The Ways and Means of American Medicine
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Citation
Allan M. Brandt. 1983. The ways and means of American
medicine. Review of The social transformation of American
medicine, by Paul Starr. The Hastings Center Report 13(3): 41-43.
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REVIEW5S
The
Ways
and
Means
of
American
Medicine
by ALLANM. BRANDT
The Social Transformation of American
Medicine. By Paul Starr. New York:
Basic Books, 1983. 514 pp. $24.95.
he history," medical logic
holds, is the key to successful diagnosis.
Buried in the past is the informationthat
will make it possible for the doctorto treat
the patient effectively. Sociologist Paul
Starrtakes this axiom to heart in a bold
attempt to diagnose the current symptomatologyof Americanmedicine. Ambitious in scope, The Social Transformation
of AmericanMedicine traces the political
economy of health care delivery in the
United States over two centuries. Elegantly written and lucidly organized,
Starr'sbook deservesthe broadattentionit
is currently receiving. In sheer breadth
alone Starr'sstudyis remarkable;for years
to come it will serve as a standardreference. In this respectStarrhas filled a longfelt need for a single-volume, synthesized
treatmentof the developmentof the American medical profession.
The Social Transformationof American
Medicine is divided into two "books."
Book I traces the rise of the profession
from an eclectic, competitive group of
practitionersin the late eighteenth and
nineteenthcenturiesto its currentpowerful
role and high social status, a process that
Starr argues was completed by the first
decades of the twentiethcentury. Book II
chroniclesthe profession'seffortsto maintain its authorityby fighting the introduction of third-partyinterestsin medicine. In
his conclusion, Starrforecasts the end of
professionalauthoritywith the emergence
of major corporationsin the health care
field, topplingthe controlof the individual
practitioner.
Justas Starr'sbook breaksnew ground,
so too it revealscriticalareasin the history
of Americanmedicine yet to be fully exALLAN M. BRANDTteaches history of
medicineat HarvardMedical School and
in the departmentof the historyof science,
Harvard University.
The Hastings Center
plored. In particular,Starrdoes not sufficiently emphasizethe role of science in the
developmentof the profession. Nor does
he take enough account of the historical
primacy of the patient-physicianrelationship. The legitimacyand power of the profession that Starr attempts to detail"professional sovereignty'
"-cannot be
fully understoodwithout adequate attention to these two themes.
The Role of Science
Starrseeks to explain one of the most
difficultquestionsin the historyof American medicine:How did the weak, divided,
insecureprofessionof the early nineteenth
century become the authoritativecultural
power of the twentieth? According to
Starr,a numberof factorsexplainthis dramatic shift. Eagerto avoid the traditional,
positivistic explanationthat scientific advances establishedthe profession,helping
it to restore order and discipline where
competition had reigned, Starr'sanalysis
essentially discounts the role of science.
Instead, Starr places the triumphof the
Americanprofession in the particularsocial and cultural milieu of the late nineteenth century.
For the profession to gain sovereignty,
access hadto be restricted.The proprietary
medicalschools, organizedto turna quick
profit for their owners, simply produced
too many physicians, creating a highly
competitive climate with many poorly
traineddoctors. In orderto attractstudents
from competinginstitutions,these schools
tossed out all educationalstandards.The
few instances when medical schools
sought to raise standardsduringthe midnineteenthcenturyproved short-livedand
costly as enrollmentsdeclined in favor of
diploma mills. Starrviews the demise of
these proprietaryinstitutions,which began
in the last years of the nineteenthcentury
and culminated in the years following
AbrahamFlexner'sfamous reportof 1910
indictingthe quality of Americanmedical
education,as a majorfactor in the rise of
the profession.
The second majorelementin the modem
development of the profession was the
growthof local and state medicalsocieties
dedicatedto limiting competitionand offering legitimacy to their members while
questioningthe credentialsandauthorityof
nonregularpractitioners.These societies,
soon recognized by state legislatures, led
to the thirdmajorchange-the restoration
of medical licensing of physicians in the
last decades of the nineteenthcentury. Licensing had been takenoff the books during the egalitarianJacksonianera as all
claims of authority became suspect.
