David Coburn & Evan Willis. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
Hardly a daily newspaper appears without an article about doctors or about the medical profession. On popular television programs physicians are portrayed either as humanistic healers meeting the complex demands of individual patients, or, more recently, as frantic super-heroes ministering to somewhat anonymous bodies in high-tech emergency rooms. At the same time, there are accounts of strife between governments, insurance companies, or hospitals and medical organizations over fees or costs. Newspapers report on the huge incomes of some doctors, the horrors visited upon patients by malpractice or malfeasance, and complaints by unorthodox healers of being persecuted by the medical profession. An apparently endless procession of new medical discoveries, as well as the much-publicized potential of the ‘new’ genetics promises much, but the day-to-day reality is less Utopian. Whereas medicine at first glance might appear as the self-sacrificing, altruistic, scientific occupation par excellence, the reality is that it contains profound dualities and contradictions.
In what follows, our aim is to cast light on the contradictions noted in the popular press through tracing underlying paths and structures. We will do so, on the one hand, by describing trends in the role of medicine within changing health-care systems, and on the other, by reviewing the ways in which these trends have been analyzed within the sociology of health and illness.
At the broadest level, our argument is as follows. Regarding health-care systems, the chief trend has been towards the development of mass markets, that is, the industrialization of health care. Regarding social theory, there has been an increasing tendency to view medicine less as a unique profession and more as an occupation subject to the same processes faced by many other occupations and professions. These two topics, trends in health care and in social theory, are, of course, related. Physicians are not immune, we argue, to the logic of the capitalist mode of production towards the rationalization and routinization of work. Both the rise of the medical profession to the pinnacle of power, and also the recent decline in this medical hegemony (together the major historical trajectory for medicine), are thus viewed here as a structurally contingent process. Contingent, that is, not simply on the progress of medical knowledge, the actions of the medical profession itself, or even of events within health care, but on the complex changing social structures in the advanced political economies.
At the outset some clarifications are appropriate. First, in this chapter we concentrate on the medical profession. Some of the processes mentioned will have application to all professions, or to other health occupations and professions in the health-care division of labour, and some will not. Second, it should be noted that there are difficulties in analyzing ‘the’ medical profession as a single entity. The profession has become highly segmented into groups and strata with significantly different interests; generalist and specialists are only the most obvious source of differentiation. Some segments have little in common apart from their shared socialization. Even the relationships between individual physicians and medical organizations are problematic, and these organizations themselves form a terrain of struggle rather than simply ‘representing’ some form of universal physician interests. In what follows, we review the state of the field, organizing our discussion chronologically around the notion of the changing nature of medical power. Our analysis is most pertinent to the English-speaking nations, although European examples are mentioned where appropriate.
Professions and Power
To paraphrase Johnson (1980) in his comments about work: ‘professions are a relation of power.’ That is, within the sociology of health, medicine has most often been viewed as being the central node in a network of relationships in which the profession both generates power over other groups or institutions and reflects or is shaped by ‘external’ factors and forces. In discussing sociological views of medicine we are thus mainly talking about the changing extent, nature, sources, and consequences of, or explanations for, medical power. Put somewhat differently, the focus has been on the social and cultural authority of medicine and its professional autonomy (Elston 1991; Starr 1982). That is, medicine possesses power as expressed in social organization, in the way people think about and act regarding health care, as well as its control over medical work itself. In fact, sociologists are preoccupied with professional power to the neglect, perhaps, of other dimensions of the profession such as the changing nature of actual medical work, or the meaning or implications of illness, caring, and cure for both doctors and patients.
While having its own distinctive history, medicine also shows similarities with other occupations and professions. The historical development of medicine is a part of larger movements of the rise of professions in general, and challenges to medical power are part of broader attacks on the welfare state; hence discussion of medicine alone may conceal as much as it reveals. Both the general and the unique need to be taken into account. Moreover, there is no consensus about how medicine is to be understood, or its social history or current situation explained. Hence, we will illustrate some of the theoretical divergencies; our account is, of necessity, somewhat idiosyncratic.
Social and Health-Care Trends
Just as sociological perspectives on medicine have changed over time, the profession has also inhabited a changing health and healthcare context. There has been a major transformation from a situation in which physicians were petty bourgeois entrepreneurs to physicians as part of huge and growing health-care markets. A situation in which health care was given primarily in the domestic sphere has been transformed into one in which most health care is provided ‘impersonally’ by paid experts within a mass market for care. In the duration of less than a century, medical work has changed from individual healers within a ‘cottage industry’ to a highly complex health-care division of labour surrounded by huge industries. Health care now dwarfs in size such industrial giants as steel and automobile manufacturing and, in most Western countries, spending on health care is in the range of 8–9 per cent of national GNPs. In this progression, physicians have become involved with large institutions, private and public. The fate of medicine is tied not only to state bureaucracies, but also to the dynamics of both health-care and non-health care businesses and to the transformation of capitalism itself. Medicine relates to other institutions whether medicine still functions mainly within a more market-orientated or a more public-orientated health-care system. The profession itself is composed of a complex series of organizations and groups in which the role of the profession as a corporate entity can, at least analytically, be separated from the actions of individual practitioners.
Current issues regarding medicine thus cannot be fully understood without contextualizing changes in the profession within broader trends towards globalization, a general increase in the power of corporations and the rise of neoconser-vatism, a decline in the relative autonomy of the state, and subsequent attacks on the ‘Keynesian welfare state.’ These processes include an increasing tendency to cap the costs of care through attempts to control utilization and to make health care more effective and efficient; that is the rationalization of care ‘from above.’ This rationalization, whether involving more competition within health care, an increased ‘managerialism,’ or greater or lesser privatization, or some combination of these, almost always implies intrusion onto territory previously controlled by medicine.
At the same time, medicine is being influenced by various social movements ‘from below,’ including the women’s movement, the patient’s rights and consumer’s movements, the struggles of other professions to escape from medical dominance, and by changes in the boundaries of medical knowledge. Some of these influences are reflected in changes within medicine itself, particularly regarding the feminization of medicine and the fragmentation of the profession by status and by speciality. Within this conflux of forces the medical profession is actively involved in attempts to control its own destiny. We are confronted with a changing medicine in a changing social context.
