In his final chapter, Starr discusses the rise of the corporation, how the medical system managed to inadvertently increase its attractiveness to corporations, and the complex effects that will result in the medical field and its patients as a result of integration with the corporate model.
Three things stand out to me the most:
1) The "benefit" of corporate integration to doctors.
2) The benefits of increased oversight to patients.
3) The harms of corporate integration to people.
Starr's analysis of of corporate integration's effects on medical professionals is complex. On one hand, Starr describes that trends with younger medical professionals suggests that they have moved away from the sometimes overbearing demands inherent in individual practices, suggesting that more doctors may welcome the convenience of corporate run group-medicine, such as group practices or hospitals. This seems like a rational trend as our work market shifts into prioritization of order and streamlined convenience.
Additionally, with no little irony, he describes the sacrifice of autonomy--that which motivated the better part of the medical profession to establish and block policies since the 1800's--that will be inherent in incorporation. This places my reaction in no little sense of irony either. Largely, Starr's depiction of the medical movement has caused me to feel criticism for the professionals involved because of their fervent need to protect their own interests first above the interests of their patients. Up until then, this has been largely due to their need for autonomy and professional gains. However, now I wonder if the modern medical professional could still be guilty of prioritizing self-interest over the patient but through the relinquishment of autonomy.
In the debate over access for the poor an the needy, before insurance this was largely controlled by professionals establishing their own fees. There is surely more of an intimate, ethical, and moral consideration required in these practices. With the advent of insurers and corporations, perhaps medical professionals are much more enticed to never have to consider the issue of access again. Similar to their desire for more regular hours, perceiving their position to be framed more and more as a regular 9 to 5 job, perhaps they are happy to be rid of the ethical and moral considerations of access and equality, allowing the corporation and the insurers absolve them of responsibility. Are their interests still vested in the same ways, but expressed through an ironic reversal of demands?
Starr also outlines 5 reformations of the health practice through corporations and one of them seems to actually posit some benefits for patients. By horizontally and vertically compiling industries, corporations can limit compartmentalism of services, an issue that University of Michigan Professor and head of Obstetrics and Gynecology Timothy Robert B Johnson, categorized as one of the three "biggest threats to women's health" in a lecture in 2007. By making all levels of services available through a single hub, patients can benefit from a major barrier to access. Whereas patients could have suffered from a unintentional or intentional lack of information or services, creating a comprehensive medical home can provide patients with all their options.
However, the final issue that I intended to broach also described the very real concern with corporationalized medical care--actual access. The nature of corporations is to build upon profit and the capitalistic model. There is no gain to serve those who cannot pay,a s Starr points out, and any action to provide services for those who cannot pay would only revisit the issue of an amendment or side-service to a larger structural problem. The paradigm issues I mentioned in previous posts remain. And though I have described some of the real benefits to patients above, what good is fantstic service if you can't even get through the door?
Perhaps we can hope for a restructuring soon that will incorporate these beneficial aspects of corporationalization while ensuring access for all, but until that paradigm shift occurs, I am skeptical. Will our nation's most recent bid for health care reform actually lad us toward an oasis, or will it only bring us unfruitfully closer to another mirage?
Friday, November 27, 2009
Book 2 CH. 4
The impact of the civil rights movement and the momentum of the 70's is a striking aspect found in "End of the Mandate" (CH. 3, Book 2). I find the analysis of health as a privilege transitioning to a human right fascinating and inspiring. Absolutely health is a right, and it is rarely treated as such.
Obviously, one of these barriers seems to be that health is approached from a capitalistic perspective. This model determines individual access by the ability to pay for the specific service. Public insurance itself is amendment or a means of appeasement under this system, with the larger structure still revolving around better service for more money rather than better service because it is necessary or because it will benefit everyone.
Until the overall paradigm of our health system shifts, then I only foresee continued difficulties in achieving, implementing, and maintaining a truly equal-access health care system.
When Starr also discusses the growing conflict between established medicine and the health rights movement, I find some very interesting points of irony. In it, Starr describes how medical professionals became vilified by many int he rights movement of the 70's. People came to believe that the interests of doctors an patients automatically diverged and thus, safeguards were required to protect the people. All of this, surely, is written with a hint of disagreement with the assumptions made about modern medicine and practitioners from Starr's perspective.
But I believe that as poor as assumptions of harm are, reading Starr's previous 7 chapters has really made me feel as though this was justified. Though spread over the better part of the decade, the industry proved itself to be much more concerned with threats to its own power, its own autonomy, and its own livelihood as a business than it seemed to have been concerned with the welfare of patients. The example from Book 1, CH. 5 (in which health clinics were disbanded for providing destitute individuals with affordable care that private physicians were unwilling to compete with) highlights this again. It's becoming a pervasive theme throughout the book and in my own entries. Though I continue to believe that most doctors in the modern era and in the past have entered the profession largely with the intent to help, it doesn't change my feelings that a lot of the suspicion and protection initiated in the 70's was born out of justified sentiment for anyone who happened to have the access to the kind of history that Starr has compiled here.
Obviously, one of these barriers seems to be that health is approached from a capitalistic perspective. This model determines individual access by the ability to pay for the specific service. Public insurance itself is amendment or a means of appeasement under this system, with the larger structure still revolving around better service for more money rather than better service because it is necessary or because it will benefit everyone.
Until the overall paradigm of our health system shifts, then I only foresee continued difficulties in achieving, implementing, and maintaining a truly equal-access health care system.
