To the Editor:

In her article, “A Misdiagnosis of American Medicine” [January], Florence A. Ruderman comes to the highly original judgment that my work is tainted by an incoherent Marxism. Of the roughly 75 reviews of my book, The Social Transformation of American Medicine, hers is the first to detect any reliance on Marxist ideas. Miss Ruderman is also unique in suggesting that I portray American society in “negative” and “derisive” terms. No one who knows my work will recognize this portrait. It is a complete misrepresentation.

Miss Ruderman fails to acknowledge that my book includes severe criticism of Marxist interpretations of the development of American medicine (see pp. 227-29). Indeed, until now the most hostile reviews have come from Marxists—and this was to be expected, since I reject the thesis that the rise of scientific medicine can be explained by the “needs of capitalism.” In commenting on this view I write: “The legitimacy of capitalism rested on more ample foundations than the alleged ideological functions of medicine in focusing attention on bacteria rather than class interests. Compared to the beliefs in economic opportunity and religious and political freedom, medicine played an insignificant role in sustaining democratic capitalism in America” (p. 228). No one given to Marxist thinking would even use the phrase “democratic capitalism.”

The introduction to my book sets forth my intellectual position and theoretical perspective on the development of American medicine. I emphasize there my general commitment to a historical approach that incorporates cultural analysis and political economy and that attempts to trace patterns of social and economic relations to the “human actions that brought them about”—that is, the purposeful choices that individuals make. My views owe much to the methodological individualism, political realism, and interpretative sociology of Max Weber. They owe little to Marx.

In my account of the rise of the medical profession, the central term (never mentioned by Miss Ruderman) is “authority”—and authority, by the way, is not a bad word in my vocabulary. Authority is necessary in a free society; what threatens freedom is unchecked power (as in a totalitarian regime) or the collapse of effective authority (as in Lebanon). Authority is also necessary for medical care, but authority relations entail dependency, and they are often troubled and ambivalent. However, when I say that I want to explain the growth of the “cultural authority” of medicine, I am not suggesting (as Miss Ruderman states) that this necessarily diminished freedom. Furthermore, I do not take the view that human motivation is exclusively economic or that the growth in the status and authority of the medical profession can be explained solely by its “pursuit of wealth and power.” Like other groups, the profession often acted to protect its interests, and this obviously gets a prominent place in any realistic account. But I explicitly reject (see pp. 143-44) the kind of one-sided analysis emphasizing power that Miss Ruderman ascribes to me.

As to some of Miss Ruderman’s specific misrepresentations in her account of the first half of my book:

1. She claims that I see a “decline of democracy” (her phrase) and that I subscribe to the “radical elitist” view that a narrow group seized control of American society in the late 1800′s. Not so. Following in a long tradition of historical scholarship, I argue that in the Jacksonian period American culture was characterized by a radical interpretation of democratic ideals, which was hostile to professional authority in all fields, including medicine. But I neither endorse this hostility to professionalism, nor argue that there was any subsequent “decline” of democracy—certainly not of political democracy, which obviously grew as the franchise was extended to new groups. Rather, between the Jacksonian and Progressive eras, there was a sharp change in the understanding of democratic ideals and their relation to medicine and science. Here is some of what I actually wrote:

From the perspective of democratic thought in the early 19th century, the seeming complexity of medicine was artificial; if properly understood, medicine could be brought within reach of “common sense.” The development of science broke that confidence. It helped establish the cultural authority of medicine by restoring a sense of its legitimate complexity. . . . Science shares with the democratic temper an antagonism to all that is obscure, vague, occult, and inaccessible, but it also gives rise to complexity and specialization, which then remove knowledge from the reach of lay understanding. For a time in the first half of the 19th century, the democratic claim [that useful medical knowledge ought to be accessible to common sense] prevailed in medicine. But the public, through its legislators and its own private decisions, gradually relinquished that claim as it became convinced of the growing complexity of medical science and the limits of lay competence (pp. 58-59).

The last sentence clearly indicates that I attribute the growth in medical authority not to the connivance of an elite but to the purposeful choices of the public, facing new conditions (including advances in science).