In this chapter, although our major focus is on the medical profession, we will unavoidably also be drawn into discussing examples from other health occupations and professions in the ‘system of health professions’ (Abbott 1988). Medicine has long been at the apex of a whole gamut of health professions in which it gained the power to exclude, limit, or subordinate its potential rivals (Willis 1989). We will argue, however, that this ‘system,’ and the role of medicine within it, is not simply the consequence of interoccupational struggles, as is often assumed. Medicine, and its relationships with other occupations and institutions, can only be adequately understood in the context of the particular social formation of which it forms a part. For us, this leads to a view of medicine as losing the almost hegemonic control it once had, not only over the context of health care, but even over the content of medical work. While not as powerful as it once was, it still retains a great deal of its professional autonomy although declining somewhat in its social and cultural authority. Our review thus emphasizes the changing nature of medical power and the explanation of these processes.
State of the Field, or How Did We Get Here from There?
Medicine was not particularly well thought of in the eighteenth and nineteenth centuries, yet by the middle of the twentieth century it was at the height of public prestige, power, and authority. From a situation in which many intelligent laypersons thought they knew as much or more than physicians did about how to cure themselves or their families, medical work came to be seen as within the purview of only a highly technically trained few. Medical training, which in the eighteenth and nineteenth centuries consisted of classical training in Greek and the humanities and of apprenticeship, was, in the twentieth century, entirely replaced by rigorous scientific training within a university.
By the end of the Second World War, in all national assessments of occupational prestige, medicine ranked at or near the top. Medicine not only controlled what happened in the medical office, but almost anything that happened in health care. Physicians, it appeared, were not only expert in the application of biological science to particular cases, but also claimed to be, and were so regarded, as public authorities on anything to do with health, including how health care was to be delivered. Medicine had social and cultural authority.
This transformation from the fringes to the centre of the circle of power might be seen as simply a direct reflection of the efficacy of medicine. It could be assumed that medicine rose to power quite rightly on the wave of its increasing ability to improve health or cure or prevent disease. However, sociologists, historians and others have questioned such an explanation. Such questioning of common sense was particularly spurred by the ideas of McKeown and others that improvements in the health of populations in the nineteenth and twentieth centuries were determined more by social conditions generally than by curative medicine (McKeown 1965, 1979). McKeown’s writings were one of the first modern critiques of the ‘more medical care means more health’ thesis (for others see Evans et al. 1994; Illich 1975; McKinlay and McKinlay 1977). McKeown’s findings were also supported by historians who claimed that medicine rose to power before it was efficacious (see, e.g., Shortt 1983). While improving efficacy, or in more complex explanations the perception of increasing efficacy, was not irrelevant, the origins and present bases of modern-day medical power cannot rest simply or directly on the base of such explanations.
Theories of the Professions
Medicine has often been used as an analytical example to advance theories of the professions because medicine is assumed to be the epitome of what ‘profession’ means. Hence, explanations for medical power are tied to theories of the professions in general.
There is a conventional history of analysis of the professions that moves from Carr-Saunders and Wilson (1933), through Wilensky (1964) and Parsons (1951, 1964), to Johnson (1972) and Freidson (1970), to Larson (1977, 1980), Navarro (1976, 1986), and McKinlay and Arches (1985), to Foucault (1973, 1976), Witz (1992), and the postmodernists. This sequence can be described in terms of a change from trait theories to functionalist theories to neo-Weberian or neo-Marxian ‘power’ theories. Most recently have come challenges to power theories, particularly from feminism and from Foucault. While we describe this conventional history, we also note that Foucault and, most recently, Krause (1996) note that the professions have their origins much earlier than the Industrial Revolution as some conventional theories seem to assume. In Krause’s case, the professions are viewed as forming a continuous line from the Guilds of the Middle Ages to the present.
Trait and Functionalist Theories
In the early ‘trait’ theories of Carr-Saunders and Wilson (1933), and Greenwood (1957), the professions were said to possess particular traits or attributes, most often including an esoteric body of knowledge, a code of ethics, and an altruistic orientation. Trait theories were followed by process theories in which it was argued that the professions moved through a sequence of the acquisition of particular traits (Wilensky 1964). Trait and ‘professionalization’ theories, often formed simply by comparing common-sense notions of the professions with the assumed characteristics of other occupations, were superseded by the advent of structural functionalism. Parsons and others in the functionalist tradition explained professional, and particularly medical, power in terms of the potential within the professions to exploit patients (clients, etc.) financially, sexually, or otherwise. Hence an implicit contract between ‘society,’ and the professions in which the latter were given autonomy in exchange for stringent self-regulation (no substance was given to the notion of society, often a convenient abstraction for arguing for a nonexistent convergence of interests or values). However, for both the trait theorists and for the functionalists in the Durkheimian tradition, professionalization was a positive aspect of modernism, in contrast to Marx’s view of the degradation of the labour process under capitalism, or to Weber’s gloomy analysis of the growth of an ‘iron cage’ of rationalized bureaucracy. For Durkheim, professionalization, as a system of the organization of work based on self-direction and autonomy, showed an alternative future to that of an ever more pervasive work alienation.
There was an inevitable challenge to the trait and functionalist claims from a number of sources, including some from analysts within the symbolic interactionist tradition (Becker 1962; Hughes 1958) who questioned whether the many positive ‘traits’ attributed to the professions were enacted in reality. In fact, it soon became clear that medicine and the other professions were far from being as rigorously self-regulating, ethical, or ‘community orientated’ as some professions, and some analysts, had claimed. Rather rapidly the professions came to be seen, not as altruistic, but as being exploitative monopolies. Medicine, the prime example of what it meant to be a profession, quickly came to be viewed as self-interested and motivated chiefly by the desire to increase the authority and incomes of physicians. Hence, the rise of ‘power’ theories of the professions and of medicine based on neo-Weberian (focusing on the market and closure theory) or neo-Marxist (focusing on mode of production and class theory) theories.
Most centrally, Freidson (1970) claimed that medicine was dominant in health and health care. Medicine controlled both the content of medical work and also clients, other healthcare professions, and the context within which medical care was given (health-care policy). Medicine had social and cultural authority as well as clinical autonomy. Whereas medical knowledge itself was assumed to be relatively untainted by social factors, the application of medical knowledge reflected, not ‘pure’ medical science, but rather the profession’s own practical interests in restricting competition, raising salaries and increasing its control over health and health care. Freidson consequently argued that the ‘real’ interests of medicine had distorted the application of medical knowledge such that, in the United States, for example, medicine led successful attempts to prevent the introduction of universal or government sponsored health-care insurance because this was viewed as an incursion on medical prerogatives.