When Starr also discusses the growing conflict between established medicine and the health rights movement, I find some very interesting points of irony. In it, Starr describes how medical professionals became vilified by many int he rights movement of the 70's. People came to believe that the interests of doctors an patients automatically diverged and thus, safeguards were required to protect the people. All of this, surely, is written with a hint of disagreement with the assumptions made about modern medicine and practitioners from Starr's perspective.
But I believe that as poor as assumptions of harm are, reading Starr's previous 7 chapters has really made me feel as though this was justified. Though spread over the better part of the decade, the industry proved itself to be much more concerned with threats to its own power, its own autonomy, and its own livelihood as a business than it seemed to have been concerned with the welfare of patients. The example from Book 1, CH. 5 (in which health clinics were disbanded for providing destitute individuals with affordable care that private physicians were unwilling to compete with) highlights this again. It's becoming a pervasive theme throughout the book and in my own entries. Though I continue to believe that most doctors in the modern era and in the past have entered the profession largely with the intent to help, it doesn't change my feelings that a lot of the suspicion and protection initiated in the 70's was born out of justified sentiment for anyone who happened to have the access to the kind of history that Starr has compiled here.
Wednesday, November 25, 2009
Book 2 CH. 3
Starr discusses some very salient political issues and concepts that I am coming to realize are so relevant not because of a specific alignment of circumstances, but rather, disappointingly, because of a disappointing habit of history to repeat itself. However, some of his political conversations seem glossed over, which detracts from the chapter's content as well.
In it, Starr describes the contributions of President John F. Kennedy and President Lyndon B. Johnson and their contributions to the effort of improved health access, though both attempts were indirect or incidental to medical care reform. In both, and rather somberly framed by a post-mortem aspect, Starr describes Kennedy's contributions after his death--actions to fight American poverty--and Johnson's subsequent continuation of those efforts as attempts at uniting the people against civil and economic disparity, that would potentially affect access to health care. but the point Starr seems to make is that neither astutely addressed how fighting poverty would directly affect or improve health care access. In this way, I interpret this to mean that any good for the movement of improved equal access health care was lost because no concrete plan supported it, if (and unlikely so) it was ever actually part of the goal when conceived by either Kennedy or Johnson.
Today we have a much more direct fight for health care reform, but the hastiness of the bill, the energy spent fighting unstiable critics, paralleles this threat of poor planning (a very real criticism of the health care bill on both sides) that very clearly reduced the benefits of Kennedy and Johnson's indirect efforts to promote human rights to equivalent health care service.
Perhaps, though, there is too much focus on the role and pwoer of politicians in this process. Investigating he situations in which reform "disappeared like a mirage" time and time again, what was the support of the people? In what capacity do the people negotiate their desire for medical reform and equivalent access and their desire for indvidual freedom of access? Will the people support it and will resounding support cause it to finally materialize? Currently a well played hand has resulted in a portion of the country fighting against reform that will most likely benefit them. It has since become a question to me as to how aware the people were each time health care reform was attempted. I certainly was unaware of efforts preceding the present beyond institutions like Medicare and Medicaid.
With such contentious debate, it seems as though history gets forgotten rather easily. Starr devotes a large portion of the chapter discussing the impact of liberals and their ideology fueling the movement toward health care reform, but civil rights from modern liberalism aren't born out of nowhere. People have to want it. Additionally, the liberalism Starr describes doesn't seem to be differentiated into classical liberalism and modern liberalism. Truly, the characterization of the medical practice detailed throughout the book is classically liberal, with the emphasis on negative freedoms of the professional community. However, much of this chapter is focused on the movement of modenr liberalism, and that is an important distinction that Starr seems to miss in this description. Therein lies a very interesting conceptualization and clash for medical and health care freedoms, especially when Starr elaborates on both parties' mutal cooperation in the past.
In it, Starr describes the contributions of President John F. Kennedy and President Lyndon B. Johnson and their contributions to the effort of improved health access, though both attempts were indirect or incidental to medical care reform. In both, and rather somberly framed by a post-mortem aspect, Starr describes Kennedy's contributions after his death--actions to fight American poverty--and Johnson's subsequent continuation of those efforts as attempts at uniting the people against civil and economic disparity, that would potentially affect access to health care. but the point Starr seems to make is that neither astutely addressed how fighting poverty would directly affect or improve health care access. In this way, I interpret this to mean that any good for the movement of improved equal access health care was lost because no concrete plan supported it, if (and unlikely so) it was ever actually part of the goal when conceived by either Kennedy or Johnson.
Today we have a much more direct fight for health care reform, but the hastiness of the bill, the energy spent fighting unstiable critics, paralleles this threat of poor planning (a very real criticism of the health care bill on both sides) that very clearly reduced the benefits of Kennedy and Johnson's indirect efforts to promote human rights to equivalent health care service.
Perhaps, though, there is too much focus on the role and pwoer of politicians in this process. Investigating he situations in which reform "disappeared like a mirage" time and time again, what was the support of the people? In what capacity do the people negotiate their desire for medical reform and equivalent access and their desire for indvidual freedom of access? Will the people support it and will resounding support cause it to finally materialize? Currently a well played hand has resulted in a portion of the country fighting against reform that will most likely benefit them. It has since become a question to me as to how aware the people were each time health care reform was attempted. I certainly was unaware of efforts preceding the present beyond institutions like Medicare and Medicaid.
With such contentious debate, it seems as though history gets forgotten rather easily. Starr devotes a large portion of the chapter discussing the impact of liberals and their ideology fueling the movement toward health care reform, but civil rights from modern liberalism aren't born out of nowhere. People have to want it. Additionally, the liberalism Starr describes doesn't seem to be differentiated into classical liberalism and modern liberalism. Truly, the characterization of the medical practice detailed throughout the book is classically liberal, with the emphasis on negative freedoms of the professional community. However, much of this chapter is focused on the movement of modenr liberalism, and that is an important distinction that Starr seems to miss in this description. Therein lies a very interesting conceptualization and clash for medical and health care freedoms, especially when Starr elaborates on both parties' mutal cooperation in the past.
