Debate o n the Political Sociology of Professionalism

THE BUSINESS OF GOOD DOCTORING OR DOCTORING AS GOOD BUSINESS: REFLECTIONS ON FREIDSON’S VIEW OF THE MEDICAL GAME John B. McKinlay This paper reflects on selected aspects of the work of Eliot Freidson and is based mainly on his three latest books-Profession of Medicine, Professional Dominance, and Docroring Togerher-in which he draws together his various contributions and elaborates a substantial argument concerning the dominant position of physicians within the institution of medicine in particular and, more generally, their unique position within the broader society. Freidson’s work is considered from the perspective of political economy. The paper discusses, on a broad level, some of the assumptions underlying his analysis, the adequacy of his theoretical orientation and level of analysis for understanding the House of Medicine in the United States, and some implications that follow.

For as long as I have had some interests in medical sociology, the work and scholarly example of Eliot Freidson have stood head and shoulders above all others in this subfield. It was Freidson who, among many notable contributions, provided the first useful overview of the state of knowledge in the subfield (l), was the first to successfully challenge the then prevailing Parsonian formulation of the sick role (2). introduced the concept of a “lay referral system” (3), highlighted elements of conflict in the physician-patient relationship (4), described how patients relate to medical organizations (5), and speculated on the changing role of the hospital in modern society (6). Consequently, it is now impossible to study medical sociology from any theoretical or ideological perspective and remain unexposed to and uninfluenced by Eliot Freidson’s excellent work, which is, of course, not limited only to medical sociology but continues to filter through to such other subfields as deviance, work, education, formal organizations, and social policy. Few indeed are the number of sociologists who have made such profound additions and improvements to the common fund of theoretical knowledge in the discipline. This paper attempts to explore and reflect on selected aspects of Freidson’s work and is based mainly on his three latest books-Profession of Medicine (7), Professional Dominance (8), and Doctoring Together (9)-in which he draws together his various contributions and elaborates a substantial argument concerning the dominant position of physicians within the institution of medicine in particular and, more generally, their unique position within the broader society. ‘nternational Journal of Health Services, Volume 7, Number 3, 1977 @

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Several excellent reviews of Freidson’s work have already appeared, a clear majority of them highly favorable and, from their own perspective, correctly so. While I generally concur with much of this favorable reaction, I am disturbed that reviewers frequently share many of Freidson’s underlying, sometimes unstated, and often questionable assumptions concerning the House of Medicine in the United States and address his work only on its own terms. (For an exception, see reference 10,) Even though nowadays to proceed in this manner is generally considered “legitimate” criticism, I do not regard this as the only and certainly not the most effective form of critical appraisal. In this paper I will reflect on selected aspects of Freidson’s work and the institution he analyzes from a viewpoint quite different from his-that of political economy. In undertaking this task, I will not be criticizing Freidson for not doing what he consciously never intended to do anyway-that would certainly not constitute legitimate criticism. What I do want to consider on a broad level are some of the assumptions underlying his analysis, the adequacy of the theoretical orientation selected and the level of analysis he adopts for understanding the tasks he does address, the questions raised, and the implications that follow. In a sentence: Does Freidson’s theoretical approach and level o f focus afford an adequate explanation o f enough of what is going on in the House o f Medicine in the United States? From the perspective of political economy it is important to be clear, first of all, on what is now happening in the House of Medicine generally and then, secondly, to all levels of medical work (including doctoring) within it. One important caveat should be set down here in order hopefully to minimize certain misunderstandings. The ideological basis of much present-day social science research on medicine appears to require a villain to whom responsibility can be ascribed. For many liberals and some radicals, for reasons I cannot discuss at length here, physicians have become an easy target. In this paper, 1 wish to move beyond this superficial level of “doctor bashing” to a consideration of the activities of physicians in relation to more basic structural processes which are impinging on them. Let me hasten to add that I am alert to some of the conservative potentialities in the argument to be presented. I certainly am nor claiming, nor do I even imply, that physicians are only in small part, or in no way, responsible for their behavior and its consequences. Indeed, I have argued elsewhere (1 1) that physicians, through a variety of tactics at their disposal, have insinuated themselves into a position from which they can self-interestedly obstruct social change and protect their own prerogatives. While I am mindful then of the “special” position occupied by physicians and how they use this to protect their own particular interests, this paper attempts to view their behavior in a broader political and economic framework.

THE MAGNITUDE OF THE FORCES SHAPING THE HOUSE OF MEDICINE I can only touch on a few of the major political and economic influences now shaping the House of Medicine in the United States.

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Medicine Is a Profitable Business

For a variety of reasons, the business of medicine has been rendered a highly desirable arena for the presence of capitalist institutions. The features which make it so attractive for such institutions are sometimes shared with all other sectors of the economy, with some other sectors, or with no other sector. But it is in the arena of medicine that these features now cluster as a unique constellation which is conducive to reducing uncertainty in the market and to maximizing the probability of stabilizing at some acceptable level of profit. In addition to the well-established fact that medicine is immensely profitable, some reasons for it being so are: (a) there exists a large and often captive market; (b) demand by the public for medicine is often given primacy over other commodity consumption and appears to be insatiable; (c) the association with medicine facilitates a strategic control over a near total consuming public; (d) it makes possible strategic control over valued technology, thereby enhancing competitive position; (e) it is an arena where the state acts as a guarantor of profit; and (f) it enables exploitive institutions to project a false image of conspicuous benevolence (12). There is little doubt that some of these economically attractive features have been associated with medicine for a long time, while the presence of others, particularly the partisan involvement of the state, has been fostered by those interests and institutions most likely to benefit by their presence (13). The Invasion of Medical Care

Given such attractive features (but also because of internal pressures in other sectors of the economy), it is not surprising that predatory organizations have invaded and now dominate the business of medicine. I use the term “predatory” to characterize the rapinous activities of capitalist institutions (mainly financial houses and large-scale industrial corporations): the act of invading, exploiting, and ultimately despoiling any field of endeavor-with n o necessary humane commitment to it-in order to seize and carry away an acceptable level of profit. Some institutions have been in the medical arena for a long time and, almost without exception, have experienced phenomenal success. A couple of examples will illustrate this. In the 1964-1973 decade, Johnson & Johnson’s net sales went from $391 million to $1612 million. Between 1959 and 1968, earnings more than trebled-rising from $15 million to $50 million. Another well-known veteran, the American Hospital Supply Company, which started out solely as a distributor, has gradually increased its own manufacturing capacity so that nearly 50 percent of its sales now involve its own products. This company’s sales rose from $176 million in 1964 to $829 million in 1973. Over the last few years, many other companies with very diverse operations have become involved in the medical business. Such conglomerates as Litton Industries and CIT Financial now have large medical enterprises within their corporate families. Aerospace companies are involved in everything from computerized medical information systems (Lockheed and Grumman) to life-support systems (United Aircraft). Even tobacco companies (Philip Morris manu-

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factures surgical supplies) and transportation enterprises (Greyhound manufactures drugs) have invaded the medical care arena. In addition to industrial capital, there are many even larger financial capital institutions-in the form of commercial banks, life insurance companies, mutual and pension funds, diversified financial organizations, foundations, and so forth-which are also stepping up their incursions into the House of Medicine and experiencing phenomenal success. Now what effect does a (statesupported) flow of financial and industrial capital of such magnitude have on the business of medicine itself and, more particularly, on the activity of physicians located within it? One simply cannot focus narrowly on aspects of physician behavior and ignore the profound structural changes being imposed on the context within which they must operate (14-18). Transformation of Medicine into Big Business

The presence of large-scale financial and industrial capital in the medical arena has dramatically transformed what formerly resembled a cottage industry into a multibillion-dollar industry (19). The medical business is now the second largest industry in the country, exceeded only by construction, and is certainly the fastest growing. In fiscal year 1976, it produced a total output of over $139 billion-over 8.6 percent of the gross national product. In terms of expenditures, there are only about seven countries with a total gross national product as large as the $139 billion that is spent annually in the United States on medical business. From 1963 to 1973, medical expenditures rose at the rate of 10 percent annually, while the rest of the economy (as reflected in the GNP) was growing at only 6 t o 7 percent. If this current rate of growth continues, and there are indications that it will, then the nation’s outlay on aspects of the medical business will most likely reach about $200 billion by the early 1980s. To account for the changing shape of the House of Medicine in the United States and its consequences for all levels of workers within it, one must first understand the nature and magnitude of the political and economic developments I have been describing and the logic they impose on all medical care activities. Indeed, to understand more completely what is happening to medicine and its six million different workers, initially perhaps we should not look at the medical business at all but, rather, at the underlying structural constraints imposed on all sectors of the economy (one of them being medicine) by the structural requirements and underlying logic of capitalism. This logic can be very briefly summarized as follows: Some form of competition forces capitalists to expand productive output and sales irrespective of questions concerning the use value of the commodities produced. Such output and sales result in expanded profits and the accumulation of capital. The presence of this accumulated capital necessitates its reinvestment in even more enterprises or in the development of more technologically efficient enterprises. Since profits must also be realized on these new investments, and a falling rate of profit avoided, even greater productive output and sales are required.