Miss Ruderman attributes to me the view that increased dependence on physicians meant a reduction in freedom. Elsewhere I have criticized Ivan Illich precisely on that point, and in my book I criticize Christopher Lasch for taking that view. With regard to Lasch I write:

Except where doctors were given legal authority or institutional power as gatekeepers, clients became dependent upon physicians only as they sought out professional consultation. That act cannot be explained as pure coercion or false consciousness. Professionals might, as Lasch suggests, “ridicule” the capacity of people to care for themselves, but it seems more reasonable to look for the origins of increased resort to professional advice in the new conditions of life at the end of the 19th century. . . (p. 142).

I go on to discuss the “pervasive changes in everyday experience” that led Americans to rely “more on the complementary skills of others and less on their own unspecialized talents.” These changes include developments in science, which take me to a second misrepresentation by Miss Ruderman.

2. My book is an attempt to account for transformations in the social and economic structure of American medicine; it is not a history of medical science. Nonetheless, where I believe that scientific developments are causally relevant—as they frequently are—I bring them into the analysis. The quotations above, as well as many other passages, indicate that I assign central importance to scientific developments. Miss Ruderman, however, is not convinced. She says that my argument is “false” because medicine has an “inner content” that determines its “outer” structure. Reasonable people may differ about how much causal significance to assign to “internal” versus “external” factors, and here Miss Ruderman and I have a genuine disagreement. She writes that science “sets its own course, defines its own goals.” But consider medicine and science in Nazi Germany. Consider genetics and psychiatry in the Soviet Union. Science “cannot set its own course” because its institutions depend on the wider political and cultural environment.

The reason that “external” forces (culture, politics, economics) loom so large in my account of the social development of medical care is that health-care institutions vary enormously in the advanced-industrialized countries. Think of health care in Britain, Sweden, and America—drastically different social and economic arrangements, and yet medical science in these countries is fundamentally the same. I reject an “internalist” view not because I am a Marxist, but because it is completely unpersuasive in comparative perspective.

The “internalist” view also fails to explain the general rise of the professions in America. While medicine in America was becoming more professionalized, so were other fields, such as the law—and yet scientific change clearly cannot provide explanatory power there. Miss Ruderman says that besides medicine’s inner content, the sources of the profession’s rise lay in cultural traits, such as Americans’ positive and activist view of the world and their concern about health. However, observers took note of such traits before, during, and after the rise of professional authority. These cultural patterns may distinguish America from some other societies, but they do not distinguish America at different periods in its history; consequently they do not help in explaining why the status and authority of medicine have varied over time in the United States.

3. On the growing power of the regular physicians in the late 19th century, Miss Ruderman is simply unable to acknowledge the complexities in the story I tell. Allegedly summarizing my argument, she writes that “after gaining control of licensing, the profession drove rival health practitioners out of the field.” This is the view of other analysts, but it is not exactly mine. Here is what I wrote: “The myth persists today that homeopaths and herbal doctors were suppressed by the dominant allopathic profession. Yet the sequence of events suggests otherwise.” The major dissident medical sects received separate recognition from many licensing boards. “Only afterward did they lose their popularity.” The reason that homeopathy died out, I argue, was that it collapsed from within:

Homeopathy had one foot in modern science, the other in pre-scientific mysticism; this became an increasingly untenable position. While regular medicine was producing important and demonstrable scientific advances, homeopathy generated no new discoveries. The contrast was not lost on many in the group. They edged further away from Hahnemann [the founder of homeopathy]; the final dissolution came of itself (pp. 107-108).

This kind of argument—which can be found in other places as well—contradicts her report that I disregard medicine’s content and treat the rise of a more homogeneous and authoritative profession as a matter of mere greed.

The first part of my book attempts to account for the rise of “professional sovereignty”; the second attempts to account for its erosion. The principal theme is first the development and then the unraveling of a system of economic and political arrangements that for a long time accommodated the concerns of private physicians and hospitals. However, many subordinate arguments are folded into the overall analysis—for example, why national health insurance was defeated; why private health plans took the form of Blue Cross “service benefits” and commercial indemnity insurance; etc. The general structure of my account emphasizes the reciprocal effects of political choice and changes in institutional structure. Thus the political defeat of compulsory health insurance opened the way to private insurance plans, whose effects on the distribution of health care posed new political choices. Postwar government policies promoted the expansion of medical schools and hospitals, whose development changed the character—and raised the cost—of health services. When passed in 1965, Medicare included provisions for reimbursing hospitals and doctors that deprived the government of effective leverage for cost control, but since the early 1970′s private employers and government have both turned to methods of cost containment that tend to reduce professional autonomy and hospital expansion.

