A Loss of Faith: The Sources of Reduced Political Legitimacy for the American Medical Profession

W riting at the beginning of the 20th century, Shaw identified one of the significant contemporary transformations in industrial democracies. In part as the result of advances in science and technology, in part as a rejection of the monopolistic abuses of industrialization, and in part as a consequence of assiduous efforts by the professions themselves, this was a period in which the legitimacy and social authority of professionals increased dramatically ( Brint 1994 ; Krause 1996 ; Larson 1977 ; Sandel 1996 ). Nowhere was this more evident than in medicine. Over several decades, medicine changed from an occupation with a mixed reputation and little political influence into one that would “dominate both policy and lay perceptions of health problems” ( Freidson 1994 , 31). In a number of countries, the professional authority and political influence of physicians also rose during this era ( Coburn, Torrance, and Kaufert 1983 ; Krause 1996 ; Stone 1980 ), most dramatically in the United States ( Starr 1982 ). The political legitimacy and policymaking influence of the medical profession have greatly declined in American society over the past 30 years. Despite speculation about the causes, there has been little empirical research assessing the different explanations. To address this gap, data collected in 1995 are used to compare attitudes of the American public and policy elites toward medical authority. Statistical analyses reveal that (1) elites are more hostile to professional authority than is the public; (2) the sources of declining legitimacy are different for the public than they are for policy elites; and (3) the perceptions that most threaten the legitimacy of the medical profession pertain to doubts about professional competence, physicians' perceived lack of altruism, and limited confidence in the profession's political influence. This article concludes with some speculations about the future of professional authority in American medicine.