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The resulting pressure t o find new buyers leads t o increased penetration of the domestic market and ultimately, through deceptive advertising, the creation of a commodity-fetishist culture. When the domestic market is eventually saturated, attention is directed toward susceptible foreign markets, either through expropriation of resources in lessdeveloped countries to reduce costs and risks (economic imperialism), or through the capture of foreign markets through direct investment (multinational expansion). Finally, the resultiqg capital from the profits of this expanded output and sales must, once again, be reinvested and the whole cycle is repeated-albeit on a more escalated scale.

As long as the medical-industrial complex is viewed in terms of its own internal logic, it will remain depicted as “inexplicable,” as “unmanageable,” or as in a “state of crisis.” Independent observers of medicine must, I believe, consider the possibility of a competing external logic and the potential offered by its use. And an awareness of this underlying logic of capitalism, of the structural pressures that derive from it, and how they are now manifesting themselves in the House of Medicine facilitates a more complete understanding of the changing position of all medical workers, even physicians. Medical Care and Collective Needs

Since it is relevant to the consideration of Freidson’s work which follows, one further point should be made here concerning the coincidental relationship between the production of goods and services in accordance with the logic of capitalism and any resulting improvements in the health and werfare of mankind. Key decisionmaking under advanced capitalism (concerning where to invest, the spheres to be penetrated, which technology should be applied and where, and so forth) is seldom influenced by an awareness of collective needs or the social costs likely to be involved. Such decisions are always dictated by criteria of profitability in accordance with the logic of capitalism I have outlined. Accordingly, those activities whose product or result is either unprofitable or unable to be measured according t o profitability criteria (including frequently the most socially needed activities) cannot, under capitalism, be given priority and, hence, may never be produced. Since there is no logical connection between the dictates of profitability and the fulfillment of collective needs, one cannot assume, as many do, that these two will naturally and inevitably be joined. Both are premised on distinct (and often conflicting) ideologies. Consequently, the House of Medicine under capitalism will never contribute t o improvements in health unless such improvements facilitate an acceptable level of profit. Now ,on some occasions the fulfillment of collective needs does happen to coincide with the initiatives of capitalist institutions. But these relatively rare occasions (which we are seldom permitted to overlook) do not represent an abandonment or any weakening of the logic of capitalism. Rather, either they constitute a profit-motivated investment in some form of social welfare (public transportation, pollution control, or medical care) or, as Gorz (20, p. 78) puts it, “the pursuit of optimum human and

464 / McKinlay economic goals and the pursuit of maximum profit from invested capital coincide only by accident.” What I term “coincidental benefits” are all that one can ever expect to derive from any institution dominated, as medical care now clearly is, by the logic of capitalism. Understanding the magnitude of the forces behind and now present in the House of Medicine, the logic they impose on this particular economic sector, and the resulting disjunction between production for profit and fulfillment of the collective needs of the public, provides, I believe, the analytic key for understanding the medical-industrial complex and the changing position of physicians (and all other workers) within it.

LEVELS OF ANALYSIS AND THE SCOPE OF MEDICAL SOCIOLOGY In my own recent work, I have found it useful to distinguish among four separate levels of analysis, each of which affords quite different ideological views of the changing nature of the business of medicine in the United States. These four levels of analysis can be distinguished as follows, in the order of their determining influence: The Level of Financial and Industrial Capital. Here I refer to the activity of vast multinational capitalist institutions-both financial and industrial corporations and the individuals and interests controlling them-and how their presence in and around the medical business is profoundly changing all spheres of medical care and especially the nature of medical work. The Activities of the Capitalist State. At this level we are concerned with how the vast resources of the state, subordinated as they now clearly are to the institutions and interests identified with the first level, are employed to: (a) protect and brokerage the prerogatives of these institutions; (b) ensure that medical care, as an area of investment, remains conducive to the realization of profit; and (c) shape, through partisan legislative action, the scope and content of medical work and the consumptive behavior of the public with respect to medical care. The Level of Medicine Itself. At this third level we are interested in howwithin the constraining context of the partisan activities of the capitalist state on behalf of the prerogatives of financial and industrial interests-medical activity is actually conducted. This most common level of analysis includes, for example, research on the training and content of medical labor, managerial studies of medical organizations, positivistic accounts of the efficiency of medical practice, and epidemiological rationalizations for the existence of medicine. And, it is at this and the following fourth level that most conservative medical sociology continues to be conducted. The Level of the Public. Here we are concerned with the vast number of people who are the potential users of, and increasingly the subjects for medicine-a category loosely termed “the public,” which may actually be incidental to medical activity itself (it could conceivably proceed without their involvement) and is presently the most vulnerable of all to the activities of those at the three other levels already distinguished.

By way of summary and analogy, therefore, one can conceive of medical carerelated activities as the game among a group of highly trained players, carefully

Reflections on Freidson’s View of Medical Game / 465 selected for the affinity of their interests with the requirements of capitalist institutions, which is watched by a vast number of spectators (involving all of the people Some of the time and, increasingly, some of the people all of the time). And surrounding this game itself, with its interested public, is the capitalist state (setting the rules by which the game ought to be played before the public), the presence of which ensures the legitimacy of the game and guarantees, through resources derived from spectators, that the prerogatives and interests of the owners of the park Cfinanciu2 and industrial capital) are always protected and advanced. In the context of this analogy, it becomes clear where most of the research and teaching effort in medical sociology, among several other fields, is now being focused. When supposedly independent medical care researchers are not caught up in observing the game of medicine itself (and I admit that it is sometimes very difficult not to), they are usually to be found observing the observers of the game (the public). And, given recent developments in sociology, some medical sociologists are even becoming involved in the observation of those observing the observers of the game! Once one becomes fully aware of the magnitude of the structural changes now being forced upon the business of medicine, then the very issues selected for investigation and the levels of analysis and concepts adopted to explain them are profoundly influenced. As it is generally practiced, medical sociology overlooks the political and economic setting within which the medical game is currently played and, consequently, remains ludicrously preoccupied with issues of relative unimportance. I am of the opinion that there is very little in the existing common fund of knowledge of medical sociology that will enable us to get a handle on what is now going on in and around the business of medicine. Indeed, the current preoccupation with, for example, phenomenology and ethnomethodology, while interesting and theoretically scintillating, is likely to yield little that will enable us to understand the changing nature of the medical game and the position of participants within it (both medical care workers and a consuming public), which could result in political action, effective social policy, and change aimed at fulfilling collective needs (see, for example, references 21-24). Now, where does Freidson stand in relation to the developments I have been discussing? What he is trying to do, generally speaking, is to understand broad aspects of the medical-industrial complex through a detailed analysis of the now dominant, but historically changing, position of one group of players, among many, in the medical game. He suggests, at the beginning of Professional Dominance, for example, that professional dominance is the analytical key to the present inadequacy of the health services (18, p. xi). And even though he is often concerned with the broader ramifications of his analysis in other spheres and at other levels, his point of focus and the theoretical perspective he adopts (social construction) impose severe limitations on the questions that can be addressed. Indeed, by focusing at the level he does, Freidson leaves unaddressed many of the very questions raised by his insightful analysis. What exactly is the nature of t e relationship of professions to the state under advanced capitalism? What are some f the political and economic consequences of the medicalization of everything? Does socialization into a clinical mentaiity only benefit physicians, or can it be viewed as serving other interests as well? What class interests are behind what is termed “professionalization” and is this phenomenon involved in the perpetuation of social inequality? While these and many other