For Miss Ruderman to pin the label “Marxist” on this analysis is outlandish. The one passage she has found where I use the terms “forces” and “social relations of production” begins with the words “It is as if . . .” and occurs a page after I criticize Marxist theories for a second time (see p. 377). Dialectical materialism is not my style.

In discussing the second half of the book, Miss Ruderman strings together unrelated phrases and ideas in an astonishing jumble of misreadings. Her basic point here is that I supposedly belittle every accomplishment of American society. She suggests, for example, that I am cynical and dismissive of “every extension” of health programs. “His chapter titles and subheadings tell the story: ‘The Mirage of Reform”; ‘Grand Illusions’; ‘Health Care in a Blocked Society.’” But let’s see what those are about. In “The Mirage of Reform” I examine why liberals thought compulsory insurance was at hand three times—before World War I, during the New Deal, and in the late 1940′s—yet each time success eluded their grasp. Hence the reference to reform as a “mirage.” “Grand Illusions” is a subheading in that chapter describing the failure of the first of these reform campaigns. And what about “Health Care in a Blocked Society”? That deals with the political stalemate over domestic policy during the Ford and Carter administrations. Miss Ruder-man’s suggestion that these titles reveal cynicism and hostility toward America is strange, to say the least.

Representative of Miss Ruder-man’s standards of criticism is her alleged summary of my explanation for the passage of Medicaid: “Medicaid was passed not so much to provide medical care for the poor, as to ‘cover . . . bad debts for hospitals.’” In fact, this is no part of my explanation for the enactment of the program. “The social programs of the 1960′s,” I write in a passage about the 20th-century shift in concern from mass to minority poverty, “were aimed specifically at reducing the exclusion from medical care of the poor and the aged, who were marginal to the core sectors of the economy where health insurance was available as a fringe benefit” (p. 373). The reference to hospitals’ bad debts occurs in a passage comparing the later support for Medicaid and neighborhood health centers. And it is undeniably true that the hospitals developed a financial stake in Medicaid that they never had in the neighborhood centers. Miss Ruderman here misrepresents as a cause for Medicaid’s adoption what I present as only one of several reasons for subsequent hospital industry support of the program.

Miss Ruderman suggests that I minimize the value of Medicaid and other health programs. “Belittle as he will, however, Starr cannot disguise the fact that an enormous liberalization of medicine has taken place.” But far from “disguising” these changes, my book and other writings of mine try to present a balanced appraisal of the successes and limitations of government programs. I argue that they widened access to medical care and contributed to the improving health of our society (see pp. 372-74 and my essay, “Health Care for the Poor: The Past Twenty Years,” in Antipoverty Policies: What Works, What Doesn’t, edited by S. Danziger and D. Weinberg and published by Harvard University Press this spring). Yet the programs also proved more expensive than if they had been established on a more cost-conscious foundation and left about one-tenth of the American people without health insurance. To point out such things is not to belittle our achievements.

I could go on with example after example. The distortions are so bold that I rub my eyes in disbelief. They do, however, fall into a pattern. Where I have given a complex explanation or appraisal, Miss Ruderman misrepresents me as having emphasized only one element, which she reports in a highly prejudicial fashion. In several instances she associates me with ideas that I specifically reject. And she likes to scramble and rearrange elements in an argument to make them sound absurd.

Consider, finally, her misreading of my political position. She says that I oppose the “pro-competition” plans for health care. I do see dangers in the current growth of corporate health care, but I have been an advocate of market-oriented health-care reforms, such as the development of health maintenance organizations, as I have explained at some length in articles in the Public Interest and the New Republic. (My book, I should note, does not include any policy recommendations, but in footnotes I cite articles of mine that do.) The book jacket carries an endorsement by the economist Alain Enthoven, one of the most prominent advocates of competitive strategies in health policy.

Now make no mistake: I am a liberal and favor the provision of health insurance to the roughly 30 million uninsured and the maintenance of a strong system of public-health services. But I am open to a range of ideas about improving our health-care system. I supported the Reagan administration’s original proposal to change the tax treatment of health insurance. Last year, when I was invited to talk about health policy over lunch with a group of Senators, my host was Senator Dave Durenberger, the chief Republican on health affairs.

