Medicine and the waning of professional sovereignty.

Abstract

Images of the future are usually caricatures of the present. They inflate some recognizable features of contemporary life to extravagant proportions, and out of fear or hope respond to every vagary of historical experience, as if it were a sign of destiny. In America, during the past decade, the future has changed shape altogether. Not long ago Americans generally believed that their society was in an irreversible ascendancy toward greater affluence; then they abruptly rediscovered the problem of scarcity and the insecurities of power and came to imagine themselves at the beginning of a long historical decline. Intellectuals, as much as others, have shared in this reversal of outlook; the more radical general ly identify the collapse around the corner as economic and ecological, while the more conservative lament the downfall of civility, self-restraint, and the demo cratic idea. All this dark pessimism has arisen, remarkably enough, at a time when there has been no commensurate downturn in American society. Despite the commotion of aborted revolts and stalled reactions, politics and culture in America?status relations excepted1?are not greatly different from what they were ten or fifteen years ago. Changes in the conditions of material life and in the structure of social institutions have been much slower and less extreme than the oscillations in mood and outlook. Like the larger society, medicine has suffered a stunning loss of confidence. It used to be the habit on public occasions to celebrate the miracles of medical science and anticipate that new research would bring still more triumphs over dread disease. Then in the last decade the economic and moral problems of medicine displaced scientific progress at the center of public attention. Enormous increases in cost have come to seem ever more certain; corresponding improvements in health ever more doubtful. In intellectual and political circles, a new agnosticism has descended on medical care, as its critics, conservative as well as radical, observe that compared to the influence of environment and be havior, medicine can do little to make people healthy. As the 1960s began, the premise of social policy, as well as popular understanding, was that America needed and would benefit from more medical care?more hospitals, more phy sicians and other personnel, and more elaborate medical technology. Most of the major federal programs were then devoted to augmenting the country's medical resources. More recently the prevailing assumptions have reversed, as those who shape policy seek ways to reduce the number of hospital beds, slow down the introduction of medical technology, and cut off a potential glut of