Social Transformation Twenty Years On

When a book is published, most authors worry that it will be criticized. Two decades later, they are generally happy if it receives any criticism whatsoever. A citation is a secret pleasure, and sharp words that once would have cut to the quick can now be treated almost as a compliment. I am especially grateful for these nineteen essays about The Social Transformation of American Medicine because they are so substantial. I published Social Transformation at age thirty-three without having paid my dues to the relevant disciplinary communities—history of medicine, health politics, health law, health care economics, even medical sociology—and have since moved on to work in other fields. Guilty first of disciplinary trespass, then of abandonment, I could hardly expect any mercy, much less sustained reflection. It was news to me that the book had attracted a new round of discussion. I was unaware of the book's influence in the law, described by Tim Jost in this volume. While the Starr Retrospective Working Group was meeting, I did not know about it, though I would have liked to have made a surprise appearance, like Tom Sawyer and Huck Finn showing up for their own funeral.

This collection has proved to be neither a funeral pyre nor a festschrift, and it has taught me much about the subject and the reception of my work that I did not know. After Social Transformation was published in January 1983—the 1982 copyright date on the book is one mistake that I will forthrightly acknowledge—I generally did not respond to critical reviews because I saw no need to restate my argument. I also hoped that an isolated attack or negative judgment would have little effect amid the positive reception the book was enjoying. But as this collection stems from so much serious deliberation, I want to make at least a preliminary effort to address some of the issues that the authors have raised.

Although most of my comments here will be directed at points of disagreement, I should emphasize that I accept many of the arguments made in these papers, even in some instances where the authors criticize Social Transformation for getting something wrong. Keith Wailoo, for example, argues persuasively that scientific and technological advances in the post-World War II era had complex effects, in some respects undermining physicians' authority and control. Thomas Oliver is surely right, in his analysis of the rise of managed care and managed competition, to highlight the critical importance of the policy entrepreneurship that led to Richard Nixon's health maintenance strategy and to emphasize the mutually reinforcing interaction of public and private initiatives. I accept William White's argument that efforts to "rationalize" health care have focused on improving quality as well as reducing costs and that both public- and private-sector initiatives have used market-oriented as well as regulatory strategies. I find much to admire in Sydney Halpern's survey of recent developments in what I called the "generalization of rights." She says that my framework "does not readily accommodate the advent of institutional processes leading to shared jurisdictions between physicians and other professionals in which physicians alone once prevailed" (836). The developments she describes, however, seem quite consistent with the approach I took. Occasionally, writers in this volume sharply distinguish their views from mine, but I see no trouble in accepting what they say and do not want to be drawn into a dispute. Some of the criticisms involve matters of proportionality and nuance rather than genuine analytical conflicts: Did I pay enough attention to a particular subject to bring out its full complexities? I am perfectly willing to grant that the book gave limited attention to many topics that warranted more research and discussion.

Among these essays, however, there are several frontal challenges to Social Transformation that it would be disingenuous of me to pretend to accept. Some of these challenges come in essays that...