large and very active branch of the sociological profession.

But “medical sociology” reflects its relative youth, and particularly its lack of an intellectual pre-history. A recent, highly acclaimed book illustrates these problems. This book, The Social Transformation of American Medicine, by Paul Starr, a young sociologist at Harvard, has had a striking success.¹ It has been hailed in the general press, by sociologists, and by medical professionals as “monumental,” “comprehensive,” “brilliant,” “lucid.” Arnold Relman, the editor of the New England Journal of Medicine, in an enthusiastic review, urged all physicians to read the book. (Dr. Relman later tempered his enthusiasm, but his admiration for Starr's “command of social forces” remains.) The book won a C. Wright Mills Award, a Bancroft Prize, and, as a crowning success, a Pulitzer Prize.

Nevertheless, Starr himself has had some rough going, having been denied tenure at Harvard. In view of the success of his book, the denial was surprising—surprising enough to be reported at length in the New York Times. In the comments that appeared in the press, however, there was again rather little criticism of the book. Instead what emerged was a divergence between “theorists” and “quantifiers” in social science. Those opposed to tenure for Starr wanted the Harvard department to develop along quantitative, empirical lines; Starr's work, they felt, was qualitative, i.e., theoretical, interpretative.

I want to look at Starr's book in some detail, for several reasons. First, although it deals with an important subject, and is widely viewed as authoritative, in fact it casts no light on any problem confronting American medicine. Instead, it obscures and confuses these problems, and presents a false picture both of medicine and of American society. Second, the book is highly revealing of current standards of sociological analysis and “theory.” Finally, I want at least to raise the question of why such a bad book should have become so successful, and why people whose business it should be to uphold scholarly standards have praised it in terms that are not only exaggerated but completely false.

_____________

I

The Social Transformation of American Medicine is an ambitious, two-part survey of the development of American medicine from colonial times to the present. Its focus throughout is on the organizational and economic aspects of medical care: that is, medicine's “structure.”

In Part I, Starr describes the early days of American medicine: the motley practitioners; their low social, educational, and economic standing; their lack of esteem or authority. He then traces the long climb upward that began, essentially, after the middle of the 19th century. Spurred by a number of factors, such as advances in biochemical sciences and improvements in travel and communications, the profession became more cohesive, and more assertive. At the same time, society's willingness to defer to medicine grew, again for a number of reasons, including (Starr maintains) a new social or political consciousness.

With its new militance, the profession embarked on a series of battles which, over the next decades, were to bring the entire field of health care under its exclusive domain. Thus, after gaining control of licensing, the profession drove rival health practitioners out of the field. Using a variety of tactics—boycotts, lawsuits, political pressures—it kept both government and industry out of direct involvement in the provision of medical care, and crushed almost all attempts to set up prepaid, group-care practices. And when the hospital became important (around the turn of the century), physicians mobilized again, this time to take control away from lay trustees and to ensure their own individual autonomy within the hospital setting: they became affiliates, not employees.

By the 1920's, physicians were a “sovereign” profession: uniquely solidary, with unquestioned authority, in full command of their territory, and with status and (in time) income to match. This rise, from lowliness to sovereignty, is what Starr calls the social transformation of American medicine, which he portrays as a long chain of defeats for the possibility of a liberal system of health care in the United States.

In Part II, Starr discusses the attempts to introduce national health insurance; the development of the private, or commercial, insurance system; and, after World War II, the increasing involvement of government in the nation's health care. In the last chapters, he views the present scene, painting a generally cheerless picture. One senses that he would prefer a system of national health insurance, or a national health service, but he never says so; nor does he examine the healthcare system of any other society. He implies that present trends, such as the “pro-competition” plans for Medicare and Medicaid, and the rising proportion of hospitals run by “for-profit” corporations, are all further steps in the wrong (illiberal) direction. He hints that capitalist hospital owners may soon deprive medicine of its autonomy, and force it to become even more profit-oriented (“acquisitive”) than it already is. But all of this appears obliquely, ambiguously, and at the very end Starr hedges even his ambiguities. “A trend,” he advises, “is not necessarily fate. . . . Perhaps this picture . . . will prove to be a caricature. . . .”

