The Power of the Doctors

The Social Transformation of American Medicine

by Paul Starr
Basic Books, 514 pp., $24.95; $11.95 (paper, May)

Social scientists have been perplexed by the remarkably favored position of doctors in American society. Few other professions conduct their affairs with so much autonomy and receive in return such generous economic benefits. In a country historically suspicious of privilege and authority doctors have enjoyed a large measure of both, and—at least until recently—their views have generally been accorded a respect usually given to astronauts, coaches of championship football teams, successful Wall Street analysts, and other heroes of contemporary culture.

The medical professions have virtually unchallenged economic control of what is now called the “health care industry.” The laws of the market seem to have little effect on this peculiar industry, and doctors, who are the suppliers of medical services, have pervasive influence over the demand for the very services they sell. Doctors seem able not only to monopolize the market but to control their own numbers and set their own standards of education and professional performance—all with public approval and, through licensing laws, government support.

Authority, self-regulation, and socially sanctioned monopoly in a defined field of competence characterize virtually all professions, but medicine in twentieth-century America has enjoyed a sovereignty unmatched by that of any other field. How did this come about?

In his important book, Paul Starr, a young sociologist at Harvard, attempts to answer this question. The first half of The Social Transformation of American Medicine is a history of the social and economic growth of the medical profession from precolonial times to the present. Medicine in America was not always the powerful and respected institution it later became. Throughout the eighteenth century and for most of the nineteenth, doctors had little economic or political power. They were often distrusted by the public and faced competition, at first with lay practitioners, midwives, and herbal folk doctors, and later, beginning in the mid-nineteenth century, with a succession of more ambitious challengers, including “eclectic” practitioners, homeopaths, chiropractors, and osteopaths.

In resisting these movements, orthodox medicine was at first hampered by its own lack of organization and its ignorance of science. Not until the final decades of the nineteenth century did the profession begin to gain public support. By the 1920s it had been transformed into a disciplined, state-licensed but largely self-regulating profession which had consolidated its social and political power and established a virtual monopoly over health care. The eclectic and homeopathic physicians were assimilated; chiropractors were confined by law to limited practices, and osteopaths, although independently licensed, were greatly outnumbered, and losing influence and prestige.

This story has been told before from different perspectives, by historians such as Richard Shryock (Medicine in America), William Rothstein (American Physicians in the Nineteenth Century), Rosemary Stevens (American Medicine and the Public Interest), and many other writers, on whom Starr has drawn. But Starr’s work is unique in the way it shows how cultural, political, and economic factors contributed to the profession’s rising power. As he points out, most other accounts emphasize the primary influence of scientific and technological change,…

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