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questions flow naturally from Freidson’s work, his level of focus and theoretical orientation preclude their ever being satisfactorily answered. And even though in the introduction to Profession o f Medicine he indicates that, while focusing on the medical game, he will be eschewing the assumptions of the medical players and adopting an outsider’s view of the profession, his is still predominantly a view of only one level of activity-if you like, a behind-the-scenes or locker room view of the so-called profession of medicine (7, p. xix). I would suggest that instead of an outsider’s view of the inside of the profession, what we need is an outsider’s view of the strategic importance of both physicians and medicine for the inside of capitalism. Bearing in mind the four levels of analysis I have identified, how has the medical profession managed to secure its special position in society? Freidson seems to give three interwoven answers to this question, each of which relates to a different level. Firstly, and most extensively, he shows how, largely through political activity, the public is persuaded to grant the profession-especially its consulting wing-some special status (7, p. 188): I suggested that scholarly or scientific professions may obtain and maintain a fairly secure status by virtue of winning solely the support of a political, economic, or social elite, but that such a consulting profession as medicine must, in order to win a secure status, make itself attractive to the general public which must support its members by consulting them. The contingency of the lay public was thus critical to the development of medicine as a profession.

Secondly, and much less extensively, Freidson argues elsewhere that the profession’s unique position is variously but “ultimately” derived from the state (8, p. 83): The foundation on which the analysis of a profession must be based is its relationship t o the ultimate source of power and authority in modem society-the state. In the case of medicine, much, though by no means all, of the profession’s strength is based on !egally supported monopoly over practice. This monopoly operates through a system of licensing. . .

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And again (7, pp. 23-24): The foundation of mediche’s control over work is thus clearly political in character, involving the aid of the state in establishing and maintaining the profession’s preeminence. . The most strategic and treasured characteristic of the profession-its autonomy-is therefore owed t o its relationship t o the sovereign state from which it is not ultimately autonomous.

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Thirdly, Freidson considers that the profession’s unique position is secured only with the blessing of unidentified strategic elites (7, pp. 72-73): A profession attains and maintains its position by virtue of the protection and patronage of some strategic elite segment of society which has been persuaded that there is some special value in its work. Its position is thus secured by the political and economic influence of the elite which sponsors it-an influence that drives competing occupations out of the same area of work, that discourages others by virtue of the competitive advantages conferred o n the chosen occupation, and that requires still others to be subordinated to the prafession.. . The profession’s privileged position is given by, not seized from, society, and it may be allowed to lapse or may even be taken away. It is essential for survival that the dominant elite remain persuaded of the positive value, or at least the harmlessness, of the profession’s work, so that it continues to protect it from encroachment.

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Reflections on Freidson’s View of Medical Game / 467 These quotations illustrate how Freidson shifts from one level of focus to another as he explains, at different points in his work, why the profession occupies a unique position in society. The last quotation, concerning elites, raises what is for me an additional limitation in his work-the failure to pursue the consequences of his own arguments. This will be discussed again in subsequent sections. Several interrelated questions are left dangling: What “strategic elites” does Freidson have in mind? What is the nature of their relationship to the state? And how are these elites and the state involved in securing a mandate from the public, for the profession? Freidson may be quite correct when he, following Fuchs (25), argues that it is impossible to explain much of the medial game in the absence of an account of the strategic importance of physicians. Physicians probably have insinuated themselves into a position of dominance within the medical division of labor so that they now have some control over center field and the everyday conduct of the game. The game would probably have little public appeal, and could even be cancelled, if the star players were absent. But, as suggested earlier, there are different levels of control operating and the amount of control that physicians exert may actually be quite limited when viewed in relation to the industrial and financial forces to which I have alluded and the controls that they exert. While Freidson takes us a long way in explaining the sources of control that physicians exert at their own level, he fails to locate this in the context of other types of control operating at other levels around the medical arena. Control of the everyday conduct of the game itself certainly does not imply control of the park! In this respect, a more important question which Freidson fails to address is: which groups control what activity, how, and for whom? Or, to look at this issue from the reverse side, one can see that physicians may have considerable freedom over the terms and content of their own labor. But, at another level, and from the perspective of political economy, physicians can be viewed as being “free” to behave in just about any way at all, so long as they realize a profit for some medical organization and the interests which control it. Now what sort of freedom is that? In this regard, Fuchs’ recent description of the physician as “the captain of the team” (25, p. 56) may not be the most appropriate metaphor. Increasingly, it seems, physicians appear to be only members of a team, playing the medical game for organizations and interests which may not always be immediately visible, abiding by rules over which they have little control if they are to score, and increasingly penalized (through regulation and malpractice threats, for example) for apparent infractions of these rules.

IS MEDICINE EFFECTIVE? The simple question-is medicine effective?-is probably the most strategically important issue presently confronting medical sociology. For, if the answer should happen to be no-that the presence of medical care as it is traditionally conceived is demonstrably ineffective, unrelated to improvements in the health status of populations, and perhaps even inversely related to them-then implications of profound significance follow at each of the four levels I have distinguished. For example, if the business of medicine is largely unrelated to improvements in the health status of

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populations, then the demand for its products is unlikely to be exhausted-a situation perhaps uncharacteristic of other spheres of production and highly favorable to the interests behind the medical-industrial complex. How can there ever be a crisis of overproduction in medicine when the goods and services being manufactured are seemingly unrelated to the need upon which their production is supposedly based? If medicine is largely ineffective, who then benefits from the $139 billion the nation now spends on the business of medicine annually? For what ends are the vast resources of the state being mobilized through such programs as Medicaid and Medicare? Can the labor of physicians (and all other medical workers) be regarded as socially useful when it appears to have such a low yield in terms of health, which, after all, is held to be its ruison d’ktre? What are the long-term consequences of the fetishization of illness and the state-supported habituation of the public to ever more medical care? At a number of points in this work, Freidson is clearly aware of the importance of this issue of the effectiveness of medicine and physicians. He even states in Professional Dominmzce that it is on the basis of effective performance that the special position of physicians should be derived (8, pp. 31-32): The special position of the medical man is after all justified by his effective performance of practical ameliorative tasks, not by his contributions to abstract knowledge. It is in the character of its application to human needs that we find medicine’s justification, and it is in medical care settings that application takes place.

Now it follows logically from the premise in this statement that if physicians can be shown to be ineffective in their performance (on commonly accepted grounds and employing a commonly accepted methodology), then any “special social position” for them is certainly not justified. Freidson even acknowledges in several places that medicine and physicians may not, in the usual case, be as effective as they sometimes appear, and he emphasizes that (7, p. 251):

. .. it is very important to separate demonstrable scientific achievements from the status of the occupation involved and the success it has had in establishing its jurisdiction. The jurisdiction that medicine has established extends far wider than its demonstrable capacity to “cure.” All of this I agree with. But where does Freidson take this argument? Does he pursue the political and economic ramifications of his own logical conclusion in terms of, say, how socially useful and productive physicians may be? Does he isolate the broader interests these generally ineffective but specially situated workers may be serving? Instead of developing his work in these directions, he turns back to look at how, even in the absence of effective performance, physicians manage to secure and retain their special position in society. Such a tack is, of course, both consistent with and a limitation imposed by the social constructionist perspective which Freidson has selected. Still, it yields what I consider to be a most convincing critique of the attributes which many obkrvers consider the bases upon which physicians ought to be accorded a special position and their activities differentiated from those of other “OrdinaTy” workers. Freidson is led to the conclusion that (7, p. 83): In one way or another, through a process of political negotiation and persuasion, society is led to believe that it is desirable to grant an occupation the professional

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status of self-regulative autonomy. The occupation’s training institutions, code of ethics, and work are attributes which frequently figure prominently in the process of persuasion but are not individually or in concert, invariably, or even mostly, persuasive as objectively determinable attributes. It may be true that the public and/or a strategic elite always come to believe that the training, ethics, and work of the occupation they favor have some exclusive qualities, but this is a consequence of the process of persuasion rather than of the attributes themselves, and the attributes may not be said to be either ‘‘causes’’ of professional status or objectively unique to professions.