_____________

II

Put simply, Starr's “argument” in The Social Transformation of American Medicine is that physicians in the United States first achieved authority on questions of health care and then used this authority to structure medicine to their own social and economic advantage. These ideas are neither new nor especially illuminating. That American medicine has enjoyed (and to a lesser degree still enjoys) vast authority is undeniable; so is the fact that it has used it in its own interests. The question that needs to be answered concerns the source of that authority. What made Americans willing to exalt medicine, to defer to it, to cede great powers to it?

The usual explanation attributes medicine's high authority to the link it formed with modern science after the middle of the 19th century. This link brought some immediate gains in knowledge and effectiveness. More importantly, it brought the promise that, henceforward, medical knowledge would be verifiable knowledge, and that the healing power based on this knowledge would grow steadily through the steady advance of science. In later years, as the link with science was strengthened—and as dramatic breakthroughs did occur—medicine seemed to acquire the authority of science itself.

Starr rejects this view, and instead advances his own explanation, which comes in two parts. On medicine's part, he summarizes the actions taken by the profession in response to changing demographic conditions, advances in communications, and so forth, actions which both made the profession more cohesive and self-aware and extended its reach and control. But behind all of these actions he sees one force, and one force only: the profession's pursuit of wealth and power. In Starr's view, this pursuit is the sole motivation in medicine, it is the sole directive force in the institution-shaping behavior of physicians.

On society's part, Starr offers a much greater array of variables, but the central idea is “dependency.” In the early years of the nation, Starr tells us, Americans were hardy, self-reliant types. They believed in themselves and in democracy, and they believed that medical problems were simple and could be solved by common sense. And so they had little need of, or respect for, medicine. But after the middle of the 19th century, Americans lost their self-assurance; they became increasingly dependent on outsiders. With this increased dependence came a new respect for, and a deference to, medicine.

What turned Americans into a dependent people? A host of factors, according to Starr: the decline of democracy (democracy ended, in the United States, around 1850); a loss of faith in the common man, and in common sense; a loss of pre-industrial skills that had made for self-sufficiency; increasing urbanization and industrialization; rising societal tensions and instabilities; the conflicts created by capitalism; the isolation of the nuclear family; the Progressives' search for a new order; and science, which convinced men that the world was complex—not simple, as they had previously thought.

This, then, is Starr's argument. With regard to the behavior of the medical profession it contains a partial truth, although as an explanation of medicine's dynamics, or as a theory of its structural evolution, it is simply false. With regard to society the argument is nonsense.

_____________

III

Starr's argument with regard to medicine is false because, no matter how important external forces may be, and no matter how powerful the drives to wealth and power, it is impossible to reduce the evolution of any institution or profession to these alone. There is always an inner content to be considered. And medicine, at least as much as any other profession, has such an inner content. It has its own purpose and functions, values and traditions, conflicts and dilemmas; it has a great and constantly developing body of knowledge, empirical and scientific. This content is dynamic; by itself it impels the field and shapes it, even its outer or “structural” aspects. At the risk of sounding naive—I have a more critical view of medicine than does Starr—I would stress that even medicine's ideals are components of the field. They too are real forces, with real effects.

I do not mean to suggest that medicine is shaped only from within, or only by positive forces. I do, however, insist that medicine has its own powerful inner content, and that its evolution cannot be explained apart from this content. I have written elsewhere about the general failure of medical sociology to incorporate a systematic study of medicine's content, and above all of its formal knowledge and the means by which that knowledge is translated into practice.² Because of the “externality” of medical sociology to medicine, the field is scientifically and intellectually weak. Starr's book is almost a parody of this externality, a supposedly “comprehensive” and “monumental” study in which the evolution of medicine is explained entirely by reference to outside, non-medical forces—and the drives of physicians to wealth and power.