In arguing that physician behaviour was more a function of the structure of the situation in which doctors practised, rather than a consequence of how they had been trained or socialized, Freidson redirected attention from the ‘socialization’ school. The latter, in good functionalist fashion, had assumed that physician behaviour was best explained through their medical training and socialization into the role of ‘doctor.’ Hence, the many studies at the time of the socialization experiences of medical students (Becker et al. 1961; Merton et al. 1957). The new structural emphasis rapidly eclipsed studies of socialization. At the same time, the questioning of medical authority was supported by changes in the pattern of disease. As infectious and acute disease gave way to the more chronic conditions of an ageing population, physicians, as the major experts in acute care, tended to give way slightly to newly emerging, chronic-care occupations.
At about the same time that Freidson was developing his medical dominance thesis, Terence Johnson, who was later to be central in attempts to develop a ‘class’ theory of medicine, wrote about professionalism as one stage in a typology of occupation-client relationships (Johnson 1972). Patronage was a type of profession-client relationship in which clients define both their own needs and the way these needs are met. Collegiate control existed when the practitioner defined the needs of the client and the manner in which these needs were met. Mediation is the situation in which a third party, usually the state, mediates the relationship between practitioner and client, defining both needs and the way in which these are filled. The ‘ideal type’ of a profession was thus collegiate control and was generally associated with a homogeneous occupational community and a heterogeneous client population. If viewed as a historical sequence these types could almost be viewed as describing the history of medicine.
Adherents of the neo-Weberian version of the ‘power’ school of the professions came to see medicine simply as one of many occupations that used exclusionary strategies to gain and maintain a market monopoly. This monopoly enabled the profession to gain unprecedented control, not only over its own work, but also over health and health care in general.
Freidson’s influential formulation was itself criticized, mainly from a Marxian position, for failing to spell out the class basis of the relationships between professions and the capitalist state (see Frankenberg 1974; Johnson 1977; McKinlay 1977). While Freidson felt that ‘relationships with an elite, and with the state’ were important, he failed to theorize the crucial links between medical power and external forms of power. Marxists (and some Weberians) were led by their perspective, which tends to look at modes of production or social formations as a whole, to take a more holistic view. Beginning in the middle 1970s, a post-Freidson analysis emerged based on a political economy perspective. Although the new political economy cannot be entirely identified with Marxism, many of the writings in the area originate in Marxism or neo-Marxism (Doyal 1979; McKinlay and Arches 1985; Navarro 1976, 1986; Waitzkin 1991). Less traditional writers in the political economy tradition include Derber (1983, 1984) and Larson (1977, 1980). The neo-Marxists ‘bring the system back in’ by insisting that the functioning of specific types of modes of production (presently capitalism), and the class structure within these, produces or conditions events in every sphere of existence, including that of health. This explains their interests in the class bases of medical power as well as the dynamics of capitalism as a whole, which ‘elicited’ or ‘permitted’ a particular kind of medicine to rise at one point but challenged it at another. This approach enabled analysts to escape from the quasi-interest group explanations embodied in some versions of Occupational imperialism (Larkin 1983) or ‘the system of professions’ (Abbott 1988) in which interoccupational competition was simply assumed. While descriptively useful, the ‘system of professions’ approach failed to explain, as opposed to describe, why there was a hierarchical structure underlying occupational differences and why some occupations rather than others come to be dominant.
A major difference between neo-Marxist writers and others in the health field lies in the neo-Marxist’s view that the logic of the capitalist system (the profit imperative, the drive to rationalize, make more efficient and controllable the means of production) and the struggle between social classes, shapes and limits occupational struggles. While medicine is powerful, Navarro and others insist that the profession is an intermediate source of power and not the ultimately determinative one. Within this formulation the state, the major guarantor of professional monopoly, is not simply a ‘referee’ between competing occupational interest groups, but is structurally constrained by its reliance on a capitalist economy as well as being influenced by class struggle in civil society.
The rise of medicine to a preeminent position within the health division of labour is seen in class terms. Navarro (1976, 1986; see also, Johnson 1977), for example, argues that medical power is partly based on its relationship with a particular class rather than with a ‘societal elite.’ Medicine emerged as a profession because its appeal to science and the dominance of curative over preventive medicine coincided with, or at least did not contradict, the interests and ideology of a rising class of industrialists – what might be called the ‘class congruence’ thesis. Brown (1979) for example, pointed to the role of the Rockefeller and Carnegie Foundations in the United States as shaping and ‘scientizing’ medical education.
Scientific medicine was particularly congruent with the new theories of scientific management in industry. Medicine’s individualist and mechanistic orientation obscured the social causes of disease. Capitalists appealed to this ‘neutral’ new science as a justification for the implementation of mass production methods, that is, new techniques of production were scientific, science was neutral, and therefore the new factory production methods, which many saw as dehumanizing and exploitative, could not be attacked on the grounds of the exploitation of one class by another or as simple profit-making at the expense of others. Medicine appealed to the ideology of science to justify its own market monopoly and its increasing control over the health division of labour (Shortt 1983).
Health itself is an arena for profit making. Through the commodification of health, the production, advertising, and distribution of drugs and hospital and medical supplies and technologies, and the direct ownership of health institutions and commercial health insurance agencies, the corporate class partly defines what medicine does and how it does it. Many analysts, particularly those in the United States, now believe that control of the health sector by corporations leads to the proletarianization of the providers. The rationalization and routinization of healthcare work accompanying state and/or corporate drives for efficiency are evidence of this process, which we will discuss later.
The predominance of class over profession is illustrated by the implementation of health policies opposed by medicine, but supported by (or, more weakly, not opposed by) the bourgeoisie or by the state (state policies being a partial reflection of a class struggle in which the working class plays a part). The implementation of health insurance schemes or national health systems and recent state or corporate attempts to ‘rationalize’ health care are the major instances. The claim is that the profession’s input is increasingly more confined to shaping existing decisions in its own interests than to the major decisions (or nondecisions) themselves.
Neo-Weberian Closure Theory
Neo-Marxist approaches have been criticized because they are sometimes restricted to highly abstract analyses. There are few Marxist empirical studies of the linkages between macro-, meso-, and microstructures (the main exception to the latter is the work of Waitzkin 1991), and because of this there are difficulties incorporating nonclass cleavages (e.g., gender, race) into Marxist theory. There is also somewhat of a disjunction between a focus on class and a focus on occupation; these intersect, but are not identical. That is, one can have class-homogeneous and class-heterogeneous professions, as well as occupationally diverse classes.
Although some have criticized specific aspects of Marxist theory, others take issue with the whole Marxian or neo-Marxian schema. Parkin (1972), for example, builds a theory, loosely based on Weber, which is partly applicable to medicine. The essence of Parkin’s position is that relationship to the market (Weber) is much more important than is relationship to the means of production (Marx). Parkin feels that the main class fissure in society is not based on differential relationships to the means of production, but occurs between those groups (based on various criteria) who are attempting to preserve or enhance a dominant market position (through ‘exclusion’) and those groups who are attempting to encroach on the power and privileges of dominant groups (through ‘usurpation’).