Book 2 Ch. 2
In Book 2, Ch. 2, Starr concludes his chapter on the evolution of insurance (successfully, private insurance) by describing what I consider to be the most profound reason for the way things conclude at that period.
Starr describes the situation as being less than ideal; those most likely to receive insurance are those who have the most income. That is, those who have the most access to the insurance to pay for their hospital bills are the ones who suffer the least and need it least. The troubling nature of the system is clear, and begs the questions "How?" and "Why isn't anyone doing anything about this?"
The answer comes in the very next paragraph: complacency. Starr writes, "the private insurance system provided enough protection for the groups that held influence in America to prevent any great agitation for national health insurance in the 1950s." This is hardly surprising, especially given that it is an affliction that eats away at American society today, but it is no less disparaging.
We see another example of how easily people's prices are paid. In a system believe that what matters if if they are taken care of, does anyone really benefit? It is cruel and against common decency to behave so selfishly, to believe that one's responsibility ends at one's self. And yet, with 2/3rds satiated with some form of health care (unequal as that access may be within that 2/3rds), we see the society of the 1950s readily accepting the injustice and throwing the other 1/3rd of the population to the dogs.
I feel as though this is how the current debate on health care reform operates now. While those pushing for health care reform push for it on the basis of equal access for all people (or so we would believe), those against it condemn it for its costs to the people. But there is a difference between both side's definitions of "people." Whereas the pro-side's conception seems to literally encompass the people en masse, the anti-side's seems to mean "the people" as a collection of individuals. They argue about the cost to one person, and another one person, and so on. The fight seems to grip at the very heart of personal loss that can be grouped together. I feel that this aspect of the anti-side really reiterates the sentiments described by Starr--so long as we are covered by our health insurance, to hell with those without (the irony being that even those without have been convinced somehow to argue against themselves).
A line following the paragraph's opening also catches my attention. Starr states that the irony is that in its ferverence to make gains through compromise, labor may have lost out int he long run. The most vunerable populations intended to benefit remain disenfranchised. Neither is this a relic of the political world. It has scarecely been 60 years since then and we saw the same concession lead to the highly politicized Emplpyment Non-Discrimination Act, where LGBT activists sold out the transgender community, a highly vulnerable population seeking protection.
So far, those pushing for health care reform seem to be sticking to their guns about the bill, so there may yet be hope. But I can't help but raise an eyebrow and wonder if they too will sell out some of the most subtle but crucial spirits of the bill in order to merely push it past. Conversely, I wonder how many are so moved to push the legislation that they're willing to let things make it through that should be reexamine or retooled.
Will history repeat itself (again)?
Starr describes the situation as being less than ideal; those most likely to receive insurance are those who have the most income. That is, those who have the most access to the insurance to pay for their hospital bills are the ones who suffer the least and need it least. The troubling nature of the system is clear, and begs the questions "How?" and "Why isn't anyone doing anything about this?"
The answer comes in the very next paragraph: complacency. Starr writes, "the private insurance system provided enough protection for the groups that held influence in America to prevent any great agitation for national health insurance in the 1950s." This is hardly surprising, especially given that it is an affliction that eats away at American society today, but it is no less disparaging.
We see another example of how easily people's prices are paid. In a system believe that what matters if if they are taken care of, does anyone really benefit? It is cruel and against common decency to behave so selfishly, to believe that one's responsibility ends at one's self. And yet, with 2/3rds satiated with some form of health care (unequal as that access may be within that 2/3rds), we see the society of the 1950s readily accepting the injustice and throwing the other 1/3rd of the population to the dogs.
I feel as though this is how the current debate on health care reform operates now. While those pushing for health care reform push for it on the basis of equal access for all people (or so we would believe), those against it condemn it for its costs to the people. But there is a difference between both side's definitions of "people." Whereas the pro-side's conception seems to literally encompass the people en masse, the anti-side's seems to mean "the people" as a collection of individuals. They argue about the cost to one person, and another one person, and so on. The fight seems to grip at the very heart of personal loss that can be grouped together. I feel that this aspect of the anti-side really reiterates the sentiments described by Starr--so long as we are covered by our health insurance, to hell with those without (the irony being that even those without have been convinced somehow to argue against themselves).
A line following the paragraph's opening also catches my attention. Starr states that the irony is that in its ferverence to make gains through compromise, labor may have lost out int he long run. The most vunerable populations intended to benefit remain disenfranchised. Neither is this a relic of the political world. It has scarecely been 60 years since then and we saw the same concession lead to the highly politicized Emplpyment Non-Discrimination Act, where LGBT activists sold out the transgender community, a highly vulnerable population seeking protection.
So far, those pushing for health care reform seem to be sticking to their guns about the bill, so there may yet be hope. But I can't help but raise an eyebrow and wonder if they too will sell out some of the most subtle but crucial spirits of the bill in order to merely push it past. Conversely, I wonder how many are so moved to push the legislation that they're willing to let things make it through that should be reexamine or retooled.
Will history repeat itself (again)?
Thursday, November 19, 2009
Book 2 CH. 1
As I doubt is surprising, I am struck by the similarities between the major deathblows to national insurance in the 1910's and what I believe to be the underlying strategies against national health care reform today. Starr describes the panic and paranoia of the war effort against Germany being one of the criticisms of health care reform, in some cases taking the form of pamphlets decrying it as insidious and evil because its country of origin, Germany, was also "evil."