In negating medicine's own content, Starr necessarily negates other forces, too—forces that exist outside of medicine but enter into it to become part of what impels and guides the field from within. Two are absolutely crucial: science and technology. Medicine, which is not itself a science, has a complex, problematic relationship with science; it has an equally distinctive relationship with technology. It is impossible to understand medicine's evolution and its place in society if these forces and relationships are not understood.

Starr does not understand them. He does briefly bring in science (and/or technology; they are essentially one to him), but to him “science” is a blank force that produces “diagnostic and therapeutic successes,” or creates tools that enhance physicians' power over the patient while increasing their dependence on organizations, or adds to their “rhetoric,” or is a “bolster” in their pursuit of wealth and power.

This is not even a child's understanding of science. Science is never a blank, it does not produce its successes or failures in a moral and intellectual vacuum. Science, moreover, is a profoundly unsettling force, undermining as well as building up; in medicine, it causes endless dislocations and conflicts. Most basically, science is a source of independent values, motives, norms of conduct, and criteria of judgment. It sets its own course, defines its own goals. As for technology, its impact on medicine is even more obvious and direct; again, not just in producing tools or power but in transmitting values and in shaping the field from within. One need only think of the artificial-heart cases now in the news to realize that the physicians involved are not simply pursuing money and political power but are impelled by a technological drive that has its own logic and values, its own momentum—and its own dangers.

There is another independently motivating force that Starr never mentions at all. However separate or “sovereign” medicine may be, it cannot be insulated from the moral, cultural, political, and intellectual currents that flow through society as a whole. Starr never credits the possibility that physicians might be influenced by the concerns of the wider society with, for example, democracy, justice, the humaneness of American institutions. But this is the case. With whatever delays or attenuations, society acts not only on medicine but also within it. One would not know this from Starr's argument.

_____________

IV

To Illustrate the points I have been making, let us look at a single juncture in medicine's history, the battle for autonomy in the hospital. Starr's explanation is simplicity itself: physicians wanted autonomy in order to increase their profits; hospital trustees yielded because they needed the money the physicians brought in.

In fact, much more was involved, on both sides. First, a major role was played by the arguments of the physicians concerning the need for specialized knowledge, for “clinical judgment,” and for a continuing, exclusive physician-patient relationship. These arguments were persuasive because they reflected something beyond self-interest, namely, professional values and commitments that were, and are, appreciated by patients themselves. It takes considerable cynicism to see in them nothing but rationalization of economic motives.

There were other impelling forces within medicine as well, having to do with a number of features peculiar to the field and still plainly visible today. The unavoidable uncertainties of medical practice, the ever-present dangers, and the tension between claims of scientific knowledge on the one hand and the vast areas of ignorance on the other, generate enormous inner pressures and lead to a variety of self-protective mechanisms, such as evasiveness, secrecy, and the unwillingness to judge colleagues. The drive for medical autonomy within hospitals cannot be understood apart from these motives, which are not themselves economic in origin (though they may have economic consequences). Starr is unaware of their existence.

Moreover, the striving for autonomy, the desire for a distinct sphere of competence and responsibility and for freedom and control over one's work, a motive force in its own right, is manifested unversally in all professions; indeed it finds expression in nearly all work roles, including the lowliest and those in which motives of increasing wealth or societal power hardly apply. Remarkably, in a book that purports to be a “monumental” study of a profession, there is no mention of this aspect of professional life.

In the end, physicians won their battle because of still another force missing from Starr's argument. They won because hospital trustees, like society at large, accepted the principle that a profession is entitled to be self-governing. This principle has deep cultural roots, and is related to the values and traditions on which political democracy iteself rests. It is part of what made medicine's autonomy possible in the past, and part of what will maintain it—with modifications—in the future. It is precisely because he is unaware of this force that Starr is unable to offer the least clue regarding medicine's future, beyond dark hints that “capitalists” may soon turn physicians into mere tools of corporate profit-making. There is not the least chance of this, but with a “theory” that recognizes only competing economic and power drives, Starr could not know it.