Again, I have no dispute with this as far as it goes. But where does this leave us with respect to the special position of physicians as justified by effective performance? Physicians may have deluded the public (and even some of the most astute social observers) and managed to insinuate themselves into a special position in our social structure. Still unresolved, however, is the question: despite what they claim and what the public falseconsciously believes, do physicians deliver the goods? Are they actually performing in an objectively determinable manner so as to justify their special social position? If not, should they be permitted to retain and secure a public mandate to occupy a special position from which they can obstruct social change? (1 1). And should the delivery of medical care continue to be based in large part on a group which, while performing ineffectively, still manages to persuade the public on the basis of its own self-interested claims that it ought to be accorded a special position? And what political strategies can be invoked either to render physicians effective performers or, perhaps less preferably, to dislodge them from the privileged position they now occupy? Freidson does not pursue the implications of his own argument in these directions. There is the assumption underlying much of this and the following discussion that a majority of medical care as it is traditionally conceived, and excluding public health, is not related and may even be inversely related, to improvements in levels of health status in society (as distinct from individuals). This is not an easy assumption for most of us to accept. Yet, I believe there is probably enough evidence already available, from different organizational and national settings and employing varying methodologies, to lend support to such an assumption, or at least to cause the most conservative to consider it seriously. For example, data in support of the assumption may be derived from the historical demography of McKeown (26-29), the international comparisons of Abel-Smith (30), the social epidemiology of Cassel (3 l), Powles (32), and Susser and Watson (33), and the randomized controlled trials advocated by Cochrane (34). Now these researchers certainly do not accept my assumption in the deliberately crude form in which I have presented it, nor do they always pursue the policy implications of some of their fmdings-a limitation commonly associated with a positivistic orientation. But there is a body of dataderived paradoxically from studies within medicine itself-which casts serious doubt on the effectiveness of much of medicine (as distinguished from public health). And, for various reasons, many medical sociologists remain unacquzinted with these data which could provide a firm empirical basis for much of their work. Perhaps a major reason lies in the continuing tendency in medical sociology to draw a distinction between the sociology of medicine and sociology in medicine-a dichotomy which, while heuristically useful, does the disservice of robbing one-half of medical sociology of an empirical foundation and the other of political and policy impact.

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With reference to my earlier point concerning the expectation of only “coincidental benefits” from all social activities under capitalism, one can see here that, for a medical care system dominated by the logic of capitalism, such questions concerning effectiveness are largely irrelevant. If medicine, under capitalism, happens to be demonstrably effective and does serve collective needs, then well and good (no doubt this information will be used to further the sales effort). However, if it is largely ineffective and fulfills no collective needs, but still turns an acceptable level of profit for the interests behind it, then its future appears just as secure. Despite what we are led to believe, the primary structural exigency of the medical-industrial complex in the United States is the realization of an acceptable level of profit, not the delivery of effective medical care in the public interest (20). Lest I be viewed here as a therapeutic nihilist, I should add that I do strongly agree when Freidson says (8, p. 181): Even in the corpus of such a scientifically based profession as medicine one finds a heart of solid skill surrounded by a large fatty mass of unexamined practices uncritically honored because of their association with the core skills.. . . The most important task o f the sociologist in studying education and welfare as well as health factories is to dissect the fat from the muscle in the imputed skill of the professional service worker and to determine the consequences o f each for what is done to the client, with what price [emphasis added].

But the political consequences of such a dissection are markedly different for me than they are for Freidson, who remains unprepared to advocate or work toward changing the physician’s unjustified position of dominance at the center of the medical game. MEDICINE’S SPECIAL RELATIONSHIP TO SCIENCE Whether or not medicine is a science, an art, or something else entirely, is a complex debate with a long history which Freidson touches on at several points. While an extensive discussion of medicine’s unique relationship with science is inappropriate here, a few points of concern can be highlighted. With respect to science, Freidson, I believe, makes three major points: Medicine does have what he terms “a scientific foundation” (7, p. 162): Medicine is of all the established professions based on fairly precise and detailed scientific knowledge, and it entails considerably less uncertainty than many other technical occupations [emphasis added] .

By establishing this “scientific foundation,” medicine became a “true consulting profession” and distinguishable from religion and law: It became a true consulting profession in the late nineteenth century after having developed a sufficiently scientific foundation that its work seemed superior to that of irregular healers (7, p. 12). .. . it [medicine] alone has developed a systematic connection with science and technology. Unlike law and the ministry, which have no important connection with science and technology, medicine has developed into a very complex division of labor. . . . (7, p. xviii).

Reflections on Freidson’s View of Medical Game / 471 It is important to distinguish between science and profession (8, p. 107):

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. . the prime structural difference between profession and science is that one has a lay clientele and the other does not. In the case of science,similarly knowledgeable colleagues constitute the consumers of the practitioner’s special skill. But in the profession,the consumers are lay clients. Freidson goes on to discuss the implications of this distinction for the everyday practice of medicine. There seem to be two main arguments commonly employed today to support the view that medicine is a science. The first relates to medical education and suggests that, while at medical school, student physicians are trained in science (biochemistry, physiology, pharmacology, etc.) and that, consequently, they perform as scientists when they eventually engage in the practice of medicine. The second relates to the epistemological basis of medical knowledge and suggests that physicians, in the everyday practice of medicine, utilize knowledge derived through science and in accordance with “scientific method.” In other words, that medical practice is, in Freidson’s term, variously “based on science.” I consider both of these arguments to be deficient. For the purpose of this discussion, science may be viewed as a paradigmatic approach to phenomena which involves the use of a particular methodology (see, for example, reference 35). One simply cannot assume either that this paradigmatic approach (even if there is such) is acquired through medical training or, if it is, that it is a characteristic that is present in most of the everyday practice of medicine. Indeed, in view of what Freidson tells us about client dependency, the features of the physician’s clinical mentality, and the overriding importance of the work setting on physician behavior, it is unlikely that science is a distinguishing characteristic present in most of modem medical practice. Moreover, some of what I have already discussed concerning the ineffectiveness of much of medicine provides a basis of doubt for both of these arguments. The closer one examines the supposedly “scientific knowledge” that forms the epistemological base of everyday medical practice, the more one finds that it does not, in fact, originate in science at all, nor does it withstand a careful scrutiny in accordance with the methods of science. Eschewing public claims to the contrary, the majority of medicine still remains a body of largely unexamined techniques and bits of information to which-despite vast expenditure, questionable effectiveness, and even its lethal Potential-the paradigmatic approach of science has yet to be applied. And even if Some common medical knowledge withstands examination in accordance with science as some probably would, there is no structural mechanism to ensure that this knowledge will or even can figure prominently in the everyday practice of medicine. There is simply no justification, either in the way physicians are trained or in the origin of the knowledge they employ in practice, for the claim that medicine, as a consulting and perhaps even as a scholarly pursuit, now has or ever will have a scientific foundation. Furthermore, there are no grounds in the argument Freidson presents for his claim that, through scientific knowledge and so forth, medicine has now achieved a qualitative break with the past. Although Freidson and I disagree on this particular Point, I am still persuaded by his discussion of the ways in which medicine, by

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claiming a special (albeit questionable) relationship with science, has become distinguishable from other activities, has secured a public mandate, and, consequently, has managed to achieve a specid position. SHOULD GOODS AND SERVICE PRODUCTION BE DISTINGUISHED?

I am aware of no logical grounds for drawing any distinction between the production of corporeal commodities and the production of incorporeal human services in any system dominated by the logic of capitalism. On this issue, Freidson, following Hughes (36), and I could not disagree more. In Doctoring Together, he says (9, p. xii): Essentially I argue, it is inappropriate t o approach the assessment of human services in the same way that one approaches the manufacture of goods. In the human services of medicine, education, welfare and law, the aim is not merely to “turn out” some measured product of a given quality at a given cost but to sexve human beings in need of help. In manufacturing we do not concern ourselves with the tortures through which fibers, plastics, metals, or the like are put in the course of the production process. But in the human services we are concerned that the course of providing help includes some sensitive recognition of and responsiveness to the human quality of the structure of flesh and bone being processed.