"Every man his own physician," an oftcited motto, reflectedthe ideals of a numberof medicalsects thathad come to question the benefits of copious bleeding and
heroic purging.
Starr sees the professionalization of
medicine occurring as American society
underwenta revolution in transportation
and communication,as cities and industry
transformedthe social fabric.The recognition of expertise, limited access to educational institutions,and higherinstructional
standardsall led to what he calls "professional sovereignty," the formationof an
economic monopoly on practice.
In the most inventive and original section of Book I, Starranalyzes the high indirectcosts of the house call in traveltime
andthe difficultyof locatingphysiciansbefore the adventof modem communications
and transportation. In this instance,
throughStarr'screativeresearch,we get a
glimpse of the hazards of practice, the
travailof illness and healthcare in the premodem era. The lesson that Starr draws
from this vignette of social history is, unfortunately,too narrow. Starr notes that
physicians in the 1940s averaged from
eighteen to twenty-two patients daily,
predcomparedto theirnineteenth-century
ecessors for whom five patientswas a logistical maximum. "Such figures," writes
Starr, "suggest a gain in productivityon
the orderof 300 percent."Such a comparison fractureshistoricaltime; an office visit
in 1940is not comparableto a house call in
1840. The real point is the remarkable
qualitativedifferencein the very natureof
practice,not the fact thatdoctorscould see
41
more patientsand thus earn more money.
search and explanation. Starr, however,
Whatdoes it mean, for example, thatdocassumes that moder science is much the
tors have spent significantlyless time with
same in all Westernnationsand thus could
their patients? Certainly other factors, not explain the distinctive nature of the
beyondthe doctor'sdesireto maximizeinprofessionin the United States. But in no
other nation was the narrow biomedical
come, explain this importantchange.
Starr'sassessmentof the developmentof
model of specific causality of disease
the modem hospitalalso suffers from too
greeted with such uniformacclaim, espenarrowan emphasison economic determi- cially among those committed to public
nants. Starridentifiesthe "moralassimila- health intervention.Doctors viewed germ
tion" of the hospitalin the firstdecades of
theorythroughthe prismof cultureand sothe twentieth century, the dramaticshift
ciety. To understandthe culturalauthority
from home to institutionalcare. This new
of the professionit is firstnecessaryto unlocus of medicinetrulytransformedthe naderstand that science is culturally conture of illness and its treatment.Yet he
structed.
To say, for example, that medical adfocuses on the doctor'seconomicpowerto
control the institution-the right to admit vance had relatively insignificantimpact
on healthbeforethe introductionof antibipatients,the ability to fill beds.
The hospital,however, had even greater otics, as many historiansnow argue with
muchjustification,is not to say that medisignificancefor cementingthe authorityof
the profession;for it was, afterall, the one
cine did not accrue tremendousauthority
from science in the half-centuryfrom 1880
place where lay people actuallycame into
contact with the wonders of moder high
to 1930. This, despitethe fact that doctors
technology.Even when these technologies duringthis period had little substantialto
were of little therapeutic benefit, their offer their patients, especially when comsymbolic function was awesome. Who
paredto the period since WorldWarII.
controlledthis technology?Who explained
The social meaning of science and its
it to the patient?Only as the doctor acparticularallure to an Americanaudience
quired this expertise were lay trustees is in large measureabsentfrom Starr'sacforced to relinquishthe administrationof
countof the rise of the profession,and yet
the hospital to the physician. This shift,
it was the criticalelement. One need only
Starrcontends,was anotherelementof the
look to Sinclair Lewis's medical epic
profession'sinsistencethat nothingshould Arrowsmith Martinis one of the few hestandbetween the doctor and the market. roes in modernAmericanliterature-or to
And yet this was no simple economic calPaulDe Kruif'sMicrobeHuntersto garner
some sense of this fascinationwith laboraculation; the physician's authority over
tory and clinic. Respect for science behospitalpolicy was groundedon the claims
of scientific expertise; these claims soon
came the bedrock of American medical
grantedthe doctorauthorityto set policies
authority-the rise of the profession canof an essentiallynonscientificnature.Scinot be understoodwithout it. Moreover,
ence repeatedlyoffered the physician enby avoiding any substantivediscussion of
tree into the realm of social and cultural the impact of science on the profession,
Starrhas, in a sense, tacitly accepted the
power.