With some knowledge of the history of professions generally, it might have occurred to Starr that the battle by physicians for autonomy in the hospital bears a striking similarity to the battles by professors for academic freedom, the principle that assures them a level of autonomy in colleges and universities which in some respects exceeds that of physicians in the hospital. Would Starr say that professors' autonomy was brought about by their greed or power drives? After all, academic freedom too can be abused, used for private gain rather than collective knowledge, and for propaganda or indoctrination. But the uses to which autonomy may be put, or the abuses to which it is subject, must be distinguished from the motives that lead to it and maintain it. And if Starr would grant that motivations other than the pursuit of wealth and power have been involved in the case of academics striving for autonomy, should he not tell us how it happens that no motivations but these have ever existed at all in the case of medicine?

_____________

V

Starr, as we saw, explains the increasing respect accorded to medicine after the middle of the 19th century by reference to a set of variables producing “dependency”: the decline of democracy, the loss of pre-industrial self-sufficiency, and so on. Not only is this not true, it is almost exactly the opposite of the truth. American medicine owes its status and power not to negative factors destroying confidence and independence, but to the reverse. It was the very openness and promise of American life that led Americans to venerate medicine and delegate to it high—excessively high—authority.

Particularly important were a number of cultural traits that prevailed here as nowhere else. These included: a receptivity to science and technology, coupled with scientific backwardness; eagerness for progress; an acceptance of health and personal well-being (“the pursuit of happiness”) as ultimate goals in life; and an optimistic, activist bias characterized by the belief that all problems, individual or collective, can be solved through the application of knowledge, technology, and enterprise. These, and not the waning of democracy, or the loss of a pre-industrial self-sufficiency, or the growth of the “isolated nuclear family,” are what provided the moral basis for American medicine's ascendancy.

Most of this Starr never mentions, for just as he sees a medical profession impelled only by greed and power, so he see an American society devoid of positive features, at least after 1850. As he denies the relevance of Americans' admiration for science, in like fashion he denies the significance of the value Americans place on health and well-being, a value striking enough to have been noted by observers from Tocqueville on but one which Starr reduces to fads and psychobabble, and dismisses.

Starr's own explanation for the rise in the authority of medicine is specious in the extreme. The fact that this rise began after the closing of the frontier, or at a time when American society was becoming more urban and industrial, does not mean that these factors caused the rise, or were even necessary conditions of it. And as for those alleged variables with a political coloration—the decline of democracy, the loss of faith in the common man, the conflicts of capitalism, the increasing grimness of American life, etc.—these are all very dubious “facts” which owe their existence less to history than to a particular, and unavowed, political perspective. According to that perspective, after the Civil War a tiny, interlocked segment of the population gained control of American government and all other institutions and has since run them for the sake of its own enrichment and power, while the great bulk of the population has become increasingly alienated and powerless. This is the “radical elitist” theory of American history, and it obviously has much in common with Marxist theory. Starr sees no need to examine its assumptions, which to him are self-evident.

But consider the claim that if early Americans did not respect or defer to medicine, and post-Civil War Americans did, there must in the interim have occurred a loss of self-assurance, or a weakening of democracy. In fact, there is no need at all to bring in political or ideological factors to explain this change in attitudes or behavior; these were simply responses to a change in medicine itself, which after the middle of the 19th century became increasingly identified with science. Certainly people did, and do, overestimate the extent to which medicine's knowledge is scientific. But this has nothing to do with the supposed decline of democracy, the isolation of the nuclear family, or any of the rest.

Or consider the concept of “dependency,” which goes, approximately, like this: as we turn to others for medical knowledge and advice, we lose faith in ourselves, in our own judgment and abilities, and thereby become less free. But this is nonsense. I depend on electricity; my great-grandmother did not. Thus I also depend on scientists, engineers, technicians, repairmen, and on industry and a distributive network; she did not. (What is more, having only a hazy idea of how to make a candle, I have “lost” a pre-industrial skill.) Does this mean that I have less confidence in myself, less faith in my own judgment and abilities? Does it mean that I am a more “dependent” person, less free, psychologically or politically? If anything, the truth is the other way around.