Miss Ruderman has apparently taken it upon herself to unmask Marxist and anti-American sentiments where no one else has detected them, but she must explain how these insidious views got past everyone else. Her theory of why “such a bad book” should have been so highly praised plainly does not fit the facts. She says that the reception reflects the dominance of Marxist ideas in sociology. Even if this doubly mistaken view were correct (doubly mistaken because I am no Marxist, and neither are the great majority of my colleagues), sociologists are not the ones who have given my book prominence. Miss Ruderman must also call into question the intelligence of the professional historians who award the Bancroft Prize in American History; the Pulitzer Prize jury; the board of the American College of Health Care Executives, which chose my book for its Hamilton Prize; and even the American Medical Association, which distributed my book to its board of trustees and had me speak to its National Leadership Conference a year ago.

Miss Ruderman’s repeated references to the public reception given my book suggest that this attention has so unsettled her that she cannot read it calmly and report it accurately. If this attention has excited a certain professional resentment, I am truly sorry. It was not my doing, and envy is one of those diseases for which even modern medicine has no cure. But if she writes out of political animus, there is a remedy at once effective and pleasant to those who take it: a decent respect for the facts.

Paul Starr
Department of Sociology
Princeton University
Princeton, New Jersey

_____________

To the Editor:

In her article, Florence A. Ruderman refers to Paul Starr’s The Social Transformation of American Medicine as a “false picture,” asks “why people whose business it should be to uphold scholarly standards have praised it in terms that are not only extravagant but completely false” (emphasis added), and goes on in ten other references (talk of extravagance!) to charges of “nonsense,” lack of knowledge, “characteristically distorted discussion,” and the like.

Surely these are excessive and arbitrary statements for a work that won a Pulitzer Prize and the Bancroft Prize (the first time an award given for American history went to a sociologist—who, according to Miss Ruderman, distorts American history), so that one would assume that responsible editors would approach such statements with caution.

Miss Ruderman never answers her own further question as to why such a “bad book should have become so successful.” The one effort she makes is laughable. She states that Starr is negative about America, and therefore fits a prevailing academic mood, and that, despite himself, he is a Marxist. She quotes one instance where Starr uses the phrase (after a wry “as if”) “forces of production,” and then writes:

. . . Starr’s book does not reflect a coherent Marxist viewpoint. . . . What it shows is that, without their necessarily being Marxists or taking consistently Marxist positions, for Starr and other sociologists like him the only available ideas are Marxist ideas. Ultimately there is no other intellectual or scientific baggage . . . that they know or consider respectable.

No, this is not laughable; it is mendacious. The “intellectual baggage” that Starr carries is not that of Marx but of Max Weber. The focus of his book was the question of cultural authority (a central Weberian problem which Marxists have never confronted since their framework is domination, class rule, hegemony, or the “needs” of the system), and with great subtlety and learning Starr sought to show how in a society which was, in the Jacksonian period, populist, egalitarian, and anti-intellectual, the medical profession was able to achieve cultural authority. And one cannot answer that this was due to the prestige of science alone.

Having characterized Starr in sledgehammer terms, Miss Ruderman turns coy in her concluding paragraph, when she writes: “What is one to say of sociologists, including some of the most distinguished in America today, who fail to recognize this kind of ‘study’ for what it is—or who do recognize it, and join in the acclaim anyway?”

Miss Ruderman will know, though the readers of COMMENTARY may not, that I was Paul Starr’s Ph.D. thesis adviser (the thesis is substantially the first half of the book), and that I read the manuscript line by line—as is clear in Starr’s acknowledgments. Would the use of my name give the reader caution about the reckless use of the “Marxist” label? Or would Miss Ruderman care to engage me in a discussion of Marxism?

What is troublesome in all this is that legitimate questions of scholarly dispute (an internalist or externalist debate about the development of intellectual and scientific institutions) become subordinate to ideological heresy hunts. What else is one to make of the statement that “the C. Wright Mills award for Starr’s book is entirely appropriate”? The Mills prize was also won by Rosabeth Moss Kanter for a book on Men and Women of the Corporation, and Miss Kanter recently has been given a chair in entrepreneurial studies at the Harvard Business School. Is the Business School also to be tainted by that association?