When applied to the health scene, this Weberian foundation led, not only to the formulation of various forms of ‘power’ theories of medicine, but to attempts to develop a theory focusing on interoccupational competition, that is, to various forms of ‘closure’ theory (Collins 1979; Murphy 1988). In this view, various occupations or groups were viewed as using a variety of criteria to exclude others and/or to attempt to usurp the power of others. Sociological studies within this genre, while descriptively interesting, had rather weak explanations for the processes described, that is, why was one group rather than another successful in its strategies? Murphy attempted to remedy this deficiency by postulating principal, derivative, and contingent forms of exclusion. Within capitalism, the legal title to private property was the principal form. Thus, Murphy, like the neo-Marxists, would view medical power within capitalism as partially contingent on its fit within the class structure.
Generally, closure theory seemed useful because it appeared to have the ability to include many ‘non-class’ factors into the analysis. That is, occupations used various rules of exclusion, whatever seemed available in the social formation at any particular time, e.g., gender, race, religion, to exclude competitors. However, as noted, such formulations also had problems (Manza 1992; Murphy 1988). Not only was the original relationship between closure and class theory often lost sight of but the application of concepts such as exclusion, usurpation, or dual forms of closure sometimes appeared to substitute for analysis or was circular in reasoning (Manza 1992). Closure analyses became little more than a study of Occupational interest groups. When closure theory appeared most cogent, as in the work of a sympathetic but critical supporter such as Murphy, it approached neo-Marxist theory even though it was formulated in an attempt to counter Marxist views. Conversely, when neo-Marxist theory seemed most persuasive it was almost neo-Weberian.
Some theorists, such as Larson (1977), were difficult to classify as being in either camp, and there were calls for the greater integration of insights derived from Weber or from Marx. Larson analysed the rise, not only of medicine, but also of the professions in general in the nineteenth and twentieth centuries. She describes the ‘professionalization project’ as including gaining control over a market for expertise and a collective process of upward mobility. Control over the market involves standardization of the ‘production of the producers’ and the development of a cognitive base for professional claims. Relating these processes to wider structures, Larson views professional ideology as congruent with a number of facets of liberal ideology in capitalist societies. The professionalization project constituted a justification for new forms of inequality since there is, with the institutionalization of professional education within the university, an apparent matching of rewards with achievement.
The Proletarianization of Medicine Debate
Power theories of medicine did stimulate a body of work on the nature and fate of that power. Historically minded sociologists, such as Larson, noted that medicine had not always been as powerful as it was in contemporary society. Medical power was spatially and historically variant. In the 1980s, almost simultaneously, fairly similar book-length analyses appeared in a number of countries including first the United States (Starr 1982), and then closely followed by Australia (Willis 1989) and the United Kingdom (Larkin 1983). (For a shorter Canadian treatment see Coburn et al. 1983.) All of these studies focused on historical variations in medical power and explanations for such variations. Whereas the initial attention was devoted to how medicine came to rise to a position of dominance, the later focus became whether medicine has experienced declines from its once almost hegemonic position, and how such changes are to be understood. The findings of these studies ranged from claims that, in the latter part of the twentieth century, medicine had declined in power, to those who argued that although medicine had been challenged, it had actually crystallized or maintained its power in the face of various threats, these often emanating from state incursions into the province of health care.
However, the debate was really begun by those writing from a neo-Marxist perspective such as Navarro (1976) and McKinlay and Arches (1985). These authors claim either that medicine had never been dominant because medical power was always contingent on the relationship between medicine and outside sources (Navarro 1988), and/or that recent developments in the ‘industrialization’ of the medical area has led to the proletarianization of medicine in general (McKinlay and Arches 1985; McKinlay and Stoeckle 1988; Salmon 1994). A debate was thus opened between those who believed that medical power had declined versus those who argued that medical power had simply changed its form or nature. The ‘proletarianization of medicine’ debate is somewhat clouded because of the use of the term proletarianization in a less than clear-cut manner, and because of the use of differing national examples. To some, the term proletarianization implies a move of medicine to working-class status, a claim which could easily be refuted. Although McKinlay and Arches had insisted that they were only focusing on a trend rather than an end point, others felt the term proletarianization implied too much. The notion that the process of proletarianization refers to developments within a particular domain of labour and not (only) to a single occupation is ignored. The proletarianization of some implies that others are gaining in power and control (Larson 1977).
Contrary to McKinlay and Arches, a number of British writers claim that medical power within the health-care division of labour (itself only one aspect of medical dominance) has been ‘crystallized’ rather than reduced by state power. That is, state regulation of the health professions (and even of unorthodox ‘competitors’ to medicine) at this particular point in history embedded in law and statute a situation of medical control over other health occupations (Larkin 1993; Larkin and Saks 1994). Even assuming Larkin and Saks are correct about the crystallizing effect of legislation, however, one might still argue that new legislation creates a new terrain, with newly legitimate ‘actors,’ on which medicine is challenged. In addition, because of the focus on only the health-care division of labour, this formulation also leaves open the possibility of the decline of medical power in other areas, for example, regarding broader health policy or regarding physicians’ relationships with their patients.
While some British writers claim that medicine, while challenged, is still dominant (for example, Elston 1991), others feel that medicine might have declined to a position of ‘responsible autonomy’ (Dent 1993) or worse (Flynn 1992). Freidson himself at first (1985) argued that medicine had not lost its power even though these arguments were weakened by an implicit move from a contention that medicine was dominant to one in which medicine was still a profession, the latter implying only autonomy rather than dominance, but there is an increasing consensus, from observers in many different countries from Australia to Norway, that medicine is on the defensive (Gabe et al. 1994; Hafferty and McKinlay 1993).
Some of the differences between writers on either side of the ‘decline’ versus ‘maintenance of power’ debate rest on whether the glass is viewed as half-full or half-empty. That is, no one would argue that medicine is not still the single most powerful profession in health and health care; the question is, is it as powerful as it once was, and is this trend reversible or not? The notion that professionalization is a strategy of gaining control over a particular work domain implies continual struggles over such control. Certainly, the rise of competing centres of power diluted the centrality of medical interests. The reasons for this lay in changes in the broader political economy rather than with the nature of medical knowledge itself. The authority of medical knowledge, one of the bases of medical authority, was itself said to be the result of political processes (Starr and Immergut 1987). Even so, wider structural changes could be viewed as interacting with internal changes within medicine. Medicine became more fragmented by speciality, in many countries more ‘feminized’ and, many analysts asserted, more divided between practitioners, scientists, and academic and medico-political elites. Medicine was being internally fragmented or stratified just at the time that it was being externally challenged. Because of their emphasis on social formations as a whole, Marxists were more likely than others to see external challenges as fundamental rather than simply superficial signs of accommodating professional and state/business interests.