Not only do I consider this distinction unwarranted on the two grounds Freidson presents-the service of human needs and service with feeling-but it appears inconsistent with much of his earlier critique of the attribute approach and raises doubts as to whether he really does eschew some commonly held, but mistaken, assumptions and adopt an outsider’s view of the medical game. Much of what I will discuss in subsequent sections concerning the nature of labor under advanced capitalism gives cause for uncertainty of the tenability of this distinction with respect to present-day medical care. At this point, however, several issues can be alluded to with respect to the distinction. The first point concerns whether Freidson gives adequate attention to the longterm structural movement toward the bureaucratization of medical practice. Even though he does offer the caveat at the beginning of Profession of Medicine that “no book can fail to reflect the time in which it was written,” I believe he overlooks the consequences of major trends in evidence in the late 1960s when he was writing. For example, he suggested in 1970 that (7, p. 91): The typical mode of medical practice in the United States is “solo practice.” This involves a man working by himself in an office which he secures and equips with his own capital, with patients who have freely chosen him as their personal physician and for whom he assumes responsibility.

And elsewhere he points out that, for a number of reasons (none of which are related to the encroachment of capitalist initiatives), “the proportion of personal health services given in complex organizations like hospitals seems to be increasing.” Over the last decade or so, there have been profound changes in the work location and task activities of physicians. The number of physicians in direct patient care in the United States increased by 48,306 between 1963 and 1973, for a gain of 19.6 percent. There were, however, within this patient care category, some marked changes. For example, over this period there was an absolute decline of 7,716 (5.4 percent) in the number of selfemployed office-based physicians. During the same period, there

Reflections on Freidson’s View of Medical Game / 473 was a corresponding increase of nearly 30,000 (84 percent) in the number of salaried office-based physicians. With regard to hospital-based practice, there was an increase of nearly 20,000 (51 percent) in the number of interns and residents and of 6,584 (23 percent) in the number of physicians who were full-time hospital employees. What I term “other bureaucratic activity,” which includes teaching, research, and administration, doubled over this same period-from 14,777 (5.6 percent) in 1963 to 29,110 (9 percent) in 1973. In summary, while 45 percent (117,778) of active physicians in 1963 were salaried, this had increased to over 58 percent (188,133) by 1973 (an increase of 60 percent on the 1963 figure) (37). While it is true that most services in the health field have been rendered in settings that are, organizationally, analogous to small shops, this is certainly no longer the case. Any distinctions between medical services and other commodity production based on some comparison of cottage industry organization with large-scale factory production are, therefore, now no longer valid. A clear majority of medical care is now produced in and distributed through largescale “health factories” (38). While clearly aware of this trend, Freidson overlooks what it portends for the control by physicians of the objects of their labor (patients), the tools of their labor (biotechnology), the means of their labor (physical plant), and the levels ofremuneration for their labor (salary scales). My second point concerns the nature of objectified decision making among all human service workers under capitalism. As a consequence of the bureaucratization that accompanies the penetration of any activity by capitalism, employees must, as Weber (39) points out, appear to avoid particularistic emotionally based involvement. AU activities are eventually approached in terms of a preexistent body of rules and formal procedures. The objects of labor, whether household appliances or human beings with unique medical needs, must be viewed impersonally and always in terms of the overall goals of the organization in question. With respect to the business of medicine, this means that the medical worker must process the objects of his or her labor (patients) without much concern for their individual uniqueness. Medical workers announce the arrival of a ruptured appendix or refer to the gallbladder on the third floor! There are, of course, situations, and medical care may sometimes be one of them, where looking at an individual as an object is to be desired. (We would probably not have faith in a physician who broke into tears every time he or she caught sight of blood). But, in other cases, and medical care increasingly appears to be one of them, such bureaucratic impersonality may become inhuman and debilitating. While in medical school, physicians are actually taught to disregard the particularistic features of each case and instead adopt an ideology that is euphemistically termed “detached concern” in order to process the objects of labor (patients) more efficiently, ensuring a higher level of productivity. And, for medical care under advanced capitalism, there is increased pressure for “physician productivity,” often spuriously measured as the number of patients able to be processed by a single physician in a given period of time. Increasingly, it seems, the practice of “good medicine” is becoming synonymous with “performing” in a productive manner so as to realize a profit for the interests behind some medical care organization. Thirdly, are physicians (and other medical workers) generally aware of these

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developments, and how are they encouraged to accommodate to them? For most people, specialization in medicine is held to be a desirable development and indeed an unavoidable consequence of the proliferation of “scientific” knowledge. Obviously, no one person can be expected to grasp the entire constantly expanding corpus of medically relevant information. The so-called advantages of the process termed “specialization” are paraded before physicians during what is also interestingly termed “professional socialization” (a euphemism for occupational indoctrination), with the result that many are seduced into bureaucratic practice (most specialized medicine does, in fact, occur in a bureaucratic context). The perspective developed in this paper affords another way of looking at the ideology and process of specialization, however: namely, as a type of false consciousness which makes palatable or obfuscates the fact that what physicians are actually increasingly involved in is highly segmentalized (“tightening of one screw”) activity as the object of their labor (an objectified patient with a “condition”) passes before them, at an ever-quickening pace, on the medical care production line. Of course, those who subscribe to the false consciousness (and functional rationality) associated with specialization are unlikely to view lheir activity in anything like these terms. One way of restating the point I am trying to convey here would be to distinguish between the manifest and the latent functions of specialization in medicine. Specialization’s wideespoused manifest functions generally relate to supposed improvements in the quality of care, keeping abreast of biotechnological advances, and so forth. But one latent function of this process, however, may be the breakdown of the now diffuse and generally mystical medical arena into discrete and manageable components. Instead of a physician being a “generalized wise man,” he/she is now encouraged, through the fostered false consciousness of specialization, to become an expert in an ever more limited area of activity. (It is, of course, difficult to segmentalize and codify the knowledge of a “generalized wise man.”) And once medical activity becomes segmentalized, it is rendered more understandable and less imbued with protective mysticism. It is possible to argue, therefore, that, through a high degree of specialization, the technical base of medicine is being continually narrowed and demystified, making it vulnerable to codification into a set of bureaucratic rules and procedures ripe for computerization and easily grasped by those without formal medical training (40). Freidson believes that, for most physicians, the ideal practice arrangement (the “sacred cow”) is the autonomy provided by solo fee-for-service activity. However, as has been pointed out, physicians are increasingly locating in bureaucratic forms of salaried practice. In such a situation, the ideology and activities associated with specialization (with all of their rapidly expanding technological appurtenances) may be viewed as a kind of “cooling out” process which enables physicians to accommodate, without undue disruption, to this lesser “ideal” of salaried bureaucratic practice. (On the process of “cooling out,” see references 41 and 42). Fourthly. granted that both human services and other commodity production may now mostly occur in a factory context, some of this activity is officiaZZy regarded as not-for-profit, while some of it is. Now does not this issue of profitability provide one basis for drawing the distinction that Freidson, among many others, subscribes to? Whether or not one should differentiate between profit and nonprofit organizations