Many years ago, Sidney Hook proposed an “ethics of controversy” in which he suggested ground rules to exclude ideological blackening as a substitute for rational discourse. I would hope that intellectual exchanges be carried on in that spirit.

Daniel Bell
Department of Sociology
Harvard University
Cambridge, Massachusetts

_____________

To the Editor:

. . . Florence A. Ruderman is not the first to remark upon a lack of theoretical coherence in the sociology of medicine, but her attempt to indict all sociology in the name of Paul Starr’s well-deserved success is, I think, particularly repulsive, hopelessly self-serving, and just plain embarrassing. Starr’s book, I think, infuriates her because it aspires to be a synthesis of historical and sociological understanding of a major institution in modern society. . . .

By citing Starr’s departure from Harvard and then viciously attacking his work, Miss Ruderman plays the ad-hominem strategy in its most destructive form. The reader unfamiliar with the characteristic lack of generosity among some sociologists, especially those in the same subfield (e.g., the sociology of medicine), might be led to conclude that Miss Ruderman’s broadside exposes a fault line that is supposed to explain why Starr was denied tenure at Harvard. This conclusion is not only false, it plays directly into the hands of those who think that “qualitative” sociology is by definition suspect, when in fact there is plenty of bad “quantitative” work that goes unremarked. . . .

The sociology of medicine does have a rich history of its own, and Miss Ruderman is mistaken when she suggests that the field is impoverished because of its recent origin or because “classical” sociologists appear to have neglected questions about medicine. I would refer her to Max Weber’s observation in Science as a Vocation that “Whether life is worth living and when—this question is not asked by medicine.” Those who ask why it is not asked by medicine have probed the meaning of medicine and its practice in ways that Miss Ruderman either willfully ignores or does not know. Weber’s observation may now be under an unprecedented revision, as a bureaucratic bioethics assumes new responsibility for asking questions that were once forbidden to be asked.

And so one is left to ponder Miss Ruderman’s ruminations over Starr’s liberalism, displayed in his interpretation that institutions, social structure, and social systems shape the practice of medicine. In her reference to medicine’s own “powerful inner content,” as if this phrase were a response to and a replacement for Starr’s own perspective, Miss Ruderman trivializes what could have been another opportunity to engage us all in a fuller discussion of the character of a profession and the character of its professionals. If all she means by “inner content” is socialization, she has merely introduced the other side of the reductionist coin. Instead of money and political power (the terms she uses for reducing Starr’s work to her size), she substitutes the physician’s knowledge and medical technology as core variables for making sense of the medical profession. . . .

Starr’s victimization, in the face of the success of his book, is testament to the fact that some sociologists are wrecked by others’ success. If he has been called to speak at medical meetings (and I expect he has, often), it is because his book speaks to the same profession about which Miss Ruderman believes he knows nothing. . . .

Jonathan B. Imber
Department of Sociology
Wellesley College
Wellesley, Massachusetts

_____________

To the Editor:

Florence A. Ruderman’s scathing analysis of Paul Starr’s The Social Transformation of American Medicine, while critically correct, ultimately misses the underlying accuracy of the book.

The medical profession is now under siege and will shortly suffer a major assault. . . . A policy is now in place . . . to curtail medical expense and to modify health practice. What form of care will develop over the next decade is difficult to assess, but the reformulation of expectations in the context of this revolution is required.

Our principles of medical care were formed during the course of a scientific renaissance that has taken place in the medical sciences over the past 100 years. . . . But when viewed critically, the process by which death rates have fallen and life expectancy has risen is a result, as many critics have noted, of modern sanitation, nutrition, and changes in “life-style.” . . . The conclusion that the sophistication of our medical practice accounts for maybe a 10-percent difference in “health” is astounding (see V.R. Fuchs, Who Shall Live?, Basic Books, 1974). Though one might disagree about the exact figure, . . . it is still lower than most people think. . . . Nevertheless, this is the powerful dialectic the medical profession has employed to sell its goods: individual life is saved, and to that end all resources must be applied. . . .