In many ways, I think this speaks to the history of xenophobia and a fear of some ever-present and yet non-existent Big Brother figure that thrived back then and continues to thrive today. The spin placed against health care reform in early 1917 was that it was a deviant foreign strategy and that American should have no part in replicating the actions of such a country as Germany. Likewise, the assertion that national insurance would result int he population being at the mercy of panel doctors who were the puppets of political figures played on the public fears of the Big Brother government, who would abuse the people for its own gain and cause harm to their most precious asset: health.
Today, this is the same. One of the most publicized and vocal criticisms of health care reform is its purported expansion of government, or the further empowerment of "Big Government." While this has been largely unfounded, former Vice Presidential nominee Sarah Palin's irresponsible and unfounded statements on "death panels" managed to channel the same panicked fears of the people--that governments would insidiously decide the health and fate of the people. The testament of this comment's ability to tap into the archetypal fears of the populace is obvious in its ubiquity in the media and the resulting protests by uninformed individuals over the "fascism" and "murderous" nature of the Democrat-controlled government.
initially, xenophobia was also exploited to support anti-health care reform arguments. Dissenters looked to the states of other countries, the people's ignorance of the systems beyond the US border, to attempt to draw conclusions that health care reform would not work and that it would cause damage to the safety of the people. However, the interesting difference in this parallel is that the countries used in comparison were allies such as the UK, and at that, ones that could demonstrate theoverwhelming benefits of health care reform. An editorial in Investor's Business Daily claimed that national health insurance such as the NHS in Britain would potentially deem individuals such as renouned physicist Professor Stephen Hawking as "worthless" and leave them for dead had he grown up under nationalized health care. But Stephen Hawking stepped into the debate to point out that he is a citizen of Britain it was NHS itself that ensured his surivial as a disabled individual where no commerical insurance company would have. I wonder if the landscape will change if these parallels cannot be maintained. If the effectiveness of nationalized health care in foreign countries, allies at that, is overwhelming, will it contribute to the solidification of reform?
Clearly the debate requires even more assistance than that. History, as Starr has shown, has defeated health care reform many times over for a variety of reasons (the largey oblivious outcry over "socialism" in today's debate compared to the assessment of Progressives and socialists in 1912 and 1916 come to mind), but I wonder when that mirage will transform into an oasis.
In many ways, I think this speaks to the history of xenophobia and a fear of some ever-present and yet non-existent Big Brother figure that thrived back then and continues to thrive today. The spin placed against health care reform in early 1917 was that it was a deviant foreign strategy and that American should have no part in replicating the actions of such a country as Germany. Likewise, the assertion that national insurance would result int he population being at the mercy of panel doctors who were the puppets of political figures played on the public fears of the Big Brother government, who would abuse the people for its own gain and cause harm to their most precious asset: health.
Today, this is the same. One of the most publicized and vocal criticisms of health care reform is its purported expansion of government, or the further empowerment of "Big Government." While this has been largely unfounded, former Vice Presidential nominee Sarah Palin's irresponsible and unfounded statements on "death panels" managed to channel the same panicked fears of the people--that governments would insidiously decide the health and fate of the people. The testament of this comment's ability to tap into the archetypal fears of the populace is obvious in its ubiquity in the media and the resulting protests by uninformed individuals over the "fascism" and "murderous" nature of the Democrat-controlled government.
initially, xenophobia was also exploited to support anti-health care reform arguments. Dissenters looked to the states of other countries, the people's ignorance of the systems beyond the US border, to attempt to draw conclusions that health care reform would not work and that it would cause damage to the safety of the people. However, the interesting difference in this parallel is that the countries used in comparison were allies such as the UK, and at that, ones that could demonstrate theoverwhelming benefits of health care reform. An editorial in Investor's Business Daily claimed that national health insurance such as the NHS in Britain would potentially deem individuals such as renouned physicist Professor Stephen Hawking as "worthless" and leave them for dead had he grown up under nationalized health care. But Stephen Hawking stepped into the debate to point out that he is a citizen of Britain it was NHS itself that ensured his surivial as a disabled individual where no commerical insurance company would have. I wonder if the landscape will change if these parallels cannot be maintained. If the effectiveness of nationalized health care in foreign countries, allies at that, is overwhelming, will it contribute to the solidification of reform?
Clearly the debate requires even more assistance than that. History, as Starr has shown, has defeated health care reform many times over for a variety of reasons (the largey oblivious outcry over "socialism" in today's debate compared to the assessment of Progressives and socialists in 1912 and 1916 come to mind), but I wonder when that mirage will transform into an oasis.
Ch. 6
I'll admit that this chapter confuses me. In it, Starr tackles the questions of capitalism's role in shaping or motivating the American medical movement. In my interpretation of the chapter, Starr takes a stance that refutes the belief that capitalism was the driving force behind the medical movement.
I find this inconsistent. If anything, Starr's examples in previous chapters seems to support the idea of capitalism's driving hand behind the vehicle of expanding the influence of medical profession. True, Starr refutes the concept of corporate capitalism's influence (and that seems consistent, in that physicians still demanded individual autonomy) but he continues in the chapter describing alternate motivations that seem, if anything, to be technicalities.
For example, he claims that "the main function of medical licensing was not so much to exclude rival practitioners as to cut down on the number of regular physicians by making medical education unprofitable." The same actions sought to eliminate the number of rival practitioners in order to maintain soverignty with their patients. What does it matter if the action was direct or indirect? The action of compromising commercial medical schools seems to have the same effect at reducing the total number of physicians as licensing would have.