Reflections o n Freidson’s View of Medical Game / 475 involves, of course, many complex issues which cannot be dealt with adequately here. Suffice it to say that I consider such a differentiation to be founded on logically unacceptable assumptions concerning the activities of, for example, churches, universities, and hospitals, and that the distinction, like so many others in the field of human service, serves to protect and advance the not always visible interests of particular groups. Even though I am constantly informed that Boston University is a “nonprofit educational institution” (and, therefore, exempt from taxation), this is inconsistent with additions to staff, salary increases, the acquisition of new land and buildings, renovations t o existing property and equipment, and so forth. What would in fact constitute a profit is, in this case, administratively disguised as a result of such expansionist activity. A comparable situation exists, I believe, with respect to hospitals. What may here have constituted a taxable profit is administratively disguised (through perpetual expansion, new staff, salary increases, additional biotechnology, and renovations-all of which give a competitive edge and benefit particular groups) and thereby rendered officially exempt from taxation and other challenges. Whatever distinction there may be between a nonprofit and a profit-making organization lies not in any differences in the “special” nature of any actual activities that are undertaken but on the ability of some interests, solely on the basis of their own selfinterested claims, to persuade the state t o classify certain of their activities as different or special-a classification for which there appears to be no logical justification. FinuiZy, it is common nowadays to draw a distinction between the “nonprofit” production of services and the for-profit production of goods on the grounds of trustworthiness. This claim to trust is almost universally accepted in Western societies and is regarded as one essential ingredient in any relationship with a human service worker. The motto of socalled “human service,” unlike that of business where cmteat emptor (“let the buyer beware”) prevails, is credat emptor (“let the taker believe in us”). On what grounds, however, can those engaged in the production of human services make a greater claim t o trust than those in other spheres of production who have been unable to persuade others, through some ill-founded distinction, that they too are different? I have already argued elsewhere that any claim to trust by human service workers cannot rest on such nebulous grounds as “calling,” altruism, service orientation, unique kinds of training, or the suggestion that the public is unable to evaluate their supposedly esoteric activities (1 1, pp. 66-70). At present in the United States, we are confronted with the dilemma of people suffering and dying, not because there is not enough medical care, but because there is, in fact, too much of it. At first sight, this seems incomprehensible, especially if one subscribes to the official ideology concerning the nature and effectiveness of the majority of medical practice. It is quite well known that iatrogenic illness has now reached epidemic proportions, and it is not necessary to assemble a catalogue of horror stories here (see, for example, references 43-45). For the purpose of this argument and by way of summary, one can refer to Susser and Watson, who, after reviewing some pertinent data, conclude that “for the first time, medical care is so widely accessible, and its methods are so powerful, that, in itself, it must be considered a population hazard” (33, p. 39). It has been claimed by L. 1. Henderson (this is alluded to in reference 7, p. 16) that it was only in 1910 that a random patient, with a random illness, contacting a random

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physician had a better than 50-50 chance of benefiting from the encounter. On the basis of the arguments I have presented in this paper concerning the addition of ever more ineffective medical care labor, my retort to this would be that we are rapidly reaching a point where a random healthy person, having contact with any random medical care worker, has a better than 50-50 chance of contracting some disease or suffering unnecessarily as a result of the encounter. With respect to medical care and on the basis of data now available, caveat emptor! In summary, I believe there are no grounds either in the ways patients are handled, the way medical care workers are trained, how medical production is organized, whether or not profit is involved, or any claims concerning trustworthiness, for drawing any distinctions between the production of corporeal commodities and the production of incorporeal services. Under advanced capitalism, there are more similarities between the production of goods and services than there are differences. SOME TYPES OF LABOR UNDER ADVANCED CAPITALISM From the perspective of political economy, what follows naturally from an awareness of the general ineffectiveness of medicine and its domination by the logic of capitalism are questions regarding whether physicians, in the type case, are engaged in socially useful or wasted labor, and the conditions under which they may be viewed as either productive or unproductive workers. Perhaps the best way of achieving some clarification on these concepts is to consider in this section, and without any reference to Freidson’s work at all, how Marx defined and distinguished between some types of labor under capitalism. After this digression we will hopefully be in a position to consider in the following two sections some additional features of the work of physicians. Specifically we will consider (a) whether physicians engaged in some aspect of “human service” can be distinguished from workers involved at some stage in the manufacture of, say, automobiles; and (b) whether physicians are socially useful (or wasted) workers, the conditions under which they may be productive (or unproductive), and whether any of this matters anyway. For Marx, the presence of useful labor-the work involved in the production of use values (products of human labor which are able to satisfy some human want) was considered a necessary condition of human existence (46, p. 43):

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. . so far therefore as labor is a creator of use value, is useful labor, it is a necessary condition independent of all forms of society, for the existence of the human race. In general, Marx conceived of useful labor as the amount of labor technically required to produce a commodity (or service) with a particular use value. Of course, all commodities and services must have some use value or else nobody would purchase themno want would be satisfied by their acquisition. And a commodity without some use value for someone would clearly be unsaleable-it would constitute useless production. It would, in other words, have no exchange value precisely because it would have no use value. Products have an exchange value only to the extent that the society in which the commodity is produced is founded on exchange, is a society where exchange is common practice.

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For Marx, then, a use value may encompass anything that is demanded-that satisfies some human want, however it originates. He appears unclear, however, on how a want for a particular use value arises, with the implication that some part of the labor associated with the production of some use values may not, in fact, be socially necessary (see, for example, reference 47). In this regard, it is clearly important to make a distinction between labor which creates, modifies, conserves, or is technically indispensable for the production of necessary use values (which I would term “socially useful labor” actually fulfilling some uncontrived need) and those activities peculiar t o the production of unnecessary use values in the form of commodities and services solely for the purpose of profit-dictated exchange on the market (which I would term “socially wasted labor” supposedly fulfdling some contrived demand). Marx makes a special point of distinguishing between usehl labor and productive labor and, since it is important to what follows, this should be highlighted here. At no point does he argue that a criterion of the productiveness of human labor depends on some notion of its “necessity” or “social usefulness.” Productive labor specific to the cupitalist mode of production is labor exchanged with capital to produce profit or surplus value (that part of social production which is gratuitously appropriated by capitalists from the labor which produces it in order that it may be exchanged on the market). In Volume I of Capital, for example, we read (46, p. 509): That laborer alone is productive, who produces surplus value for the capitalist, and who thus works for the self-expansion of capital. . Hence the notion of a productive laborer implies not merely a relation between work and useful effect between laborer and product of labor, but also a specific social relation of product, as the direct means of creating surplus value [emphasis added].

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Marx reiterates again and again this fundamental property of productive labor under a capitalist mode of production: Only labor which is directly transformed into capital is productive (48, p. 393). From the capitalist standpoint only that labor is productive which creates a surplus value (48,p. 153). Productive labor, in its meaning for capitalist production, is wage labor which exchanged against the variable part of capital . . reproduces not only this part of capital (or the value of its own labor power) but in addition produces surplus value for the capitalist (48, p. 152) [emphasis added].

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For Marx, therefore, productive labor was distinguished by the social relations embodied in the labor, rather than either by the material characteristics of the product or by the content of the labor or by the “good intentions” of those involved in the labor. In Volume I of Capital we read (46, p. 509): If we may take an example from outside the sphere of production of material objects, a schoolmaster is a productive laborer when, in addition to belaboring the heads of his scholars, he works like a horse to enrich the school proprietors. That the latter has laid out his capital in a teaching factory, instead of a sausage factory, does not alter the relation.

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Productive labor is, of course, the sine qua non of capitalism and must be distinguished from unproductive labor (48, p. 396): Productive labor is only a concise term for the whole relationship and the form and manner in which labor power f m e s in the capitalistic production process. This distinction from other kinds of labor is, however, of the greatest importance, since this distinction expresses precisely the spedfic form of the labor on which the whole capitalist mode of production and capital itself is based.

If productive labor is that which is exchanged with capital to produce some form of surplus value, then, according to Marx, unproductive labor is labor which is exchanged with revenue (or what is now regarded as “income”). Included in this unproductive category are “artists, orators, actors, teachers, physicians, priests, etc.,” many of whom were employed by the state or church and whose services were purchased out of revenue and unproductive on this count (48, p. 157): An actor, for example, or even a clown, according to this d e f ~ t i o nis, a productive laborer if he works in the services of a capitalist (an entrepreneur) to whom he returns more labor than he receives from him in the form of wages;while ajobbing tailor who comes to the capitalist’s house and patches his trousers for him is an unproductive laborer. The former’s labor is exchanged with capital, the latter’s with revenue.