The public, however, knows better. By consensus, decisions on care no longer rest entirely with the physician. . . . Physicians are trained as scientists who apply scientific principles to disease. But that is no longer sufficient. . . . The rise of holistic medicine, the diversity of common conceptions of disease and health, and the demand for physician accountability are mere reflections of the public’s ambivalent attitude toward medicine and physicians as technicians of health. While acknowledging the power of modern medicine and its agents, the limits of science and technology are broadly appreciated. The scrutiny of medicine as a business, with excess costs and demands on society, is really the voice of a more skeptical public, alerted to the danger of total reliance on the scientific panacea. . . .

As Miss Ruderman clearly states, . . . medicine is now facing an adjustment in its place in society’s structure. . . . The crisis is not only in the new restrictions on medicine’s economic growth, but in the expectations of its promise. . . . Doctors are no longer primarily regarded as physicians, but rather as technocrats, or, at best, scientists. . . . When doctors were perceived as healers, ministering to each aspect of care—physical, mental, emotional, spiritual—integration of all health factors was accomplished. As the doctor became a technician, relying on the necessary but insufficient power of science, he lost his credibility as healer . . . and is now perceived as just another interest group. The profession may no longer pray only to the fallen idol of science, but must again become the physician of the body, mind, and soul. Until this is undertaken by the doctor as a professional goal, the larger debate will go on without him, to the detriment of both parties.

For the physician’s part, I argue that we must again assert the healing hand comprehensively. This process must begin in medical school, be firmly established in postgraduate training, and be continually developed professionally. Doctors must become recognized as ethicists, psychologists, and good Samaritans. Why should a recent poll show that 85 percent of the respondents had either changed physicians in the past five years or wanted to, and that their reasons were not those of professional competency? . . . Why is the attendance of a physician at a patient’s funeral considered unusual? . . .

Only by addressing the “humanity” issue directly will the medical profession refute that part of Starr’s analysis which rings true and has evoked the positive reception given his modest “masterpiece.” Once credibility is again established, the healing mission will again have its best advocate.

Alfred I. Tauber, M.D.
Boston University School of Medicine
Boston, Massachusetts

_____________

To the Editor:

I have been deeply troubled by all the attention Paul Starr’s book has received, especially in view of its negativism and its neglect of such factors as the influence of technology. Those of us who try to do a good job as medical sociologists are sometimes overwhelmed by a book like Starr’s. Therefore I welcomed Florence A. Ruderman’s wonderful article, which I found refreshing in its clarity and good common sense—a very useful contribution.

Gordon H. DeFriese
Health Services Research Center
University of North Carolina
Chapel Hill, North Carolina

_____________

Florence A. Ruderman writes:

Let me thank Gordon H. De-Friese for his kind comments.

Alfred I. Tauber’s letter provides a good example of the kind of reasoning that helped make Paul Starr’s book so widely acclaimed. There is a general sense, among physicians and laymen alike, that there is much wrong with medicine today, and that the field is facing new challenges without a clear sense of direction. In this climate of uncertainty and internal self-doubt, Starr’s book, which piles up and muddles so many variables, seems to have something to offer. But that is all it does offer: an illusion. The book provides no analysis of anything that Dr. Tauber mentions. Even with regard to medicine’s structure and economics—Starr’s primary focus—the book offers little insight into any current issue, and on such matters as medicine’s relationship to science, to technology, to “healing,” Starr, as I indicated in my article, has nothing to say. Not only does he say nothing about how these relationships might be reshaped, he does not even define them or discuss the problems surrounding them. What he does is to create so much confusion, so much pretense of saying something, by piling up so much loose, vague, and even incoherent argumentation, that many people have been willing to assume that he must be saying something profound—or to read into the book’s ambiguities and pretenses a meaning that simply is not there.

Jonathan B. Imber accuses me of ad-hominem arguments, but I can hardly imagine a more ad-hominem attack, or jumble, than his letter. To reply to only a few points: my article was not “supposed to explain why Starr was denied tenure at Harvard.” I mentioned this matter simply as part of the controversy that surrounds Starr. My subject was Starr’s book. I did not argue that the sociology of medicine lacks a history of its own. My point was that medical sociology does not have a long intellectual pre-history comparable to that of sociology’s “core” fields, nor does it have the kind of classic works of theory and methodology that the founders of sociology provided for these core fields. On Mr. Imber’s reference to Max Weber: in developing the idea that all fields accept certain values or beliefs as axiomatic, Weber gave as an example medicine’s belief in the value of life. Does Mr. Imber bring this up to try to claim that Weber provided a study of medicine? He did not. Or is Mr. Imber arguing, apropos of nothing, that beliefs that are unquestioned at one time may be questioned at a later time? If so, what has that got to do with the present discussion? Finally, I find it interesting that Starr and his supporters can only imagine base or petty motives for a critical analysis of his book. Are there really no other possibilities?

