Sovereignty and Science: Revisiting the Role of Science in the Construction and Erosion of Medical Dominance

The medical profession . . . 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 beliefs. . . . Medicine occupies a special position. . . . [Physicians] serve as intermediaries between science and private experience . . . [and] offer a kind of individualized objectivity. . . . The therapeutic definition of the profession's role also encourages its acceptance. . . . On this basis, physicians exercise authority over patients, their fellow workers in health care, and even the public at large in matters within, and sometimes, outside, their jurisdiction.

—Paul Starr, The Social Transformation of American Medicine

In the opening pages of The Social Transformation of American Medicine (1982), Paul Starr writes of the central place of science in building medicine's dominance as a social institution in twentieth-century America. Science, it seems, provided one essential element—a crucial pillar of intellectual and social authority bolstering the growing status of American medicine. In Starr's telling, even if new sciences such as bacteriology did not determine the rise of the profession, they lent enormous cultural legitimacy to medicine. Moreover, such sciences provided a new unity to an enterprise that had been—throughout the nineteenth century—fragmented by sectarians and lacking cultural credibility. Science, in short, underwrote the social transformation and emerging sovereignty of modern medicine in the twentieth century.

Historians have long been fascinated by, and somewhat skeptical of, the neatness of this narrative. The following pages reexamine the role of science in the building of medicine's dominance as a social institution—not only a central aspect in Starr's book, but also a common theme in histories of medicine more generally. Science, that is, the advent of bacteriology, laboratory medicine, physiology, animal experimentation, and antiseptic surgery, was portrayed in Starr's volume as a singularly powerful force, a crucial foundation for modern medicine. But in Starr's impressive and synthetic history, science is presented as a uniform and somewhat monolithic undertaking, the impact of which is straightforward; seldom is science treated as a problematic and contested theme in the transformation of medicine.

To be sure, in Starr's analysis, the impact of the sciences changes over time. For example, when science next appears as an important force in Starr's narrative, we are in the post-World War II years, and it is not bacteriology but the new sciences (molecular biology, for example) that play powerful roles in buttressing medicine's postwar authority. The power of science—so central in the origins of modern medicine's legitimacy—remains central. It is present at the origin, powerful behind the scenes, pervasive in its influence, and strong in buttressing medical diagnosis and therapy. This interaction, to read Starr, apparently built to a crescendo in the post-World War II years.

The special relationship between the medical profession and science (while not explicit or appearing everywhere in the book) remains a vital part of the underlying logic—an important pillar in the architecture of the narrative. Like a silent drumbeat in the background of a fascinating symphony, science is the underlying theme that defines medicine well into the late twentieth century. Early in his impressive narrative, Starr argues that the profession's exalted status in society stems from physicians' roles as intermediaries between science and the private experience of patients. Doctors had become arbiters of science for the public by the early twentieth century. Thereafter they put science to work for them in diagnosis, in therapy, and in hospitals and clinics across the nation. Thereafter they always could draw upon their relationship with science as a resource for building, sustaining, and continuing the development of their sovereignty, their status, and their profession's cultural authority.

Yet the relationship between science and medicine (as Starr himself notes on occasion) was not at all that simple. Even at the time when Starr's volume appeared, scholars of the history of medicine saw the relationship of science and medical authority as something of a puzzle, and their descriptions were different, more nuance-filled, than Starr's. They wrote not...