ARE PHYSICIANS AND OTHER HUMAN SERVICE WORKERS DIFFERENT? Even though it is closely related to the preceding discussion of the similarities of goods and services production under capitalism, I wanted to defer a consideration of whether workers engaged in these activities should be analyticdy distinguished until after some types of labor under capitalism had been discussed. Now, can physicians engaged in some aspect of human service be distinguished from workers involved at some stage in the manufacture of commodities? Braverman puts the question as follows (49, pp. 359-360): The worker who is employed in producing goods renders a service to the capitalist, and it is as a result of this service that a tangible. vendible object takes shape as a commodity. But what if the useful effects of labor are such that they cannot take shape in an object? Such labor must be offered directly to the consumer, since production and consumption are simultaneous.

Adam Smith, in The Wedth 0 f N ~ t i 0 n s(1776), saw productive labor as that which “fmes and realizes itself in some particular subject or vendible commodity, which lasts for some time at least after labor is past,” while he considered services to be unproductive labor because they “generally perish in the very instant of their performance and seldom leave any trace of value behind them” (50, p. 430). According to this view, productive labor is in some part based on the material characteristics of some product, rather than on the nature of the social relations embodied in the labor. Although it is clear that Marx explicitly rejected this Smithian view, some people feel that, at least in some of his work, he appeared to exclude human services by associating productive labor with the production of material goods. In his Critique of the Gotha Programme (51), for example, he argued that an expansion in the employment of teachers and physicians, which would most likely result from the development of communism, would represent the addition of unproductive labor.

Reflections on Freidson’s View of Medical Game / 479 For Marx, therefore, and t o reiterate an earlier point, productive labor was distinguished by the social relations embodied in the labor, rather than either by the material characteristics of the product itself or by the “determinate content” of the labor or by the “good intentions” of those involved in the labor. During the late eighteenth and nineteenth centuries when Smith and Marx were writing, the distinction between material and nonmaterial production appears largely confounded with the distinction between productive and nonproductive labor. Although, by the early twentieth century, the capitalist mode of production controlled a sizeable proportion of material production, it still had impinged very little on nonmaterial production, such as medical care. Thus for Marx, “productive” workers were almost exclusively found producing material goods for capitalists and creating a social surplus product, while workers who were providing services (nonmaterial production) which were generally paid for out of revenue, filled his definition of unproductive workers. Braverman considers the situation of service occupations under advanced capitalism and suggests that although they have always formed a large share of the division of labor, they have come t o constitute a “productive” part only recently. And he points out (49, p. 360): When the worker does not offer [this] labor directly to the user of its effects, but instead sells it to a capitalist, who resells it on the commodity market, then we have the capitalist form of production in the field of services.

THE USE VALUE OF MEDICINE On the basis of this admittedly lengthy but important discussion of labor under advanced capitalism, we are in a position t o consider some additional features of the work of physicians. Consider the situation of automobile production. In earlier times, the automobile was a relatively simple commodity (with a necessary use value) which, for some people, fulfilled an uncontrived need for transportation. Over the years, and primarily in response to the structural requirements of capitalism, unnecessary use values (supposedly fulfilling contrived demands) in the form of vinyl roofing, whitewall tires, walnut panelling, orthopedic posturing, and so forth have been perpetually tacked onto the original commodity with its necessary use value so that we are now confronted with the paradox of more value being derived from its unnecessary (“added value”) than from its necessary parts. Indeed, it is now difficult for the average person, confronted with a vast sales effort, t o even know what constitutes the automobile’s unnecessary and necessary parts. So much has been added that the automobile nowadays bears little resemblance to its counterpart of former times. And, of course, even if one could distinguish between its necessary and its unnecessary parts, one cannot now purchase the former without also purchasing the latter. Most importantly, more workers are now associated with and more surplus value is extracted from the unnecessary added value part than from the necessary use value Part of automobile production. A comparable situation now exists with respect t o the business of medicine. Starting as a relatively simple set of possibly effective procedures fulfilling some uncontrived human needs, medical care under capitalism has become transformed into an increasingly sophisticated, yet ineffective, body of unnecessary use values. What

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are included here under medicine’s unnecessary value added part are the wasteful use of biotechnology, unneeded ancillary testing, ritualistic surgery, the overutilization of hospitals, superfluous appointments, and so forth. Such socially wasteful activities probably now outweigh the demonstrably effective and necessary use value part of medicine. It is now impossible for the average person t o distinguish these parts and no enlightenment is likely to be forthcoming from those who are self-interestedly involved in their production. One cannot obtain the relatively simple yet effective part of medicine nowadays without also being obliged to purchase its expensive yet unnecessary and ineffective part. And, clearly, more highly trained workers are now involved in the socially wasteful task of producing those unnecessary added values in medicine than in the socially useful production of effective, low technology health care. We have now reached the point where greater profits (surplus value) can be extracted from socially wasteful than from socially useful labor in medicine. In summary, what I am suggesting here is that, because of its subordination to the logic of capitalism, the business of medicine in the United States (in common with business in other areas of production) is predominantly involved in the manufacture of demonstrably ineffective and unnecessary use values and that, consequently, an ever-increasing number of medical workers must engage in socially wasted labor. That this labor effort is largely ineffective is (in the context of the preceding discussion of the logic of capitalism and the expectation of only “coincidental benefits”) quite irrelevant. Irrespective of its determinate content and the nature of any use values produced, so long as this labor is productive-namely, that it reproduces not only the variable part of capital but, in addition, produces surplus value for the interests behind medical care production-then it will survive and the production of unnecessary use values unrelated t o collective needs will continue to expand. It should be evident from the preceding discussion of Marx that it is important to distinguish conceptually between labor which is socially useful or wasted, on the one hand, and labor which is productive or unproductive, on the other. With respect to medical care, this enables us to distinguish between: physicians performing socially useful labor but who are unproductive in the present system (e.g. general practitioners or primary care physicians-a fairly vulnerable group). physicians performing socially wasted labor but who are productive workers in the present system (e.g. many specialists employing high technology). physicians performing socially useful labor who are also productive workers in the present system (the situation of “coincidence” that I have described). physicians performing socially wasted labor who are also unproductive workers in the present system (structurally the most vulnerable group). In summary, an understanding of the character of the labor process under capitalism provides, I believe, a more adequate explanation for the continuing special position of ineffective physicians than does Freidson’s more limited analysis of the internal structure and everyday activities of the medical profession. That physicians are, in the usual case, engaged in socially wasted labor is, as we have seen, largely irrelevant. What is important for medicine under capitalism is that, irrespective of questions of effectiveness and social usefulness, physicians remain productive-that

Reflections on Freidson’s View of Medical Game / 481 they return ever more value in the form of social surplus than they receive in the form of wages. In other words, under capitalism, the explanation for the special position of physicians is to be found in their productivity, not in their effectiveness or social usefulness. The justification for a special position is, of course, another matter and this should, for physicians and any other worker for that matter, rest on grounds of demonstrable effectiveness, as Freidson suggests. And, on these grounds, we are justified in undertaking a dramatic restructuring of the medical game and the relegation of some currently dominant players-to a position more in line with their capacity to play effectively. Freidson, however, appears unprepared to pursue this inescapable implication. MEDICINE AND THE CLASS SYSTEM It is clear from what Freidson says at the beginning of Professional Dominance that he considers the relation of the class system to the medical division of labor an important issue to which sociologists, among others, ought to address themselves (8, p. 3). Unfortunately, in none of his work does he take on this issue directly. While attempting to distinguish different levels of analysis in this paper, I did begin to identify some broad class interests behind the medical-industrial complex and the forms of control they impose on and through it. But even if one only focuses at the level of physicians, as Freidson generally does, it is still possible to detect clear class interests. We know, for example, that at the present time in the United States medical schools accept only 14,000 of those 43,000 highly qualified applicants who have not already been discouraged from applying (52). Over 40 percent of medical students come from families who take in $15,000 or more per year, whereas, of all families in the United States, only about 12 percent have incomes over this amount (53). Since such a disproportionate number of physicians come from high earning groups, it would appear that whoever is “calling” people to medicine, they are doing it in a highly biased and mutually protective fashion! It is expected that between 1970 and 1990 there will be an 80 percent increase in the number of physicians-from around 300,000 to nearly 600,000. And if present trends continue, and there is reason to expect that they will, then there will be about one physician for every 400 people in the United States by 1990 (54). Such data concerning the number and social selectivity of physicians and their ratio to the general population have important implications for the rigidification of the class structure and the perpetuation of social inequality. But there are broader political and economic questions involving physicians at the other levels I have identified as well. For example, how are physicians and other medical care workers increasingly engaged in the service of financial and industrial interests lurking behind the public game of medicine? What are the long-term consequences of physicians donating ever more labor power to ever more socially wasteful production for profit, of ever more ineffective medical care? And who eventually receives the profit from the social surplus which forms an increasing proportion of whatever it is that Physicians are engaged in producing? What processes may physicians be implicated in when they false consciously habituate ever more people to ineffective medical services? In addition to physicians (and the sociologists who study their game), who