If Daniel Bell had read my article more calmly, he might have seen that I did not accuse Starr of being a Marxist, but of engaging in “Marx-babble,” and of providing an interpretation of medicine’s behavior that is in fact a very crude derivative of Marxism. In Starr’s book, medicine is motivated solely, exclusively, by the pursuit of wealth and power. His analysis develops no other motivation, goal, or drive—ever—in over 200 years of the profession’s history. Are we now to learn that this approach is Weberian?

As for the claim that the book is Weberian because it deals with authority, a major concern of Weber’s—this is simply beside the point. The topic may be Weberian; Starr’s treatment of it is not. Nothing in Starr’s method, theory, mode of argumentation, or anything else is remotely Weberian. On the contrary, in his consistent denial to medicine of any significant motivation but the pursuit of wealth and power; in his equally consistent refusal to grant causal force to positive values in American culture, at least since the “end of democracy” in 1850; in his treatment of all problems now facing medicine as though they involved only competing economic and power interests, and never genuine medical, scientific, and policy dilemmas—in all of this and much more, Starr in his book is un-, and even anti-Weberian.

Moreover, in citing one particular example (not an isolated instance), my point—which both Messrs. Bell and Starr ignore—was not simply that it is Marx-babble, but, more fundamentally, that if Starr’s analysis were sound, it would cast light on the changes that have been taking place in medicine’s authority and structure. As it is, however, the “theory,” pretentious as it is, leads nowhere, illuminates nothing: hence the babble.

On the C. Wright Mills Award: I considered it appropriate because Starr’s book (in its method, general orientation, etc.) is in the Millsian tradition. I said nothing about other books that have won this award, just as I said nothing about other books that have won the Pulitzer Prize. Rosabeth Moss Kanter’s book is a good book; I use it in several of my courses. This point of Mr. Bell’s is simply irrelevant.

Finally, Mr. Bell’s fury carries him to an extraordinary length: he implies that I should not have criticized Starr’s book for Marx-babble (or anything else?) since I knew that he—Daniel Bell—was Starr’s adviser. Is he serious? Sociology may have drifted far from scientific norms in recent years, but surely not that far. The Social Transformation of American Medicine is a bad book, muddled, pretentious, and with a crudely negative view of medicine and American society. I can only deplore the fact that Mr. Bell has done so much to give it its unmerited reputation, and now comes to Starr’s defense with rage and irrelevancies.

In his own letter, Paul Starr-manages to evade, or confuse, every issue that I raised. I cannot deal with everything in his letter here; only a few central points.

First, to repeat what I have already said in my response to Daniel Bell, I do not consider Starr a Marxist. I did not accuse him of taking a Marxist position; in fact, I accused him of having no coherent or avowed position of any sort. But throughout his book there is a crude economics-and-power reductionism; a consistently negative and often snide tone about every aspect of American life, culture, and politics; recurrent bits of Marx-babble and flirtations with a radical posture. (The examples I gave were not even the most egregious ones.) And this is made all the worse by the fact that there is never an attempt to argue or defend what the insinuations, the slurs, and the general negativism imply. Starr-does, in three pages, reject one particular Marxist interpretation of medicine’s development: this is the far-fetched thesis argued by E. Richard Brown in Rockefeller Medicine Men, according to which American medicine was given its direction, or focus, by philanthropic foundations acting to shore up capitalism. As far as it goes, Starr’s discussion here is good, but these three pages seem to have blinded many readers to the mixture of economic reductionism and stray Marx-babble that otherwise pervades the book.