Starragaingives shortshriftto the influ- notion that science is neutral and valueence of science in his treatmentof the defree. The profession's ability not only to
controlmedicalknowledge, but to shapeit
velopmentof publichealth.In his view the
battlelines in Americanpublichealthhave
as well, has been a fundamentalaspect of
been drawn over the boundariesof who
twentieth-centurymedicine.
would provide care. Would the private
physicianor the stateassumeresponsibility
The Physician-Patient Relationship
for those needinghealth care? Such a forBook II constitutes a more narrowly
mulation,however, misses a criticalpoint;
constructedanalysisof healthcare politics
both privatedoctors and public health ofin the twentiethcentury, in particular,the
ficers adoptedessentially the same model
of healthand disease duringthe first years profession'srear-guardbattles against the
incursionof outside controls on practice,
of the twentiethcentury,a model thatemits opposition to federal insurmedical
individual
the
need
for
especially
phasized
attentionrather than social interventions ance programsand prepaidgrouppractice.
The centralfocus of Starr'sargumentis the
such as betternutritionor housing.
considerationof health care as a comrefurther
so
demands
this
was
Why
42
modity, one thatthe professionhas consistently contended must-because of the
unusual nature of the healing relationship-be offered to the buyer (patient)directly by the producer(doctor).
Starrseems to distrustthis rationale,to
see it as a subterfugeon the part of the
professionin orderto maintainits power.
But he never takes on this argumentdirectly. What has been the significanceof
the doctor-patientrelationshipfor determiningthe patternof care that emergedin
twentieth-century American medicine?
And how has it changed over time?
Though the AMA's persistentand largely
successful efforts to keep the government
out of health care are critical, as Starr
clearly demonstrates,these overt political
efforts fit into a larger patternof cultural
politics. The American medical profession's ability to maintain its power and
authoritywas as much the resultof private
exchanges in the doctor's office as lobbying in congressionaloffices.
Considering the work of medical sociologists, historians, and anthropologists
duringthe last decadein reconstructingthe
particularcontexts of health, disease, and
healing, Starr's study is surprisingly
orthodoxin its focus on the traditionalpolitical economy of medicine. How, for example, has this complex structureof health
care that, Starrargues, was createdlargely
at the behestof the profession,affectednot
just the qualityof healthcare, but also the
productionand distributionof health and
disease in our society? Moreover, how
does this system of care affect the way our
society identifiesproblemsof disease and
dependency?
Such questions are critical to understanding the social transformation of
Americanmedicine; yet they remain outside the frameworkof Starr'sanalysis. His
book is less about the hows and whys of
practicethanaboutthe ways and means;it
is aboutthe doctor'sbattleto establishexclusive rightsto the clinical domainrather
than the nature of practice within that
sphere.The blood and guts of the practice
of medicine are missing-the internaldynamics and value conflicts, the burdenof
illness, the power and limits of intervention. In short, this is antisepticmedicine.
Missingfrom Starr'saccountis any substantivediscussionof physicians'incomes
in the twentiethcentury.It is on this issue,
however, that the historical tension between altruismand self-interest,obligation
and elitism, is often broughtforth, helping
The Hastings Center Report,June 1983
to articulatethe ethicalconflictsinherentin
practice.But it is not the doctorswho are
the villains of Starr'sbook. Indeed, their
grasp on Americanhealth care is quickly
slipping. Rather, it is the so-called
medical-industrialcomplex, the corporate
ambulance-chaserswho threaten to turn
health care into franchise businesses like
MacDonald'sor BurgerKing.
Starrfinds the prospectof an industryof
multinationalsreplacingindividualpractitionersominous. And indeed, the very notion of hospital chains offering sales on
triple bypass surgery-"'have it your
way"-or factoryrebateson renaldialysis
machines offers a poor prognosis for
American health care. Many physicians
and patients will, no doubt, read Starr's
conclusionsandgasp;but it is his view that
the corporationis here and the future is
bleak, the result of a growing supply of
doctors,federalmismanagement,and current political policies favoring the private
sector.