And while medicine "played an insignificant role in sustaining democratic capitalism in America," it's clear that the spirit of capitalism was maintained in scientific medicine. As Starr seems to outline the motivations of the medical movement, every action seemed to work toward sustaining the influence, status, power, and commercial authority of the medical professional. Competition was eliminated, particularly those efforts that compromised the charges made by professionals (see the previous entry on disbanding health clinics). Eliminating competition, eliminating the expression or threats of capitalism, seem paradoxically capitalistic to me. It demonstrates reverence to the system and the utilization of its principles to reach top-dog status. Once they obtained the level of control and authority, they attempted to disengage the system to keep others from threatening what they had achieved.
Destroying the ladder once they reached the top doesn't erase their history of using it to get there.
I find this inconsistent. If anything, Starr's examples in previous chapters seems to support the idea of capitalism's driving hand behind the vehicle of expanding the influence of medical profession. True, Starr refutes the concept of corporate capitalism's influence (and that seems consistent, in that physicians still demanded individual autonomy) but he continues in the chapter describing alternate motivations that seem, if anything, to be technicalities.
For example, he claims that "the main function of medical licensing was not so much to exclude rival practitioners as to cut down on the number of regular physicians by making medical education unprofitable." The same actions sought to eliminate the number of rival practitioners in order to maintain soverignty with their patients. What does it matter if the action was direct or indirect? The action of compromising commercial medical schools seems to have the same effect at reducing the total number of physicians as licensing would have.
And while medicine "played an insignificant role in sustaining democratic capitalism in America," it's clear that the spirit of capitalism was maintained in scientific medicine. As Starr seems to outline the motivations of the medical movement, every action seemed to work toward sustaining the influence, status, power, and commercial authority of the medical professional. Competition was eliminated, particularly those efforts that compromised the charges made by professionals (see the previous entry on disbanding health clinics). Eliminating competition, eliminating the expression or threats of capitalism, seem paradoxically capitalistic to me. It demonstrates reverence to the system and the utilization of its principles to reach top-dog status. Once they obtained the level of control and authority, they attempted to disengage the system to keep others from threatening what they had achieved.
Destroying the ladder once they reached the top doesn't erase their history of using it to get there.
Wednesday, November 18, 2009
CH. 5
Ethics are the issues that stand out for me in Ch. 5 of "The Social Transformation of American Medicine."
One of the most interesting things here is how Starr takes a strong stance as an aside to refute accusations or interpretations of the motivations of the medical community made by Marxists and Liberals. While Starr has generally maintained a style of "objective writing," his footnotes and later sections of the book are unabashedly pointed. But it is his statement...
"Insofar as public health and medicine reduce disease, they augment the power of individuals to realize their own objectives, not simply to fulfill socially prescribed obligations."
...that makes me consider the two kinds of ethics described in one of the course tutorials. Medical ethics are defined as promoting individual autonomy while public health ethics have a caveat stating that individual autonomy should be respected unless it conflicts with the social good or causes another or others harm. While certainly neither is a set-in-stone definition, it is interesting to consider how Starr defends public health ethics as providing a source of self-actualization and autonomy, when part of the reality of public health is defining what individuals should and shouldn't do as rationalized by its impacts on the welfare of society. Clearly this is an oversimplification, but it was something that piqued my interest as I encountered it.
To continue with ethics, while describing the formation of health clinics, the irony could be cut with a knife when I read about medical professionals balking and ultimately shutting down a low-cost health clinic on the grounds that it unethically competed with their services. the choice to label these reasons as a matter of ethics is ironic, given the harm that it did to patients who were poor and could not afford the almost 500% greater fees charged by medical professionals. Part of the Hippocratic Oath is the promise to "do no harm." Yet this action is an indirect violation of this promise.
The issue arises again in recounting the restrictions imposed on county health departments by officials due to the pressure from the medical professional community. That there would be restrictions from performing "any curative medicine" is absurd, as stated in the text, and highly unethical in my opinion. I begin to wonder when ethics became the primary concern and not the status and power that medical professionals continued to demand ("...Too little recognition and power is [sic] given to the medical professional..." [for a flashback, the quote at the end of page 164 in Ch. 4 is another great example of this, and would be a hoot and a holler if it wasn't so depraved.])
One of the most interesting things here is how Starr takes a strong stance as an aside to refute accusations or interpretations of the motivations of the medical community made by Marxists and Liberals. While Starr has generally maintained a style of "objective writing," his footnotes and later sections of the book are unabashedly pointed. But it is his statement...
"Insofar as public health and medicine reduce disease, they augment the power of individuals to realize their own objectives, not simply to fulfill socially prescribed obligations."
...that makes me consider the two kinds of ethics described in one of the course tutorials. Medical ethics are defined as promoting individual autonomy while public health ethics have a caveat stating that individual autonomy should be respected unless it conflicts with the social good or causes another or others harm. While certainly neither is a set-in-stone definition, it is interesting to consider how Starr defends public health ethics as providing a source of self-actualization and autonomy, when part of the reality of public health is defining what individuals should and shouldn't do as rationalized by its impacts on the welfare of society. Clearly this is an oversimplification, but it was something that piqued my interest as I encountered it.
To continue with ethics, while describing the formation of health clinics, the irony could be cut with a knife when I read about medical professionals balking and ultimately shutting down a low-cost health clinic on the grounds that it unethically competed with their services. the choice to label these reasons as a matter of ethics is ironic, given the harm that it did to patients who were poor and could not afford the almost 500% greater fees charged by medical professionals. Part of the Hippocratic Oath is the promise to "do no harm." Yet this action is an indirect violation of this promise.