Second, to repeat again, I noted that in Starr’s portrayal, the medical profession is motivated by nothing except a drive to wealth, status, and power. I asked: can any profession’s behavior be explained this way? Do medicine’s values, its ancient and universal traditions, its commitment to society, its daily struggles with human suffering, really play no role in motivating the field? Are these factors really never significant in doctors’ decisions and actions that shape the structure of medicine? This is not a marginal issue; it is crucial. Starr’s answer is characteristically evasive and misleading—“I do not take the view that human motivation is exclusively economic or that the growth in the status and authority of the medical profession can be explained solely by its ‘pursuit of wealth and power’”—and he refers us to pp. 143-44 of his book. Thus he evades my question with a vague generality, and then shifts the ground to something else, “the growth in the status and authority of the medical profession” (this is what the pages he cites deal with). But my question had to do with the motivations of medicine, not with the growth in the external status and authority of the profession. The latter, as I made clear in my article, Starr attributes to a whole sea of variables, including “the decline of democracy,” urbanization, the telephone, etc., etc. The former, medicine’s motivations, he connects solely with a concern with material advantage: solidarity, income, monopoly. Starr is unable to refute this; he cannot cite one instance in his almost 500 pages in which he shows any other motivation or drive as a significant factor in medicine’s actions or decisions. Not one.

I want to call attention also to the fact that—again in an absolutely characteristic way—Starr willfully misunderstands what I said about medical sociology’s “externality” to medicine. He argues that an “internalist” position ignores social structure, economics, etc. This is nonsense, and not at all the point I was making. My criticism was directed not at his having included structural factors such as economics, but to his having totally excluded medicine’s interior forces. Starr’s lack of grasp of the subject—and, incidentally, of anything Weberian—is shown precisely in his insistence that one must take an “either-or” position: either only external, non-medical forces shape medicine, or only internal, purely medical forces do. This is precisely what I argued against.

Third, I wrote that Starr’s thesis, which purports to explain why American society became increasingly respectful of medicine and willing to accord it authority after the middle of the 19th century, is specious and vacuous. I noted that the commonly accepted explanation attributes this development to medicine’s growing identification with science; and I added that a role was also played by powerful cultural forces such as the high value put on life, health, and well-being; the receptivity to science and technology coupled with scientific backwardness; the eagerness for progress; optimism; activism. Every significant cultural feature of American society, from the start, was favorable to the emergence of medicine as a venerated profession, which would be accorded great leeway to shape its own structure and be lavishly rewarded. But this process could not begin until the relevant sciences had reached a critical point, and medicine had drawn closer to them. Until that time, there was no rational basis for allowing physicians great authority, or ceding power to them; the village granny or one’s own “common sense” did just as well.

No elaborate argument positing a change in political and social consciousness is necessary to account for society’s changing attitude toward a changing profession. It was not the Jacksonian ethos (belief in the common man, etc.) that made medicine’s status low in the early period—and not the absence or decline of this ethos that made it high in a much later period. Starr’s argument here, I wrote, is simply an enormously elaborated tautology. Phrases like “changes in . . . forms of consciousness,” “the retreat of private judgment,” etc. sound meaningful but are really meaningless. Starr creates an unnecessary mystery about medicine’s rising authority in order to solve it with a tortured and vacuous “argument.”

Fourth, in analyzing Starr’s interpretation of medicine’s rise, I noted that a central concept—one of three, he tells us in the introduction, on which his argument rests—is dependency. (The other two are authority and legitimacy.) Both he and Daniel Bell now accuse me of “concealing” the fact that Starr deals with “authority,” or “cultural authority.” But there was nothing to conceal. I was making the point that all of Starr’s concepts involve stunning amounts of pretense, muddle, and ambiguity, and in the end turn out either to have no meaning, or to have the most ordinary, commonplace meaning. This point is unaffected by whether one considers just one of Starr’s key concepts or all three (or, for that matter, any other concept in his book).

I asked: what does this key concept of dependency mean? In Starr’s discussion it is always surrounded by dire hints of loss of freedom, diminished belief in oneself, the decline of democracy. I then suggested that it may actually have none but the most obvious, commonplace meaning. And now Starr in his letter confirms that this is so. He does not actually give a definition, but this is about as close as he comes: “Authority is . . . necessary for medical care, but authority relations entail dependency, and they are often troubled and ambivalent.” For this no one needed Starr’s theory.

My criticisms of Starr’s book remain. His letter, despite its length, has not answered them, or it has answered them in such a way as to strengthen my case that the book offers a theory that is meaningless, and a caricature of medicine, of American society, and of sociology.