How American medicine was able to
embracemodernitythrougha new science,
Morality
and
at the same time clinging to an essentially
traditionalsystem of health care provision-the independentpractitionerworking for fee-for-service-remains one of the
most compelling paradoxesof twentiethcentury social history. Starr's excellent
narrativedoes not make explicit how the
professionwas able to achievesuch largely
uncontestedstatus and authority.
The answerto this questionmay well lie
outside the realm of professionalinterest
and politics. The faith in science; the reliance on experts;the social meaning and
distributionof health and illness; the ultimatetriumphof a therapeuticdiscourse,as
well as the primacy of the doctor-patient
relationship;all need to be considered
more fully. Clearly, additionaltests must
be conducted before a differentialdiagnosis of the crisis of Americanhealthcare
may be offered. The fact that Starr'saccount makes this researchagenda clear is
to its credit. If the cure is to be found, it
will requirefurtherinvestigationssuch as
The Social Transformation of American
Medicine.
the
Mundane
by THOMASH. MURRAY
I
Moralities of Everyday Life. By John
Sabini and Maury Silver, New York:
Oxford University Press. 1982. $19.95
hardcover;$6.95 paperback.
A
1
oralities of Everyday Life is an irri-
tating-and occasionally intriguingbook. Writtenby two social psychologists,
its thesis is thatwe cannotunderstandhow
people think and act without referenceto
THOMASH. MURRAYis Associate for
Social and Behavior Studies, The Hastings
Center.
The Hastings Center
some notion of morality. Their goal is to
isolate the moral content in mundane
things; their method, to analyze concepts
fromeverydaylanguage,seasonedwith an
occasionaldollop.of psychologicaldataor
theory.Justwhatdo they meanby "moralities," and just what does psychological
knowledgetell us about ourselves as irreducibly moral beings? Moralitiesfirst.
Except for the concluding sections and
one on ". .. the Sociopsychology of the
Holocaust," each chapter follows essentially the same pattern:Sabini and Silver
ask "what X really is." They invariably
discover something moral at the core,
whetherX is gossip, envy, procrastination,
flirtation,anger, moral reproach,or character.
The convincingcases are very good indeed. Gossip, for example, allows people
"to exteralize, dramatize, and embody
their moral perceptions." In sharing our
disapprovalof one person with a confidant, we ratifyour own moralstandardsas
concreteand correct, and convict the subject of gossip as a moraldeviate. This is, I
think, an accuratedescriptionof gossip's
role in sustaining a community's confidence in its moraljudgments.
Their discussion of flirtation, on the
other hand, becomes a meditation on
fudged intentionsand the virtuesof ambiguity: a study, that is, of ways to avoid
moral disapprovalthrough artful vagueness. Relevant to morality? Yes, in an
amoral sort of way. Gossip, for one, is
equally suited to support an abhorrent
moralityas an admirableone. (The American South, 1855:"Did you hearaboutthat
horribleMr. Greeley?He wantsto abolish
slavery!")
Whether they realize it or not, the
authorsremainloyal to modem social science's commitment to "value-free" inquiry. Theirdescriptions,at times remarkably penetrating, at times strained and
unpersuasive,are precisely that: descriptions, not prescriptions.Their only moral
judgmentsare reservedfor the least effective chapterin the book, much of it a stale
paeanto StanleyMilgram'sfamiliar"obedience" research and its supposed relevance to the behaviorof Nazi concentration camp guards. It also ignores recent
scholarshipdisputingthe meaningand significance of Milgram's studies. Sabini's
and Silver's gifts for original and dispassionate analysis deserted them when
needed most.
The book as I said is irritating-in part
because it treats contemporaryAmerican
morality as an ethnographer describes
some exotic tribalrituals:fromabove, with
no involvement. This is forgivable; it
comes with the scientific tradition,I suppose. But the style of humor is culpable.
They get off some genuinely funny lines.
But too often the jokes are obscure and
pedantic, a reminderto the readers how
much more learned are the authors than
they. Portionsread almost like a Woody
Allen parodyof hip scientific prose.
Inventiveand capricious,humorousand
snide, Moralities of Everyday Life delights
in paradoxesand ends up a paradoxitself.
Perhapsthe authors'next effort will bring
discipline to the originalityapparent,but
unharnessed,here.
43