Precis of Paul Starr's The Social Transformation of American Medicine

Editor's Note: The following is a presentation of selected passages from The Social Transformation of American Medicine (original page numbers enclosed in parentheses) in tandem with the names of the authors in this retrospective issue and the various themes and issues they address.

BOOK ONE: INTRODUCTION: The Social Origins of Professional Sovereignty

White (Rationalization)

The Dream of reason did not take power into account.

The dream was that reason, in the form of the arts and sciences, would liberate humanity from scarcity and the caprices of nature, ignorance and superstition, tyranny, and not least of all, the diseases of the body and the spirit. But reason is no abstract force pushing inexorably toward greater freedom at the end of history. Its forms and uses are determined by the narrower purposes of men and women; their interests and ideals shape even what counts as knowledge. Though the works of reason have lifted innumerable burdens of hunger and sorrow, they have also cast up a new world of power. In that world, some people stand above others in knowledge and authority and in control of the vast institutions that have arisen to manage and finance the rationalized forms of human labor.

White (Rationalization)

Modern medicine is one of those extraordinary works of reason: an elaborate system of specialized knowledge, technical procedures, and rules of behavior. By no means are these all purely rational: Our conceptions of disease and responses to it unquestionably show the imprint of our particular culture, especially its individualist and activist therapeutic mentality. Yet, whatever its biases and probably because of them, modern science has succeeded in liberating humanity from much of the burden of disease. Few cultural relativists, suffering from a bad fever or a broken arm, would go so far to prove a point as to trade a modern physician for a traditional healer. They recognize, in behavior if not always in

Goldstein (Medical Pluralism)

argument, that in medicine the dream of reason has partially come true.

Klein (Open Moments)

But medicine is also, unmistakably, a world of power where some are more likely to receive the rewards of reason than are others. From a relatively weak, traditional profession of minor economic significance, medicine has become a sprawling system of hospitals, clinics, health plans, insurance companies, and myriad other organizations employing a vast labor force. This transformation has not been propelled solely by the advance of science and the satisfaction of human needs. The history of medicine has been written as an epic of progress, but it is also a tale of social and economic conflict over the emergence of new hierarchies of power and authority, new markets, and new conditions of belief and experience. In America, no one group has held so dominant a position in this new world of rationality and power as has the medical profession. Its rise to sovereignty in the late nineteenth and early twentieth centuries is the first part of the story I have to relate; the emergence in our own time of a bureaucratic and corporate regime is the second.

Goldstein (Medical Pluralism)

Power, at the most rudimentary personal level, originates in dependence, and the power of the professions primarily originates in dependence upon their knowledge and competence. In some cases, this dependence may be entirely subjective, but no matter: Psychological dependence is as real in its consequences as any other kind. Indeed, what makes dependence on the professions so distinctive today is that their interpretations often govern our understanding of the world and our own experience. To most of us, this power seems legitimate: When professionals claim to be authoritative about the nature of reality, whether it is the structure of the atom, the ego, or the universe, we generally defer to their judgment.

Wailoo (Science)

Pescosolido and Martin (Cultural Authority)

The medical profession has had an especially persuasive claim to authority. Unlike the law and the clergy, it enjoys close bonds with modern science, and at least for most of the last century, scientific knowledge has held a privileged status in the hierarchy of belief. Even among the sciences, medicine...