The issue arises again in recounting the restrictions imposed on county health departments by officials due to the pressure from the medical professional community. That there would be restrictions from performing "any curative medicine" is absurd, as stated in the text, and highly unethical in my opinion. I begin to wonder when ethics became the primary concern and not the status and power that medical professionals continued to demand ("...Too little recognition and power is [sic] given to the medical professional..." [for a flashback, the quote at the end of page 164 in Ch. 4 is another great example of this, and would be a hoot and a holler if it wasn't so depraved.])
Tuesday, November 17, 2009
CH. 4
My largest reaction toward this chapter is in the descriptions Starr provides in "The Triumph of the Professional Community." The best summary of the section for me is that it is all too funny. Yes, funny.
There is something humorous about observing how childishly private practitioners squabbled to all get a place on the wagon. It reminds me of toddlers crying because some other child had something they didn't. Only in this case, there is no parent to say, "Well I don't care what so-and-so got."
I would even go so far as to say that the descriptions of the concerns and criticisms of private practitioners are downright adorable if it wasn't for the fact that they were predicated on a genuine seriousness as grown professional men. It is that very fact that makes the description sobering in some way, leading me to feel incredulous as I step back and look at the situation.
While Starr's comparisons to the European movement of medicine happening concurrently with the American movement always casts a tarnishing light, never before has he made the American movement look quite so immature, hypocritical, and childish. It is through Arpad Gerster's quote that he accomplishes this so poignantly: "They must be shown, however, that the hospitals do not exist mainly for the indiscriminate benefit of the medical profession, but are here, first, for the benefit of the patients, and secondly for that of the community."
Though Gerster ultimately speaks to the necessity of economic reform, his observations (including those not mentioned above) clearly cast the American controversy as petty and self-involved. The irony is that all this is of greatest concern in a profession meant to be concerned for others.
It becomes less and less surprising, though, since Starr has made it very clear that the American medical movement was largely concerned with itself as a profession first and foremost, rather than as a calling to serve the people. And though it shouldn't be surprising, I cannot help but feel some level of disappointment as I read about the back-scratching, the competition, the fervency for status as associated with the hospital as an institution and the ultimate transformation of hospitals as "instruments of professional power." It feels as though one more testament to service falls to the ever insatiable stomach of status, power, and control.
Rather than being concerned for their ability to serve their patients, doctors were much more concerned with gaining more prestige and viewed the hospital as a ladder or cash cow. Even the rationalization of inequity to receive training and betterment through education seem like thinly veiled excuses to obtain the true goal of privilege and advantage.
In fact, the seemingly incessant demand for access and advantage for all at the most likely well know cost of quality and service of the hospital to patients is like a retelling of the famous King Solomon parable, with American physicians and European physicians (or those who understood the need for some exclusivity) as the two women fighting over the baby. While one woman was content to have any part of the child regardless of the cost to the child itself, the other is concerned primarily for the welfare of the child. It is only because these are grown men that I classify this as almost savage rather than childish.
I guess it is good to reflect, then, on why I find this so humorous. Is it funny because it's funny? Or because it's one big joke?
There is something humorous about observing how childishly private practitioners squabbled to all get a place on the wagon. It reminds me of toddlers crying because some other child had something they didn't. Only in this case, there is no parent to say, "Well I don't care what so-and-so got."
I would even go so far as to say that the descriptions of the concerns and criticisms of private practitioners are downright adorable if it wasn't for the fact that they were predicated on a genuine seriousness as grown professional men. It is that very fact that makes the description sobering in some way, leading me to feel incredulous as I step back and look at the situation.
While Starr's comparisons to the European movement of medicine happening concurrently with the American movement always casts a tarnishing light, never before has he made the American movement look quite so immature, hypocritical, and childish. It is through Arpad Gerster's quote that he accomplishes this so poignantly: "They must be shown, however, that the hospitals do not exist mainly for the indiscriminate benefit of the medical profession, but are here, first, for the benefit of the patients, and secondly for that of the community."
Though Gerster ultimately speaks to the necessity of economic reform, his observations (including those not mentioned above) clearly cast the American controversy as petty and self-involved. The irony is that all this is of greatest concern in a profession meant to be concerned for others.
It becomes less and less surprising, though, since Starr has made it very clear that the American medical movement was largely concerned with itself as a profession first and foremost, rather than as a calling to serve the people. And though it shouldn't be surprising, I cannot help but feel some level of disappointment as I read about the back-scratching, the competition, the fervency for status as associated with the hospital as an institution and the ultimate transformation of hospitals as "instruments of professional power." It feels as though one more testament to service falls to the ever insatiable stomach of status, power, and control.
Rather than being concerned for their ability to serve their patients, doctors were much more concerned with gaining more prestige and viewed the hospital as a ladder or cash cow. Even the rationalization of inequity to receive training and betterment through education seem like thinly veiled excuses to obtain the true goal of privilege and advantage.
In fact, the seemingly incessant demand for access and advantage for all at the most likely well know cost of quality and service of the hospital to patients is like a retelling of the famous King Solomon parable, with American physicians and European physicians (or those who understood the need for some exclusivity) as the two women fighting over the baby. While one woman was content to have any part of the child regardless of the cost to the child itself, the other is concerned primarily for the welfare of the child. It is only because these are grown men that I classify this as almost savage rather than childish.
I guess it is good to reflect, then, on why I find this so humorous. Is it funny because it's funny? Or because it's one big joke?