And what does this concept of dependency mean with regard to our relation to medicine? Does Starr mean that we are “overmedicalized”? No. He argues for more medicine, and against “neo-conservatives” who, he says, would reduce the availability of medical care. Does he mean that we should rely more on our own judgment, that “common sense” in medical matters may be better than professional judgments? No, again. In his introduction we find this statement: “In general, patients are not the best judges of their own affairs; neither are their families.” Does he mean that, if not for capitalism, industrialization, urbanization, and so on, we would not be patients? He never says this, either. Or does he mean simply that we should not allow physicians to be the sole judges of medicine's organization and economics? But this is a conclusion we as a society arrived at some time ago: physicians' exclusive control over medicine has ended, while all the factors that presumably created our dependency have remained in place, or intensified.

Starr's argument amounts to a complete muddle. Modern medicine arose in the latter part of the 19th century as society was becoming more complex, urban, industrial, scientific, technological. All of these factors are interrelated; they are all part of the world we live in—and on which we depend. If modern medicine did not exist, we wouldn't depend on it. (If planes didn't exist, we wouldn't fly.) Starr's is not an analysis, and not a theory. It tells us nothing of the multiplicity of forces that have determined medicine's course, and shape, and position in society; it elucidates no specific relationships in medicine's continuing evolution. It is a diffuse and tendentious tautology.

_____________

VI

Part I of Starr's book ends with medicine a mighty monolith, holding all of society at bay. Part II, which deals with developments after World War II, shows something completely different. Medicine has suffered a stunning loss of authority; it is being challenged, questioned, criticized on all sides. Its structure, too, is weakening, as government, business, and the public at large make increasing inroads into its “sovereignty.” On the basis of Starr's argument in Part I, these changes are not only unexpected, they are completely incomprehensible. And sure enough, Starr abandons his argument completely. We never hear of it again.

Instead, Starr now attributes medicine's loss of authority to a general decline in the authority of all professions in the 70's; to the rise of the “women's movement”; and to “therapeutic nihilism,” by which term he refers to the views of a number of writers—physicians, economists, and others—who, in different ways, have questioned medicine's effectiveness in dealing with some of modern society's most prevalent illnesses. Among other things, these analysts have suggested that huge, federally-financed medical programs may not be the best approach to illnesses which are at least partly social or psychological in origin. In a characteristically distorted discussion, Starr lumps these writers together with Ivan Illich, a radical Catholic social theorist who has argued that medicine should be abandoned altogether, along with science, industry, and most of the values and institutions of the modern world.

Even apart from the distortions and misrepresentations, however, this is an ad hoc and completely external explanation of a phenomenon with roots deep within medicine itself, and long antedating the factors Starr cites. The public loss of authority parallels and in part reflects an inner crisis in medicine, which has become increasingly self-critical and self-questioning. It reflects, also, a growing scientific sophistication in society, which makes people increasingly unwilling to accept claims on faith. And it involves the continuing action of American society's own enduring norms and values, which press for rationality, openness, fairness, equality. But these are forces that have no existence in Starr's book.

Most of Part II, however, is devoted to the changes now coming about in medicine's structure: its organization, financing, regulation. Here, Starr does not even have ad hoc explanations to offer.

The postwar decades saw a vast expansion of medical programs and services, of hospitals and neighborhood health centers, of medical schools and medical research. The government began to plan for health care on a national basis, and took the first steps toward coordinating the nation's huge and fragmented health-care system. Health insurance grew, at first largely through the spread of private policies and union medical plans and then, in 1965, through the passage—despite the opposition of the medical profession—of Medicare and Medicaid. The profession, which had always been able to defeat unwelcome legislation, now offered much more accommodating counterproposals, and ultimately acquiesced, reaping great economic gains in the short run but at the same time yielding some of its hitherto inviolate “sovereignty” and thus making further erosions inevitable.

