Compared to 40 years ago, when physicians fought against Medicare tooth-and-claw, Medicare and Medicaid are now sacrosanct and doctors now seem to favor socialized medicine in some flavor for everyone—whether the Obama administration’s anemic version or the single payer system just adopted by Vermont. What happened? Did advocacy change the values of physicians?
No. What changed is that doctors have been proletarianized. For most of the 20th Century, physicians were independent shopkeepers with the corresponding consciousness drawn to conservative Republicanism focused on low taxes and low government involvement. With the rise of managed care in the medical system and the dominance of the insurance industry in medical practices, the doctor as a small business owner has become less and less viable. Instead, doctors are going to work for medical organizations. Instead of shopkeepers, doctors are increasingly wage earners.
Another shift has likely affected doctors’ political shift leftward. At the beginning of the 20th Century, virtually all doctors were men. Today, the majority of medical school graduates are women. Of course, caution has to be taken with this gendered aspect of the shift. On the one hand, so-called successful women have shown themselves capable of callousness equal to that of men in equivalent positions of power. On the other hand, women as a class tend to be more compassionate than men in politics and issues of social responsibility.
Doctors are trained to alleviate suffering. One would expect the profession to be populated by compassionate people. Once making a living as a small business is removed, that instinct steps forward and takes center stage. Not for all doctors, of course. And even as wage earners, there are those who are in it for the money. But still, removing the need to stay in business removes a systemic barrier to those compassionate instincts.
The irony, of course, is that the rise of managed care—the very thing that forced doctors out of their shops and onto the assembly line—was actively promoted by doctors themselves. It was the promise of making the medical business work more efficiently that enlisted support. And it did. But the efficiency was in making money for what became the big dogs in the medical care industry, not for the small-scale doctor’s office. As so often happens, large capitalists pushed out small ones who were then turned into wage slaves. Talk about unintended consequences.
There are a number of lessons here. One is that people make their own history, but not just as they please. Another is that a person’s values don’t fall from the sky but come from the conditions of their material existence. In The Three Penny Opera by Bertolt Brecht, the main character MacHeath (more famously known as Mac the Knife) says this to a do-gooder who is sermonizing about changing values “Food first, then morality.”
I was reminded of how those material conditions work while reading about expert opinion on whether bisphenol A poses a health threat. As reported in Chemical and Engineering News, a publication of the American Chemical Society—which is the professional organization for chemists—some chemists worry about BPA, some do not. In one article, concern is raised that no “viable alternatives… match the cost and shelf-life performance” of BPA-containing resins used to line food containers.
What caught my eye is how “viable alternatives” is defined: cost and shelf-life. These are issues concerning how production and product meet a business need. I wondered what this had to do with the chemistry and health effects of BPA. More specifically, I wondered about the chemists and other technologists working on the uses of BPA and its “viable alternatives.” I wondered how the conditions of their material existence would have to change in order for “viable alternatives” to be measured in terms of health risks as well as (or even instead of) cost and shelf-life. I wondered what if performance were measured by the health effects of the food in the can and not how long it can sit on a shelf or how far it can travel—neither of which have anything to do with the food’s value to its consumer but everything to do with its value to the seller. I went on to wonder about the wide variety of experts upon whom we rely to design and create the vast array of production processes and products that make up our modern political economy.
I think the lesson from the doctors’ experience is this.
Direct contact with people is inherent to a doctor’s work. As a shopkeeper, the doctor’s relationship with an actual human being is obscured by the abstract relationship of seller to buyer. Once removed, the essence of the work is human contact. For most experts in our political economy, human contact is not the essence of the work. The people affected are people in the abstract, not someone the expert runs into at the grocery store and has a nice chat about their kids’ soccer team—or has to face in justifying a characteristic of the production process or product they have designed.
There are people working to change this, where production is local, incorporates human and ecological health, meets real human needs, and expert work is applied in the context of face-to-face contact with the actual human beings affected. This kind of work is being done by such organizations as the New Economy Network, the Business Alliance for Local Living Economies, and the Community Economies Collective.
We might not be able to make history just as we please because of the political economy that weighs upon us like a nightmare, but we can work on creating the material conditions that will help us wake up.