Tuesday, October 27, 2009
CH. 3
One of the most striking aspects of this chapter is the extent to which social inequity and class systems factored into the history of medical practitioners. On one level, you have the struggle of practitioners for legitimacy in their profession. With any physician being able to practice regardless of a standardized education or document, physicians as a whole were relegated to a lower class with the exception of those elite who managed to rope in high-paying clients. It is interesting that despite the fact that their lack of a unified standard kept them at a low scale of security and respect, physicians from the three distinct classes were divided on their support of formalizing one and with very different motivations.
As Starr described, the sectarian physicians and physicians without licenses or diplomas were against standardization for fear that it would exclude them. Elite physicians opposed it in order to maintain their social status by maintaining "lower" untrained physicians in the pool. But only physicians in the middle--those with legitimate degrees, but less clientele--fought for standardization. The objective is clear: only those in the middle would benefit by reducing competition for the average citizen by cutting out physicians without legitimate degrees while elevating their qualifications to the same level as their more successful colleagues.
But the irony of the social status debacle is not lost on me. On the whole, physicians were struggling to stabilize their standing socially and professionally. However, the fragmented social hierarchy within their profession was at odds, with most objecting to the one move that would secure the profession stability and legitimacy in the long run.
And yet, these divisions were masked form the public to maintain the facade of unified perspective in the field. In many ways, this is the perception that the public still has today about medical research and health provision. The interesting change in our current society seems to be that any division that might exist within the field is enjoyed less because of the actual debate on research or perspective, but because of its conflict. We live in an era where the existence of differing viewpoints is viewed as far more interesting than the actual viewpoints themselves. "Scientific" journalism (or what passes for it these days) seems to have trouble differentiating between legitimate differences in health perspectives and those that are on the fringe.
However, I wonder how one might categorize the division between the medical society and the homeopathic movement that Starr wrote about. In this instance, the fractured profession seemed unified in its derision of the homeopathic philosophy. Even these seem to be tied in subtle ways to class and social standing. As Starr points out, homeopathy emphasized above all else, the testimony of the patient and an empathetic attention and treatment. This support of the patient as an elevated individual rather than another patient to be quickly diagnosed highlights other ways in which social status of the physician (which had its own intra-level dynamics) interacted with the social status of the patient.
Very cool.
As Starr described, the sectarian physicians and physicians without licenses or diplomas were against standardization for fear that it would exclude them. Elite physicians opposed it in order to maintain their social status by maintaining "lower" untrained physicians in the pool. But only physicians in the middle--those with legitimate degrees, but less clientele--fought for standardization. The objective is clear: only those in the middle would benefit by reducing competition for the average citizen by cutting out physicians without legitimate degrees while elevating their qualifications to the same level as their more successful colleagues.
But the irony of the social status debacle is not lost on me. On the whole, physicians were struggling to stabilize their standing socially and professionally. However, the fragmented social hierarchy within their profession was at odds, with most objecting to the one move that would secure the profession stability and legitimacy in the long run.
And yet, these divisions were masked form the public to maintain the facade of unified perspective in the field. In many ways, this is the perception that the public still has today about medical research and health provision. The interesting change in our current society seems to be that any division that might exist within the field is enjoyed less because of the actual debate on research or perspective, but because of its conflict. We live in an era where the existence of differing viewpoints is viewed as far more interesting than the actual viewpoints themselves. "Scientific" journalism (or what passes for it these days) seems to have trouble differentiating between legitimate differences in health perspectives and those that are on the fringe.
However, I wonder how one might categorize the division between the medical society and the homeopathic movement that Starr wrote about. In this instance, the fractured profession seemed unified in its derision of the homeopathic philosophy. Even these seem to be tied in subtle ways to class and social standing. As Starr points out, homeopathy emphasized above all else, the testimony of the patient and an empathetic attention and treatment. This support of the patient as an elevated individual rather than another patient to be quickly diagnosed highlights other ways in which social status of the physician (which had its own intra-level dynamics) interacted with the social status of the patient.
Very cool.
Tuesday, October 20, 2009
CH. 2
The evolution of the role of the physician is the main focus of this chapter. In readings from the first chapter of Williams & Torrens, their chart was broken into several components that affected change, one of which was the social organization of the culture and society to handle health care. It is interesting to see the mapping out of cause and effect laid out by Starr regarding social organization and how it shaped the role physicians played and how it freed and constrained their abilities.
For example, Starr describes the advent of hospices and mental institutions and how they were originally institutions of isolation and how their transformation facilitated the evolution of the medical physician's position. Previous to this you can consider health provision as being an omnipresent concept--health was everywhere and never in one place. Health was practiced by every family, doctors traveled wherever they were summoned, or a location had its own doctor on staff. Physicians were at the beck and call of circumstance. But the creation of mental institutions and hospices centralized health, creating a domain of ownership in which physicians were rulers of their own services and where power became focused--it is almost metaphysical to consider the way in which creating a locus of their abilities facilitated the transformation of physicians into figures of power. Of course, this may have been more circumstantial than purposive, but I find the transformation to be quite amazing.
While calling it metaphysical may seem odd, another way to describe it may be to portray it in the light of modern business and marketing theories. Medical practitioners existed in the role of being available and subject to patient's control. The establishment of a base with which to be sought is a basic principle of pro-action and marketability. Though it was not purposive, medical practitioners were elevated to a higher status by shifting the paradigm of their services and availability. In essence, they created demand for their services and in a new way that forced patients to seek them out in a power exchange.
