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A solid, provocative history of power in American medicine that leads to some well-based predictions for the future. Harvard sociologist Starr traces two major movements in the development of our medical system: first, the rise and incipient fall of the ""professional sovereignty"" of physicians; second, the emerging transformation of medicine into a bureaucratic and corporate regime controlled by business (pharmaceuticals, medical equipment). Throughout, medical care is viewed in the context of a larger power and social structure--beyond the usual limits of physician-patient relationships, medical practice, or other internal health-care forces. To give equal time to cultural and institutional analyses, Starr alternates between descriptions of collective consciousness and of organizational structure as he traces the growth of the cultural authority of physicians, and the translation of that authority into control of markets, organizations, and governmental policy. It must not be assumed, he argues, that physicians have always occupied positions of ""honor and comfort"": ""there is no necessary and invariant relation to social structure of a function such as caring for the sick."" And not until the 20th century did physicians become wealthy, powerful, and prestigious enough to reorganize the structure--especially the financial structure--of American medicine. In Book One, he traces the rise of medical authority and the making of our present medical system--beginning in 1760, with English and other European roots--through to the consolidation of professional authority by 1920, and physicians' first strong resistance to corporate control. Book Two describes the ongoing struggle: in the early 1970s, private physicians' chief ""counterweight"" was the government, as previously private, professional decisions became public and political; of late, we are no longer moving in that direction--but neither are we returning to where we were. As Start relates in his final chapters, private corporations are becoming the new power-holders in American medicine, and though this trend is getting a boost from the current Administration, its origins are rooted in the past which Starr has detailed. Starr's aim, then--for readers to understand medicine as an economic and business phenomenon, as well as a cultural one--is well realized. Voluminous and detailed--but also trenchant.

Pub Date: Oct. 27th, 1982
Publisher: Basic Books