There also were differences in emphasis about the major challenges to medicine. Some, such as Haug (1975), emphasized a decline in medical authority over patients (i.e., deprofessionalization). Others focused more on the increasing surveillance of states or corporations over medical work (i.e., proletarianization). Recently, Weiss and Fitzpatrick (1997) have interpreted the concepts of deprofessionalization and proletarianization, not as alternative ways of viewing challenges to medicine, but as referring to distinctly different processes. They argue that proletarianization pertains to occupational control, whereas deprofessionalization is tied to the demystification of medical knowledge.
The increasing specification of what is meant by physician dominance and control, that is medical dominance over what, where, and when, and the different domains in which medical power is exercised, however, has also led to discussions about the meaning of autonomy, said to be the basis of professional power. Even examining the notion of’self-regulation,’ the measure of professional autonomy, it is clear that one cannot assume a profession is self-regulating simply because of the existence of organizations supposedly embodying self-regulation. Moran and Wood (1993), for example, point to the increasing prevalence of a ‘state-constrained’ self-regulation. There is a type of meso-corporatist medicine-state relationship (Cawson 1985), but this relationship is heavily state-shaped. Still, few would disagree with the argument that the exertion of power by medicine brings with it countervailing attempts to control or curb that power by others or, conversely, that medicine is now attempting to protect its own privileged position from external attack (Light 1995; Mechanic 1991). We are speaking of a process rather than an ‘end-point.’
Given the various dimensions of dominance, and the variety of ways in which dominance or autonomy could be assessed, there is much room for confusion and controversy over the rather crude issue of a possible decline in medical power. Has some crucial threshold been passed? Arguably yes, since the contingent nature of medical power is now more visible. There is, however, more consensus about a decline of medical control over health-care policy, the context of care, than there is about a decline in other domains of medical power.
As noted, the contention of decline is not simply based on changes in the health-care division of labour, but on much wider processes. Not only are states and corporations intruding on medical territory, but within the legal system there is evidence of a broader questioning of medical authority. In Canada, for example, legal rulings have increasingly favoured patients regarding what constitutes adequate information regarding consent to treatment. Legal criteria have shifted from judging adequate consent as being what a reasonable physician would divulge, towards what a reasonable patient would want to know. Some see evidence for the decline in the dominance of the medical profession in the rise of alternatives to, or complements to, medicine and the inability of medicine to prevent this. The question though, as Saks (1995) has argued, is whether these changes are more the result of wider sociopolitical forces rather than anything specific about the alternatives themselves. The nature of these wider sociopolitical changes are encapsulated in debates about the posited historical transformation of the advanced capitalist economies from (late) modernism to postmodernism. One feature of this mooted change is the emergence of what might be called postmodern values, which include a scepticism about the ability of science and technology to provide answers to the problems of humanity, including illness, and the resultant emergence of ‘new age’ and alternative health-care practices. Challenges to medicine are thus social and cultural, and not only organizational or technical (Hafferty and McKinlay 1993).
Much of the literature on medicine is still embedded in the ‘decline or stability’ debate to the neglect of other areas of interest. The decline argument has become partially specified into whether individual physicians or the profession as a whole is declining. In the restratification thesis, for example, Freidson (1994) claims that the profession as a corporate identity has retained power, while individual physicians may have become more open to influence from these elites (Annandale 1989). Contra Freidson, however, others assert that the state, in particular countries at particular times, has influenced medicine through coopting or constraining the organized structure of medicine (Coburn et al. 1997). It is true though, that the nature of the relationships between practitioners and the organized profession is always problematic, and that more attention now needs to be devoted to medicine’s changing internal structure in interaction with ‘external’ developments.
The ‘rise and fall’ debates also tended to ignore national differences. There may be both ‘real’ and ‘theoretical’ differences among nations. Much of the ‘rise and decline’ debate focused on the English-speaking world and on Europe. Even within this restricted range of nations, however, there are striking differences in the role of medicine. In many European countries, in particular, the profession had all along much closer ties with the state than it did in the Anglo-American context even though, in most of these countries, medicine is being challenged by the state or by the possible introduction of state-regulated markets (Wilsford 1991). However, not only do national social structures, health-care systems, and the role of medicine within these vary, but social scientists in these countries adopt particular theoretical perspectives. For example, in Britain, after a period in which Marxism had appeared to be theoretically ascendant, neo-Weberian sociology, viewed as in opposition to, or as a corrective to, Marxism, gained many adherents. In fact, some forms of neo-Weberianism were so ‘adapted’ to the increasing right-wing political scene in Britain that it sometimes seemed a justification, not only for liberalism, but also for neoliberalism. More generally, political analyses of health care, or of the role of medicine, seldom mention broader structural forces. The structural determinants of politics disappeared into the analysis of particular political personalities such as Margaret Thatcher or Ronald Reagan.
A crucial aspect of many views of medical power is the role played by knowledge; for example, the trait theorists’ emphasis on the role of esoteric knowledge in leading to, or producing, professional power. This emphasis on knowledge was reinforced by the more recent Foucauldian view of the inseparability of knowledge/power. The control, by a relatively small, homogenous community, over a body of knowledge applied to health care, a vital aspect of human societies, was, many felt, an important, perhaps crucial, underpinning of medical power. This formulation indicated the importance of medical control over the production and application of new medical knowledge. Although much ‘medical’ knowledge was produced by nonphysicians, it was created within medical schools, health science centres, and hospitals, in which physicians had administrative control, privileged access to research funds and to patients, and whose research was heavily reinforced by the association between medicine and the pharmaceutical industry. Physicians’ monopoly of access to patients and to the prescribing of drugs were powerful barriers to research by other professions.
Implicit in the view that knowledge is the basis of the power of medicine is the assumption that only some aspects of medical practice are potentially reproducible. Jamous and Peloille (1970) noted that professional practice embodied a ratio of both a less reproducible tacit form of practice (indeterminacy) and a more reproducible ‘science’ (technicality), the I/T ratio. The lower the I/T ratio, presumably, the more the profession was open to routinization and proletarianization. Yet, recent developments towards the ‘rationalization’ of health care undermined the authority of medicine. Planners, managers, and economists were now more expert in healthcare systems, or so they claimed, than were physicians. Even at the level of clinical practice, new corps of clinical epidemiologists and others, often at the behest of governments, were busy formulating what worked and what did not, or what were optimal or general ‘clinical guidelines’ to form the basis for ‘evidence-based medicine’ (Rappolt 1997). These guidelines can be understood as lowering the I/T ratio by increasing technicality at the expense of indetermination. Medical knowledge had shown itself vulnerable to being nibbled away at the edges. Knowledge boundaries, it seemed, were set politically rather than by any inherent logic of science (Starr and Immergut 1987). Medical knowledge, said to be one of the major sources of medical power, was being undermined. The focus shifted from the assessment of knowledge to study of the determinants of ‘claims to knowledge.’