It is also interesting how the creation of a physical location shaped the medical profession in other ways. Starr describes most medical professionals of the time also having other equivalent or more important professions besides medical care. He also explains how many medical practitioners held positions that made them powerful or respected members of society. By tethering medical professionals to hospices and mental institutions, the requirements of the profession, the time commitment, and the responsibility probably made it less and less feasible to hold a second or primary profession outside of medical care. Medical professionals probably had to devote more time to being medical professionals and the added time and attention probably contributed to the expansion of knowledge and consideration for the practice itself. Thinking about the various effects of the environment and institutional changes on the direction of a profession (one in which medical practitioners are full time work or more) is fascinating and a definite highlight of this chapter.
For example, Starr describes the advent of hospices and mental institutions and how they were originally institutions of isolation and how their transformation facilitated the evolution of the medical physician's position. Previous to this you can consider health provision as being an omnipresent concept--health was everywhere and never in one place. Health was practiced by every family, doctors traveled wherever they were summoned, or a location had its own doctor on staff. Physicians were at the beck and call of circumstance. But the creation of mental institutions and hospices centralized health, creating a domain of ownership in which physicians were rulers of their own services and where power became focused--it is almost metaphysical to consider the way in which creating a locus of their abilities facilitated the transformation of physicians into figures of power. Of course, this may have been more circumstantial than purposive, but I find the transformation to be quite amazing.
While calling it metaphysical may seem odd, another way to describe it may be to portray it in the light of modern business and marketing theories. Medical practitioners existed in the role of being available and subject to patient's control. The establishment of a base with which to be sought is a basic principle of pro-action and marketability. Though it was not purposive, medical practitioners were elevated to a higher status by shifting the paradigm of their services and availability. In essence, they created demand for their services and in a new way that forced patients to seek them out in a power exchange.
It is also interesting how the creation of a physical location shaped the medical profession in other ways. Starr describes most medical professionals of the time also having other equivalent or more important professions besides medical care. He also explains how many medical practitioners held positions that made them powerful or respected members of society. By tethering medical professionals to hospices and mental institutions, the requirements of the profession, the time commitment, and the responsibility probably made it less and less feasible to hold a second or primary profession outside of medical care. Medical professionals probably had to devote more time to being medical professionals and the added time and attention probably contributed to the expansion of knowledge and consideration for the practice itself. Thinking about the various effects of the environment and institutional changes on the direction of a profession (one in which medical practitioners are full time work or more) is fascinating and a definite highlight of this chapter.
Monday, October 19, 2009
CH. 1
Starr begins his Pulitzer Prize-winning work with an interesting and surprising look at the very humble beginnings of the physicians and the evolving practice of medicine from the 1760 to 1850. My initial interpretations of the practice of medicine were that since the age of Asclepius, physicians and other healing practitioners were venerated and that their expertise was one passed down as a solemn oral history.
Starr's description of the diffusion and transformation of medical information astutely shoves my perception of the field of medicine off its pedestal. Not only was my perception incorrect from a historical perspective, but as the Introduction described, this is not even a universal guarantee of a prestigious career. It is incredible to consider the myriad of ways in which medical information (and medicine itself) has been passed on, warped, redefined, transformed, and rediscovered.
There were many transformations and interpretations of medical knowledge and what it meant to practice medicine throughout the eras, such as William Buchan's Domestic Medicine, displacing it from mystified Latin and technical terminology and supporting medical practice with the layman. That the concept of medical practice could shift from formalized academia to casual salt of the earth (and back again) is astounding.
What I find most interesting in these examples of the fluid and every changing "practice of medicine" is the story about James Still. Still's very elementary means of tapping into medical knowledge--buying a book and following its instructions--is a delightful counter to the common view of medical practice. I think typically, we are lead to believe that medical practice is a highly regulated body of knowledge where you have to learn from square one and must have accreditation and license to even begin providing basic care. The basic medical school education requires study in organic chemistry, physics, microbiology, and biochemistry to even begin schooling. Yet it is easy to forget that behind the lectures and the lecture halls and within the pages of text books is the raw history of medical instruction. Still's case is a reminder that the spirit of medical practice need not be mired in academia and rigid pathways to knowledge. Medical practice is not just in the office or in a sterile room. It occurs with everyday people applying scientifically supported knowledge to promote their health and the health of those around them.
Starr's description of the diffusion and transformation of medical information astutely shoves my perception of the field of medicine off its pedestal. Not only was my perception incorrect from a historical perspective, but as the Introduction described, this is not even a universal guarantee of a prestigious career. It is incredible to consider the myriad of ways in which medical information (and medicine itself) has been passed on, warped, redefined, transformed, and rediscovered.
There were many transformations and interpretations of medical knowledge and what it meant to practice medicine throughout the eras, such as William Buchan's Domestic Medicine, displacing it from mystified Latin and technical terminology and supporting medical practice with the layman. That the concept of medical practice could shift from formalized academia to casual salt of the earth (and back again) is astounding.
What I find most interesting in these examples of the fluid and every changing "practice of medicine" is the story about James Still. Still's very elementary means of tapping into medical knowledge--buying a book and following its instructions--is a delightful counter to the common view of medical practice. I think typically, we are lead to believe that medical practice is a highly regulated body of knowledge where you have to learn from square one and must have accreditation and license to even begin providing basic care. The basic medical school education requires study in organic chemistry, physics, microbiology, and biochemistry to even begin schooling. Yet it is easy to forget that behind the lectures and the lecture halls and within the pages of text books is the raw history of medical instruction. Still's case is a reminder that the spirit of medical practice need not be mired in academia and rigid pathways to knowledge. Medical practice is not just in the office or in a sterile room. It occurs with everyday people applying scientifically supported knowledge to promote their health and the health of those around them.
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