On Tue, 28 Sep 1999 09:53:30 -0400 Doug Henwood <dhenwood at panix.com>
writes:
>Carl Remick wrote:
>
>>It's amazing how capitalism can alienate even those who do quite
>>well by it, such as American doctors, who have an average net income
>>of over $160,000 a year. A front-page article in today's Wall
>>Street Journal reports that U.S. doctors increasingly identify
>>themselves as Democrats rather than Republicans because of the loss
>>of autonomy they've experienced under managed care.
>>
>>What impressed me was the type of language used by one physician
>>quoted in this article, viz.: "'Republicans represent capital and
>>Democrats represent labor,' says Dr. [David] Duffner, the Tyler
>>[Tex.] orthopedist. 'Physicians used to be capital, but now we're
>>labor in the view of managed care. We're fungible commodities. So
>>if they drop one doctor from a [managed care] contract, they just
>>get another, even if it means that a family that has been coming to
>>you for 20 years has to switch to another doctor.'"
>
>Treacherous petits bourgeoises. Can't trust 'em.
>
>Doug
>
I think that a persuasive argument that physicians and other health care professionals are undergoing a process of proletarianization. At this moment I am looking at some old reprints I have of a mid-1980s debate over the proletarianization thesis that took place in the International Journal of Health Services. Medical sociologists, John B. McKinlay and Joan Arches in their paper "Towards the Proletarianization of Physicians" made a case for the proletarianization that in the light of subsequent events in health care seem IMO to be remarkably prescient. McKinlay and Arches saw health care as becoming increasingly dominated by forces associated with big capital so that medical practice was starting to become dominated by the imperatives associated with the "logic of capitalist expansion." In arguing that physicians are being proletarianized as a consequence of this, McKinlay and Arches make a point of clarifying what proletarianization means for Marxists and why it is applicable to highly paid, seemingly very privileged professionals like doctors. As they pit it:
"How can someone earning $100,000 annually
be a proletarian?" While understandable, these
simple questions overlook the facts and trends
already discussed and evidence little comprehension
of the labor theory of value as applied to physicians.
The point of course, is not the absolute amount that
a physician may earn in the way of a salary, but
the amount that he or she generates for some employer
(e.g., hospital, for-profit nursing home, HMO). A
physician may generate a million dollars for an
employing organization and its owners (its investors)
and receive back perhaps 10%, or $100,000 as
salary. Most importantly we must ask: Where does
the balance, the 90% (or $900,000), go? We argue
that the ratio of what is earned to the amount generated
for an employing organization is gradually moving
against the average physician (i.e., the rate of
exploitation is increasing).
Against McKinlay and Arches, Milton I. Roemer in his paper, "Proletarianization of Physicians or Organization of Health Services." argued that McKinlay and Arches misapplied Marxist concepts of class exploitation while misunderstanding the dynamics of health service systems. First, Roemer made the argument that most of the trends in health care that McKinlay and Arches described could be better understood as represent the bureaucratization of health care. In other words Roemer seemed to think that these trends could be better understood in qausi- Weberian terms rather than in Marxian terms, although Roemer also asserts that he preferred to describe what was going on as "social organization" rather than bureaucratization since contrary to Weber he thought that bureaucratization was just one aspect of organization. Roemer saw this process as involving also specialization, the division of labor to achieve efficiency, effective use of costly technology, planning in relation to needs, regulation to protect consumers,and integrated teamwork. He saw these trends as being driven by the demands of people for better health services, mediated largely through political processes. He saw physicians as being transformed from small entrepreneurs, with the freedom to mishandle patients, into social clusters of health personnel who were increasingly being held accountable for providing their patients with better and more cost-effective health care. Clearly, Roemer saw this process as a benign one which would benefit the general public. He denied that physicians were being proletarianized as a part of this process, citing the high salaries and other benefits and perks that salaried physicians enjoyed. He denied that these doctors were in any sense being exploited. He also was critical of the development of physicians unions in Europe and North America which he saw as a selfish attempt to block the socially necessary regulation and organization of health care.
McKinlay and Arches in their response, "Historical Changes in Doctoring: A Reply to Milton Roemer" challenged Romer's contention that what he called the "social organization" of health services as being driven by the "demands of the people. . ." For McKinlay and Arches nothing could be further from the truth. They first of all sought to refute the view that this change in health care was as benign a process as Roemer would have it. They made reference to the difficulties that patients have in getting effective primary care, the burning out of health care workers in HMOs and urban hospitals to suggest that the changes in health care were not so benign. They then went on to challenge Roemer's assertion that salaried physicians were profiting from large investments "made by the people. . ." as representing a serious confusion concerning the maldistribution of wealth in the US. They pointed out that there only a tiny fraction of the US population was affluent enough to invest in the health care system and thus to profit from it. American health care is owned by a small wealthy elite. They then go on to review Marx's labor theory of value to clear up they regarded as Roemer's misunderstandings of it and to make the case once again that the fact that many salaried physicians were enjoying high salaries did not negate the fact of their exploitation. As McKinlay and Arches put it "It is not the absolute amount that is earned (or the fringe benefits and job security enjoyed) that really matters, rather it is the physician's changing relation to the means of medical care production that is important." McKinlay and Arches go on to suggest that Roemer might benefit from a consideration of Erik Olin Wright's notion of "contradictory locations."
Certainly IMO McKinlay and Arches presented a more profound analysis concerning what was going on in health care in the 1980s than did Roemer and as I asserted before subsequent events seem to better conform to their analysis rather than to Roemer's
Jim Farmelant
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