Although neo-Weberian and neo-Marxist power theories of the profession have been the most popular (for a critical view see Saks 1983), there are challenges to both of these paradigms. First came the challenge of feminist theory, then that of a new view embodied in Foucault’s writings, and, more generally, postmodernist or relativist views of the human condition. To a very brief consideration of these we now turn.
Medicine and Feminism
The development of ‘women-orientated’ approaches in sociological theory was, perhaps, more evident in the area of health and health care than in any other. Feminists focused on women as carers and women as patients. Feminists claimed that most healers had been women; and the rise of medical dominance in the eighteenth and nineteenth centuries meant that men appropriated much of the healing that had previously been the task of women. Furthermore, conventional approaches to the professions, it was argued, were gender-blind (Witz 1992). A frequent case study was that of midwifery (Bourgeault and Fynes 1997; Donnison 1977/1988), in which women helping other women were, in the nineteenth century, replaced by male obstetricians. Conversely, the recent revival or ‘rise’ of midwifery in a number of countries might counter some of the ‘continued dominance’ thesis. Riska and Wegar (1993), Witz (1992), and others seized on closure theory as a way of explaining female subordination within health care and within medicine. That is, the health occupations were viewed as territories of exclusion and usurpation in which gender was a major exclusionary criterion. However, female-dominated professions themselves attempted to subordinate female alternatives (dual closure).
Within the health-care system most of the ‘subordinate’ health professions were composed of women. Thus, the health-care division of labour developed into a form characterized by a largely male medicine controlling a largely female group of ‘auxiliary’ providers. The latter reflected what some had claimed was the ‘uniquely’ feminine role of caring and housekeeping. The female caring occupations had become part of the official health-care division of labour at a time when it was generally assumed that women’s roles in the public sphere should approximate those in the household (i.e., caring and housework rather than the ‘technical’ work of curing). Within medicine itself women had first been excluded, then only grudgingly admitted. Since the Second World War, however, women have, in most countries, rapidly risen as a proportion of medical students, although not yet as a large proportion of the practicing profession (apart from in some of the Eastern European countries). Still, it was claimed that, even with the advent of a powerful women’s movement, patriarchal ideologies and structures permeated medicine and ensured that women were kept in low-status ‘feminine medical enclaves’ such as pediatrics and family practice (Riska and Wegar 1993). There are still few female surgeons or women Deans of Medicine. It might also be claimed that those women who are more ‘successful’ are either in feminine enclaves, or have been ‘masculinized.’ There is also discussion about the relationship between the ‘proletarianization’ of medicine and the increasing number of women medical students and physicians. Is medicine becoming proletar-ianized partly because of the increasing percentage of women in the profession, or is the increasing number of women a sign that medicine had already begun to decline in status and power?
Approaching health care from the viewpoint of women also opened up study of ‘unpaid healers.’ That is, there is a greater focus than previously on the extent to which health care is given in the home, generally by women. This forced more consideration than previously of the linkage between the ‘public’ and ‘domestic’ provision of health care, a topic previously ignored. Much feminist attention, however, was paid to the health of women rather than to the health-care system per se. There was a particular emphasis on the relationship of patriarchy to the topics of women’s sexuality and reproduction. The male dominance of medicine or of healing generally had its consequences, feminists assert, in the ignoring of female medical conditions and/or in the examples of various sordid periods of medical history of the late nineteenth and early twentieth centuries of ‘sexual surgery.’ Medicine, far from being some form of neutral ‘science,’ rather directly reflected the class and patriarchal nature of society at that time (Ehrenreich and English 1972, 1976).
However, recent decades have witnessed the rise of powerful female social movements aimed at reclaiming health care for women, exemplified by one of the earliest women’s health books with mass popularity, the Boston Women’s Health Collective’s book, Our Bodies, Ourselves. This publication, and the movement underlying it, illustrated the beginning of attempts to re-appropriate what was previously ‘women’s territory’ from the male-dominated profession, often through an emphasis on self-care. Such women’s issues as matters of reproduction, childbirth, and the menopause are major foci of attention. The midwifery movement, which in some countries constitutes a challenge to medical hegemony, was reinforced, and elsewhere revived. Still, questions of ‘too much’ or ‘too little’ care (versus most appropriate care) arose, and the pronounced longevity of women as compared with men led to an emphasis on illness and care rather than on length of life.
Feminist writers have made a major contribution simply by pointing out how gender had previously been ignored both regarding the functioning of health-care systems and regarding women’s health. Medicine is viewed as one vehicle through which patriarchal modes of control are produced and reproduced. There may, however, be a historical difference between forms of male domination. Turner (1995) has made the useful distinction between patriarchy and patrism. The former refers to a situation in which male dominance is embedded in law, statute, and societal norms. In the latter, patrism, there is less legal and open political support for female subordination. Such a formulation might help us understand the changing, yet in some ways unchanging, gendered nature of the medical profession, and of the health-care system generally.
Foucault (1973, 1976) also broke with the Marxian/neo-Weberian schools by focusing on the micropractices of power. Not only did Foucault argue that power was both enabling as well as constraining, but also that power and knowledge were inextricably intertwined. Theorizing an area meant constructing it and gaining power over it. Foucault’s writings also emphasized the double-edged nature of the move from crime or punishment to medical care (medicalization). Both involved aspects of social control, the latter no less than the former. Thus, the advent of ‘public health’ or ‘health promotion,’ for example, could be viewed as an extension of the panoptic ‘medical gaze’ into lifestyles and the most intimate habits of the general population, and not only as a beneficial strategy in the drive to ‘cure or prevent disease’ (Petersen and Bunton 1997). As Johnson (1995) notes, the professions, and medicine specifically, form part of the expression or projection of ‘governmentality’ into civil society.
