Medical history as justification rather than explanation: A critique of Starr's The Social Transformation of American medicine

This paper discusses the major positions presented in Paul Starr's The Social Transformation of American Medicine and critically analyzes the major ideological and political assumptions that sustain Starr's explanation of the evolution of the institutions of medicine in the Unites States. These assumptions include, among others, that the evolution of medicine is an outcome of conflicts among the different interest groups that exist within medicine, interacting within the parameters defined by the majority of Americans whose beliefs and wants eventually determine what occurs in medicine, and the hegemonic positions in the ideology, practice, and institutions of medicine are dominant because of their powers of persuasion. This paper questions these positions on theoretical and empirical grounds and it presents an alternative explanation of the evolution of medicine. In this alternate explanation, the evolution of medicine (including its recent corporatization) is viewed as the outcome of power relations defined not by the majority of Americans but by a series of conflicts between classes, races, genders and other power groupings, within a matrix of dominant-dominated relations, in which dominance is reproduced by coercion and repression, and not merely by persuasion. Specific historical events are analyzed and alternative explanations are given to Starr's interpretation.