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else benefits from what is termed “professionalization,” their professional dominance, the medicalization of everything, and so forth? Is the state through its involvement with medicine legitimating and financing the rigidification of class interests, the social control of the public, and the perpetuation of social inequality on behalf of other interests? It is to these and related questions concerning medicine and the class system that some investigators, employing the perspective of political economy, are now fruitfully addressing themselves. Freidson, more than anyone else, has, I believe, led us to these important questions. But we do not find in his work the means by which we may begin to answer them. REFERENCES 1. Freidson, E. The sociology of medicine: A trend report and bibliography. Current Sociology 10-ll(3): 1961-1962. 2. Freidson, E. Patients’ Views of Medical Practice. Russell Sage Foundation, New York, 1961. 3. Freidson, E. Client control and medical practice. American Journal o f Sociology 65: 374-382, 1960. 4 . Freidson, E. Dilemmas in the doctor-patient relationship. In Human Behavior and Social Processes, edited by A. Rose, Ch. 10. Routledge and Kegan Paul, London, 1962. 5 . Freidson, E. Medical care and the public: Case study of a medical group. Annals o f Amer. Acad. Polit. SOC.Sci. 346: 5 7 4 6 , 1 9 6 3 . 6. Freidson, E. The Hospital in Modem Society. Free Ress, New York, 1963. 7. Freidson, E.Profesrion ofMedicine, Dodd Mead and Company, New York, 1970. 8. Freidson, E. ProfessionalDominance. Atherton Press, Inc., New York, 1970. 9. Freidson, E. Doctoring Together. Elsevier, New York, 1975. 10. Frankenberg, R. Functionalism and after? Theory and development in social science applied to the health field.Int. J . Health Seru. 4(3): 411-427,1974. 11. McKinlay, J. B. On the professional regulation of change. In Professionalization and Social Change, edited by P. Halmos. The Sociological Review Monograph 20: 61-84,1973. 12. McKinlay, J. B. Why corporate invasion of medical care? Unpublished paper, Boston University, 1975. 13. Renaud, M. On the structural constraints to state intervention in health. Int. J. Health Seru. S(4): 559471,1975. 14. Bodenheimer, T., Cummings, S., and Harding, E. Capitalizing on illness: The health insurance industry. Int. J. Health Seru. 4(4): 583-598,1974. 15. Murray, M. J. The pharmaceutical industry: A study in corporate power. Int. J. Health Seru. 4(4): 625440,1974. 16. Navarro, V. The political economy of medical care: An explanation of the composition, nature and functions of the present health sector of the United States. Int. J. Health Seru. S(1): 65-94,1975. 17. Salmon, J. W. The Health Maintenance Organization Strategy: A corporate takeover of health servicesdelivery.Int. J. Health Serv. 5(4): 609424, 1975. 18. Health Policy Advisory Center. The American Health Empire. Vintage, New York, 1971. 19. Kelman, S. Toward the political economy of medical care. Inquiry 8(3): 30-38.1971. 20. Gorz, A. Strategy for Labor. Beacon Press, Boston, 1967. 21. McNall, S. G., and Johnson, J. C. M. The new conservatives: Ethnomethodologists, phenomenologists, and symbolic interactionists. Insurgent Sociologist S(4): 4945,1975. 22. Reynolds, J., and Reynolds, L. Interactionism, complicity and the astructural bias. Catalyst 7: 76-85,1913. 23. Gouldner, A. W. The Coming Crisis in Western Sociology. Basic Books, New York, 1970. 24. Mayri, W. W. Ethnomethodology: Sociology without society. Catalyst 7:lS-28,1973. 2 s . Fuchs, V. Who Shall Live? Basic Books, New York, 1974. 26. McKeown, T., and Brown, R. G. Medical evidence related to English population changes in the eighteenth century.Populotwn Studies 16: 94-122,1955. 27. McKeown, T., and Record, R. G. Reasons for the decline of mortality in England and Wales during the nineteenth century. Population Studies 16: 94-122,1962.

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28. McKeown, T., and McLachlan, G. Medical History and Medical Care: A Symposium of Perspectives. Oxford University Press, London, 1971. 29. McKeown, T., Record, R. G., and Turner, R. D. An interpretation of the decline of mortality during the Twentieth Century. Population Studies 29(3): 391-422,1975. 30. Abel-Smith, B. Value f o r Money in Health Services. Heinemann Educational Books, London, 1976. 31. Kaplan, B. H., Cassel, J . C., and Gore, S. Social Support and Health. Paper presented t o the American Public Health Association, November 9,1973. 32. Powles, J. On the limitations of modern medicine. Science, Medicine and Man l(1): 1-30, 1973. 33. Susser, M. W., and Watson, W. Sociology in Medicine. Oxford University Press, New York, 1971. 34. Cochrane, A. L. Effectiveness and Efficiency: Random Reflections on Health Services. Nuffield Provincial Hospitals Trust, London, 1972. 35. Kuhn, T. S. The Structure o f Scientific Revolutions. University of Chicago Press, Chicago, 1962. 36. Hughes, E. C.Psychology: Science and/or profession. The American Psychologist 7:441-443, 1952. 37. American Medical Association. The Distribution o f Physicians in the US.,1973. Center for Health Services Research and Development, Chicago, 1974. 38. Freidson, E. Review essay: Health factories, the new industrial sociology. Social Problems 14(4): 493-500,1967. 39. Weber, M. Bureaucracy. In From Max Weber: Essays in Sociology. pp. 196-244.Oxford University Press, New York, 1958. 40. Haug, M. R. The deprofessionalization of everyone? Sociological Focus 8(3): 197-213,1975. 41. Goffman, E. Cooling the mark out: Some aspects of adaptation t o failure. Psychiatiy 15: 451-463,1952. 42. Clark, B. The “cooling out” function in higher education. American Journal of Sociology 65 : 569-576,1960. 43. Sartwell, P. E. Iatrogenic disease: An epidemiological perspective. Inf. J. Health Serv. 4(1): 89-93,1974. 44. D’Arcy, P. F., and Griffin, J. P. Iatrogenic Diseases. Oxford University Ress, New York, 1972. 45. lllich, I. Medical Nemesis: The Expropriation of Health. Pantheon Books, New York, 1976. 46. Marx, K. Capital, Moscow edition, Vol. I, Ch. 1, pp. 42-43,1961. 47. Cough, I. Marx’s theory of productive and unproductive labor. New Left Review 76: 47-72, 1972. 48. Marx, K. TheoriesofSurplus Value. Moscow edition, part 1,1969. 49. Braverman, H.Labor andMonopoly Capital. Monthly Review Press, New York, 1974. 50. Smith, A. The Wealth ofNations (1776), London, 1970. 51. Marx, K. Critique of the Gotha Programme (1875). In Marx and Engels, Basic Writings in Politics and Philosophy, edited by L. S. Feuer. Doubleday, Garden City, N.Y., 1959. 52. Medical study-Few chosen. New York rimes. March 4,1975. 5 3 . American Medical Association. Socioeconomic Issues o f Health ‘74. A.M.A. Center for Health Services Research and Development, Chicago, 1974. 54. US. Department of Health, Education, and Welfare. The Supply ofHeaIth Manpower. DHEW Publication No. (HRA) 75-38,1974.

Manuscript submitted for publication, December 4, 1976

Direct reprint requests t o : Dr. John B. McKinlay Department of Sociology Cokge of Liberal Arts Boston University 96-100Cummington Street Boston, Massachusetts 02215