Faiths that failed? Professionalism, technology, and science in 20th-century America

I have no particular expertise in the history or present condition of the American health care system. I would like to offer some thoughts, nevertheless, about this strange moment in the life of the medical profession-a moment of unprecedented scientific promise, yet also of tremendous economic, political, and even cultural difficulty. I would like to try, in a small way, to suggest at least a part of a context within which to think about the particular problems that many physicians face every day.

Those problems are probably most visible in the form of the tremendous economic and administrative strains that have been confronting the medical profession, and the world of health care generally, for at least the last decade: the rapidly spiraling costs (unmatched by comparable increases in the incomes of most doctors); the increasingly powerful and intrusive role of insurance companies, HMOs, and government agencies; and the steady loss of control by doctors themselves over the economic and institutional conditions in which they work. There have been numerous efforts to bring some order and control to this messy new health-care world, most notably President Clinton's politically disastrous attempt in 1994 to create a national health insurance system. But so far at least, our society has lacked the social and political will-and perhaps also the knowledge-to find any coherent solution to these problems.

I do not want to minimize in any way the seriousness of the concrete economic, administrative, and political problems that plague the health care world today. But there is also, I think, another set of issues that have affected the medical profession-and indeed many other professions-in our time that have made those concrete problems even more difficult to solve. Those issues revolve around a large loss of public faith in the capacities of institutions and ideas that …