_____________

These changes, and many others that Starr never mentions, produced far-reaching effects. They completely altered the face of American medicine. The benefits they conferred—in increased availability of medical care, in rising indices of use, in improved health, in falling death rates—were dramatic. But Starr gives little credit to society, or to medicine, for this progress. Instead, every advance, every extension of entitlements, every massive investment in medical services, facilities, education, and research is discussed cynically, and characterized as a diversion or a missed opportunity. His chapter titles and subheadings tell the story: “The Mirage of Reform”; “Grand Illusions”; “Health Care in a Blocked Society.”

Throughout, the view of American society is negative, the tone derisive and patronizing. Increased public attention to questions of the availability and quality of American medicine is treated not as a widening of social consciousness, nor even as a strengthening of a popular claim to health care as a right, but as a growth of hypochondria, spurred by Henry Luce and the drug manufacturers. Truman's proposal for national health insurance in 1945 is said to have failed because of the cold war. Starr relegates to a murky footnote the fact that opinion polls of the time showed a minority of the public in favor of the bill; that there could be grounds for opposing it other than those of displaced anti-Communism is never suggested. Nixon's liberal health-care policies are treated as attempts to buy popularity and to “divert attention from the Watergate affair.” Medicaid was passed not so much to provide medical care for the poor, as to “cover . . . bad debts for hospitals.” And so on. Finally, when progress cannot be wholly dismissed as a diversion or a mirage, it becomes a lapse: thus the two great health-care acts of the 60's, which brought health-insurance coverage to almost 90 percent of the population, were a fluke, passed “at a rare moment of liberal political success. . . .”

Belittle as he will, however, Starr cannot disguise the fact that an enormous liberalization of medicine has taken place. But how, if one's attitude toward American society and American capitalism is negative and derisive, if one regards progress as an illusion and reform as a mirage, if one sees medicine as motivated solely by the pursuit of wealth and power, can the sweeping changes of these decades be explained?

Starr does not really try. He offers instead, these sentences:

It was as if an internal dynamic were playing itself out in the postwar decades. In virtually the classic Marxist fashion, the forces of production in health services—government subsidies, private insurance, technology, consumer demand—were breaking down the old social relations of production and preparing the way for more decisive change. . . .

Ponder these “classic Marxist forces of production”: government subsidies, i.e., massive public programs directed to the disadvantaged, social and medical services for the nation as a whole, federal financing of medical education and research; private insurance, chiefly union-sponsored insurance plans and the incorporation of health care into collective-bargaining agreements between labor unions and employers; technology; consumer demand. Now, ponder the equally “classic Marxist” product: health services. This is not Marxism; it is Marx-babble.

But it is not funny. Starr's book does not reflect a coherent Marxist viewpoint; it does not reflect a coherent viewpoint of any sort. What it shows is that, without their necessarily being Marxists or taking consistently Marxist positions, for Starr and other sociologists like him the only available ideas are Marxist ideas. Ultimately there is no other intellectual or scientific baggage, no other theories or modes of thought that they know or consider respectable. Given such an impoverishment of both knowledge and thought, is it to be wondered at that Starr fails to understand American medicine, or the American society of which it is a part?

_____________

VII

Physicians, on the whole, have difficulty dealing with all of the social-scientific studies now inundating medicine. It is not surprising that the editor of the New England Journal of Medicine has been impressed by Starr's “command of social forces.” The C. Wright Mills Award for Starr's book is entirely appropriate. And as for the Pulitzer Prize, well, Starr's argument with regard to medicine is one that has broad appeal (and even, as I have indicated, some justice); and his argument with regard to society, with its muddled discussion of the decline of democracy, the evils of industrialization, the pathos of the “isolated nuclear family,” and so on, rings bells in liberal ears. That it is meaningless is obviously secondary.

But what is one to say of sociologists, including some of the most distinguished in America today, who fail to recognize this kind of “study” for what it is—or who do recognize it, and join in the acclaim anyway? What is one to say of a field in which this kind of work is not only accepted but hailed as “brilliant” and “lucid”?

¹ First published in hardcover by Basic Books in 1983, it is now available in paperback (Basic Books, 514 pp., $11.95).

² “What Is Medical Sociology?” Journal of the American Medical Association, March 6, 1981.