Most recently, Lupton (1997) believes there is a more complex relationship between doctors and their patients than previous structurally oriented theories seem to permit. Arguing that, following Foucault, power can be viewed as ‘power to’ and not simply ‘power over,’ she notes that both patients and doctors might gain in power at the same time, that is, power might not be a zero-sum concept. These findings, along with those of Weiss and Fitzpatrick (1997), suggest that viewing medicine versus the state, versus managerial control, or versus patients might not adequately represent the complex forms of power that emerge from interaction among patients, doctors, and the institutions in which doctors work
Of contemporary theories, Foucault and feminist theory have so far had the most influence on theories of the medical profession. Yet it seems unlikely that the current ferment and fragmentation of sociological theory will not have an impact in the future. For example, postmodernist or social constructionist perspectives, with their scepticism of knowledge, including medical knowledge, are relevant to theoretical perspectives on medicine. Similarly, sociological theories characterizing high modernity as ‘the risk society’ (Beck 1992) may assume importance. Given an emphasis on risk, and the ambiguity of health risks, expert knowledge, including medical expert knowledge, could be central social foci. Certainly, as Turner (1995) points out, there now is an insatiable appetite for things medical, an ever-increasing medicalization. Whether the medical profession is the chief origin of this trend, or is its major beneficiary, is in doubt. However, when particular types of supposedly healthy, everyday foodstuffs can be categorized as ‘neutraceuticals,’ the role of health-care business and the centrality of ‘healthism’ are underscored.
There are, however, somewhat more prosaic, but still potentially important, theoretical openings. One of these is the neo-institutionalist view of the professions of Thomas Brante and his colleagues in Sweden (Brante 1998; Castro 1998). These researchers point to the different institutional domains in which medicine (and the other professions) practice, and the effect of these settings on the values, attitudes, and actions of practitioners. For example, physicians in public service or in the private sector develop quite different views about various types of publicly provided health services. The neo-institutionalist view, incidentally, reinforces the notion of the increasing fragmentation of the medical profession.
Yet, as noted, the newer theoretical trends sometimes point in different directions, with postmodernism indicating scepticism of things scientific, medical, or otherwise, while risk theory would tend towards elevating medical knowledge and medical experts to prominence. Although these different visions, and more culturally and phenomenologically orientated viewpoints, are prominent in sociology, their influence on theories of medicine still lie mainly in the future.
Contemporary Changes in Health Care and Theories of Medical Power
Medicine and health care face fundamental changes in the contemporary era. Within the advanced capitalist countries came the rise of neoliberalism. The Keynesian welfare state, however muted, or however divided into various ‘types’ (the Anglo-American countries are generally of the market-orientated or ‘liberal’ variety-see Esping-Andersen 1990), was powerfully attacked by worshippers of market solutions (Stubbs and Underhill 1994).
Although in many ways confined and constrained by various forms of health insurance, medicine benefited financially from the onset of the welfare state and the emergence of mass markets for medical care, whether these had been more state-directed or more market-orientated. While on the one hand physicians gained income or income certainty, on the other hand, their professional prerogatives began to be cribbed and constrained by increasing public or private pressure and regulation. The claim of those who had all along felt that medical power was contingent on the congruence of its interests and ideology with those of dominant classes also received support. When nonhealth corporations saw health-care costs as a problem, their interests were no longer aligned with those of a profession that saw itself as profiting from larger health-care budgets. Physicians no longer controlled state policy making from the inside; they were increasingly ‘external’ to a state that had its own reasons for gaining control over the health sphere. At the same time, major corporations in the United States, for example, formed an implicit or explicit coalition with state efforts to control health care costs and the work of physicians, although business was divided between those involved in health care and those not (Bergthold 1990; Martin 1993).
Although medicine is currently challenged, might the rise of neo-conservatism and struggles over the role of the state generally, as well as the internationalization of capital, consolidate or even increase medical power? Some physicians still hold to the ‘ideal’ of private practice in the marketplace, and these might be seen as having common interests with an increasing number of neo-conservative governments, but such interest-congruence is not automatic. Strongly ideological market-orientated governments tend to view the professions as unneeded market monopolies. Strikingly, when the Conservative government under Margaret Thatcher decided to reform health care in Britain (instituting, not a private health-care service but a public service in which there was competition and a clear provider/purchaser distinction), the policy committee that made such recommendations totally excluded physicians. If physicians in some countries benefit from neo-conservative policies or attempt to shape these towards their own interests, this is a highly contingent process. Medicine no longer has the power to define health and health care on its own terms. Which is not to say that medicine is totally unsuccessful or that it is not striving mightily, and sometimes in some instances and in some places for some segments of medicine, successfully, to protect its own interests (Barnett et al. 1998).
More generally, on international differences, it seems no accident that the proletarianization thesis first arose in the United States, where private health service provision is prominent. In the United States, privately owned provider organizations have a direct economic interest in ensuring that physician services are efficient and profitable. Thus arose more microcontrols over physicians in the United States than in countries in which the provision of medical services was more public in nature. Dohler (1989) goes so far as to suggest that physicians’ clinical autonomy is more protected in ‘state run’ health-care systems than in those more entrepreneurial or private in nature. In the publicly run systems, once some form of control over increasing costs had been put in place, the state, it is claimed, tends to leave purely ‘clinical’ matters in the hands of the profession. This is particularly true, it appears, because politicians do not want to be involved in messy medical matters, easily made the subject of daily newspaper headlines. Such a formulation, however, probably overemphasizes the distinction between microcontrols over medical work and macropolicy (Light 1995). Certainly, in a number of publicly run systems, macrocon-trols, such as the almost universal controls over the use of technologies, has an impact on what individual physicians do or are capable of doing at the clinical level. The work of physicians is also influenced, directly and immediately, by the forms and content of payment mechanisms (e.g., fee-for-service versus salary versus capitation). Also, the prospect of real competition promised by some New Right political parties, makes many professional groups nervous. Still, the exact trajectories and nuances of state/business involvement vary across countries, as do the sources, nature, and degree of challenges to medical power. What does seem common, however, is that medicine no longer sets the agenda.
Theories of the rise of supranational trade blocs and globalization brought speculation concerning how various phases of capitalism and changes in medical power might be related. It was suggested that the change from entrepreneurial to monopoly to global capitalism is reflected in the historical rise, maintenance, and then decline of medical power (Coburn 1999; Ross and Trachte 1990). In particular globalization, carrying with it rising business power and unity, produces an increased incongruence between the interests and ideology of business and that of the medical profession.
On a less abstract level, some theorists feel that the rise of supranational organizations, as in the EU, leaves an opening for professional associations, including medicine, to regain some of the power lost under specific national governments. The lack of existing supranational organizations provides leeway for the well-organized medical profession (among other professions) to begin setting its own standards and regulations, free from the constraints it had previously faced when medicine was regulated within national boundaries. Others argue that the state is ‘withering away,’ or is being replaced by the ‘regulative state (Ruggie 1996).’ The regulative state is not directly involved in the provision of services, but it still provides the standards and rules for those in the private sector who do. Whether these developments are real or only speculative, and whether or not they can be exploited by medicine to its own advantage are still open questions.
