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270 16 Health-Care Professions, Markets, and Countervailing Powers Donald W. Light, University of Medicine and Dentistry of New Jersey Durkheim and others as standing over against markets. By the 1970s, however, historical and contemporaneous evidence indicated that the medical profession was a kind of self-serving monopoly operating within protected markets (Berlant 1975; Burrow 1977; Freidson 1970a, b; Larson 1977). This radical recasting, as well as evidence of overtreatment, undertreatment, mistreatment , and excessive charges, led to a revolt by governments, businesses, and other payers that transformed them into active buyers demanding accountability and good value. (I described the dynamics and evidence of this transformation in previous editions of the handbook [Light 1989, 2000]). Since 2000, however, organized professional bodies have mounted campaigns to restore their professionalism and lost trust, with Eliot Freidson’s last work (2001) as an intellectual beacon and inspiration to them. Yet as we will see, the professions-and-markets debate ignores a graver development of the commercial construction of medical categories, medical evidence, and clinical behavior that sociologists have largely overlooked in their research on risk, illness, and treatment. The Countervailing Powers Framework Single accounts of the rise of professions, while describing their relationships with the state, universities, and other bodies, tend to be what Professionalism is an Anglo-American disease. —Eliot Freidson, 1983 Monopoly is essential to professionalism. —Eliot Freidson, 2001 For more than two decades, an international crisis of professionalism has pervaded health care and weakened the grip of professional organizations over the training and oversight of professional work, especially in the United States and United Kingdom where professionalism is a preoccupation . Governments and other institutional payers have moved in to monitor professional behavior, control costs, and reduce large variations in the quality of clinical practice (Hafferty and Light 1995; UK Secretary of State for Health 2007). The unquestioned trust in the medical profession to apply the best scientific and technical information and skills to the needs of patients and fulfill a tacit social contract has been shaken. I focus here on some aspects of the shaken trust in the medical profession that have to do with “markets,” a term that refers to dynamically constructed arenas of economic exchange but also to the actors in those markets who have been challenging the elevated status of professions as state-protected monopolies that claim to provide complex and vital services to clients for their benefit in an impartial manner. For decades during the Gilded Age and into the twentieth century, professions were widely regarded by Health-Care Professions, Markets, and Countervailing Powers 271 Andrew Abbott (2005) wryly describes as the “historiography of imminent development,” and they tend not to consider the wider ecological context. The framework of countervailing powers enables one to consider through historical periods the changing tensions, alliances, interests, rhetorics , and degrees of control among key stakeholders (Light 2000). They include organized professional groups, the state as legitimator and regulator, payers such as the state and insurers, clients as individuals or larger organized bodies , and corporations that make up the medicalindustrial complex. This framework resonates with and expands on Elliott Krause’s (1996) major comparative study in which he emphasizes three parties—the state, capitalism, and the professions—at the corners of a triangle. They vie to construct the reality of a domain, the structure of markets, the culture of professional work and its organization, status, and power. Jill Quadagno (2004) has made a valuable contribution by analyzing , with her theory of stakeholder mobilization , how these conflicts translate into decisions. The countervailing powers framework first instructs researchers through the process of identifying the domain or field force, the major actors, and the nature of relations between them. Each in turn is made up of countervailing powers, such as the occupational competitors for professional status and greater jurisdictional control in a given domain (Abbott 1988). The professional constellation of countervailing forces ranges from the crucible of its academic and research segment , with strong ties to the medical-industrial complex, to competing providers both within medicine and in alternate paradigms of healing, to forms of clinically managed care that employ protocols to shape how professional work should be done. The state is a constellation in itself of countervailing power groups or divisions with different functions and priorities: the sponsor of health-care services and public health, the funder of most basic research to foster innovation and economic growth (Light 2006), the promoter of commerce at home and abroad, and the creator and enforcer of regulations...

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