In lieu of an abstract, here is a brief excerpt of the content:

  • Epilogue

The Social Transformation of American Medicine is both a narrative about power and a powerful narrative. Its focus on medical authority provided coherence to Starr's analysis, as he traced the implications of that authority through the diverse domains of academic institutions, congressional hearings, corporate boardrooms, and individual households. As the essays in this volume document, this coherent narrative helped physicians to make sense of the complex and rapidly changing environment in which they practiced, lawyers to think more comprehensively about the legal underpinnings of medical relationships, and scholars to better understand the ways in which diverse social forces interacted to shape American medicine.

Yet Starr's narrative of power inevitably abstracts from the reality of a complex health care system and an even more complicated American society. Each of the transformations traced in the book occurred for reasons that can only be partially explained by medical authority. Similarly, the roots of that authority—the reasons that the American health care system and health policy reflected the interests of organized medicine—are only imperfectly explicated by the factors described in The Social Transformation. No book could do more. No coherent narrative can ever fully explain a social reality that is often anything but coherent.

Over twenty years on, the book's significance is confirmed by a continuing large readership and by admiration for its prescience in anticipating the current troubles of the medical profession—even if the particular [End Page 1021] nuances of medicine's corporate troubles and organizational transformation could not be presaged. As the preceding essays highlight, there is also a marked ambivalence about the book—characterized by agreement and admiration of, as well as contention and frustration with, the book's core arguments, its linear narrative style, and its placement of doctors at the center of the story of medicine. Starr's impassioned response to the essays of three of our contributors demonstrates the continuing contentiousness of these issues. Jennifer Klein, for example, argues that Starr puts too much weight on the political power of the medical profession during the New Deal period and too little on the strength of business interests, while Deborah Savage contends that the economic power of the medical profession had more to do with the embedded nature of specialized knowledge in the medical profession than with licensing or other forms of monopolization. Starr's vehement rejection of their positions illustrates both the depth of his commitment to a particular vision of the development of the American medical profession and why that vision has continued to provoke controversy.

This apparent discord also illuminates two additional important perspectives for interpreting The Social Transformation. Paul Starr remarks in his essay that several of the authors in this volume seem to have read a book different from the one he wrote. This is a telling point, and in our assessment is quite correct. But it is less an indictment of those authors than a reflection of the inevitable ways in which our understanding of history is itself historically contingent—how our reading of a text changes with time.

Read today, The Social Transformation is a different book from when it was written in the late 1970s. Times have changed, academic paradigms have evolved (or regressed, depending on your assessment of those changes), and the health care system (along with the policies that shape it) is quite different from the one that existed a quarter century ago. Moreover, Starr's own efforts, both in The Social Transformation and his personal engagement in health policymaking, have themselves transformed the way in which we think about American medicine. None of these changes, of course, alter the intent with which Starr wrote particular sections of the book. But neither does an author's intent ever fully define the meaning, or implications, of his or her work.

For precisely those reasons, the central charge we gave our authors was not to focus on whether they agreed or disagreed with Starr's conclusions or analytic choices, not to try to judge whether these choices were in some sense "right" or "wrong." Their primary objective was instead to explain [End Page 1022] key features of the book, using those features (the coming...

pdf

Share