Finally, although we have emphasized the influence of society on medicine, the impact of medicine, and recently medical science, on society is considerable. New diseases such as HIV/AIDS and new methods of diagnosis of ‘invisible’ defects promote the view of all of us as ‘deficient’ or ‘at risk.’ Scientific and technological innovations in the areas of reproduction and genetic manipulation produce, not only new ethical dilemmas, but visions, some Utopian, others more Machiavellian, of new forms of social life and organization based on radically different concepts of what were previously taken to be ‘natural’ human conditions and institutions. These, however, are fairly speculative issues and it is uncertain what their implications are for the role of the medical profession and for medical work.
The picture that emerges from a focus on the power of medicine is one that increasingly portrays medicine not as a unique occupation, but as one whose work is seen more and more as subject to processes of regulation and codification, similar to those affecting other occupations. While medicine can certainly still claim to possess clinical autonomy, its claims to dominance are less persuasive than they were, although this is true in some areas more than in others. This occurs, ironically, at a time of seemingly ever-increasing medicalization and scientific medical innovation.
It is now difficult to believe that medical knowledge itself has unique properties, which are the main source of medical power. Certainly medicine is a complex occupation, charged with highly emotional tasks associated with birth, illness, and death, but its knowledge is clearly supported by particular social practices, such as its control over the production of new knowledge and its association with the drug industry, rather than being of some ‘special’ nature. No doubt physicians will never be told what to do in their day-to-day work, although that work will be limited, shaped, and directed by external forces, including payment mechanisms and the nature and source of funding of care. Still, we also do not direct the detailed ‘clinical’ work of a plumber either. The boundaries of the claims of medicine to control over its own work and knowledge are clearly political in character. While scientific knowledge advances, medical knowledge is now viewed with some postmodernist scepticism.
The rise of neoliberalism on a worldwide basis has produced a number of strains on the medical profession. On the one hand has come increasing public and private institutional pressure towards the rationalization of care. On the other there are rather ambiguous relationships between medicine and currently dominant neoliberal governments and ideologies. Given the reliance of the medical monopoly on a mandate from the state, changes in the state, or in those societal institutions influencing state power, have ramifications for the medical profession. While there are some ideological affinities between neoliberalism and some segments within medicine, even the prospect of privatization is not necessarily appealing to most physicians. Ironically, in some instances physicians are now viewed as defending one of the remaining outposts of the welfare state, that is, the public provision of health care. To protect their own work domain, which in many countries lies in the public sector in national health systems or national health insurance schemes, doctors, if perhaps only coincidentally, defend health care against neoliberal attacks.
On the theoretical level, neo-Weberian theories appear useful in the description of interoccupational struggles, and in including ‘non-class’ aspects of social closure, but are less successful in understanding these conflicts or in relating these to wider processes. Neo-Marxist approaches are more adequate regarding understanding interoccupational successes or failures through delineating how these are embedded within broader class structures, while they are not as successful in understanding occupations per se. Perhaps neo-Marxism can more successfully exploit recent changes towards the internationalization of capital to its own explanatory ends than can Weberian theory. In the more sophisticated versions of both approaches, medical power is viewed as contingent on medicine’s relationships with dominant elites or classes. However, much more needs to be done to explicate the precise mechanisms and institutions through which medicine is shaped.
Recent theoretical perspectives do not as yet present anything like complete alternatives to the two major approaches noted. Rather, these constitute comments about what is missing in these, or promise much but are as yet undeveloped. Foucaultian perspectives embody a somewhat oppressive view of ‘the medical gaze.’ Feminist theory has shown the blind spots in existing theory, but it is as yet unclear whether this will demand an entirely new theory of medical power or simply modifications of existing theories. Postmodernist or social constructionist views, as well as attempts to theorize the body or to emphasize the risk society, have focused attention on the ‘constructed’ nature of medical knowledge and on medicalization, social control, and the perhaps increased status of experts (Turner 1995). Yet the role of medicine, even in the process of ‘medicalization,’ is unclear. Much medicalization in the modern era reflects the commodification of health as much as the interests of medicine. In the modern era, medicine has thus, never actually been the mistress of its own fate. Ever since it became more attractive to see a physician than to actually avoid one, medicine has been intricately linked to ‘external’ factors and forces at the same time as its internal composition was itself altered.
We began this chapter by noting the dualities and contradictions surrounding medical work. We have claimed that the change from cottage industry to mass markets in health care has profoundly influenced the role of medicine. More and more, in its struggles to maintain or increase its control, prestige, or income, medicine seems like many other health, and nonhealth care, occupations. However, viewing medicine in this way, as simply another occupation seeking monopoly and power, surely does injustice both to medicine and to many physicians. In the first place, the actual work of physicians and the role of medicine are more complex than current theories would indicate, and the somewhat cynical views of medicine in the scientific literature or in the public media have, perhaps, had an influence on physicians themselves, who might increasingly come to see themselves as others do. Yet the original premise of the professions was for more. Medicine still appeals to observers as a ‘service’ occupation, which promises an outlet for altruistic motives. Viewing medicine in ‘power’ terms is surely as one-sided as the previous view of medicine as actually possessing the traits which its leaders claimed (Brante 1988). Whether the altruism, which many individual physicians feel, can actually be fully expressed within current forms of social organization which emphasize the commodification of all forms of goods and services is another question. The organized medical profession itself seems inevitably to focus on power and money, although many individual practitioners do not. While there has obviously been an over-generalization of the authority of medicine, some form of ‘relative autonomy’ is still a minimum condition for the expression of individual creativity and altruism, whether by professionals or by any other worker. An overly regulated medicine directly reflecting state or provider organization goals and aims does not seem an improvement over an overly powerful profession. There is at least an element of truth in some medical politicians’ claims that an ‘independent’ profession is a protector of patients’ interests. Certainly, the interests of patients, individually and collectively, vis-a-vis physicians and the organized profession needs more exploration.
Hence, the dualisms or contradictions with which we began. Modern medicine contains the possibility of doctors as servants and healers, yet they are found within an organized profession with specific interests. The profession is part of health-care systems which often contain incentives perverse to doctors’ more altruistic orientations, and which hinder the ‘rational’ application of various types of expertise. Within the current political, social, and economic context such contradictions cannot, perhaps, be escaped; they can be understood and confronted.