Professional authority and state power

The relation between professional authority and state power is not to be found in the political clout of the A.M.A. or the A.B.A. nor in the fact that lawyers work at every level of government and doctors often occupy key policy making positions. The relation between state power and professional authority that I have tried to underline is more diffuse and embedded in the very work doctors and lawyers do. But even this claim can be misleading, because what's at issue here is not how doctors and lawyers use their expert authority to extract consent from and normalize patients and clients. In fact, it is the erosion or deconstitution, as I have called it, of this authority by the commodification of legal and medical services that has brought out more subtle problems and more revealing ties to state power. The HMO doctor who has to advise a patient about emergency service coverage is a good example of the way in which medical service, state administrative power, and economic interests are visibly intertwined in the actual provision of medical care at the ground level. When we take this one step further, the role of the state in the crisis of the professions begins to emerge. State licensing laws and insurance regulations are restructuring the already fragile relations among patient, doctor, HMO, and insurer. The patient in this example, outraged by pseudo-medical advice on emergency coverage, may soon recognize that it is not only the doctor who is incapable of assessing his or her medical needs. The political domain itself is becoming a maze of tort laws and tort reform proposals. What difference does all of this make? Right now, for the professions it may mean slightly more competition among practitioners and, for some, a loss of status. For the state it means a new kind of oversight and intervention. Instead of licensing professional autonomy, state power is now being used to stabilize the process of commodification by encouraging backsliders and disciplining those who would go too far. One reason unethical behavior is drawing closer state scrutiny is its high economic costs. Joel Brinkley, “Medical Discipline Laws,” , September 2, 1985. 1, 18. Although these are obviously important consequences, I have tried to emphasize a more theoretical one. At the same time the state is being drawn into the commodification of professional services, the professions are losing their ability to interpret persuasively the origins and scope of human needs. This means that the repoliticization Habermas and Offe anticipate makes even more sense. Not only is the state's role in previously private matters subject to criticism, it seems unable to provide a forum for critical needs interpretation of the pragmatic sort at a time in which the professions are seen as derelict in their traditional duty of needs interpretation. This point can be made more precise by distinguishing two ways in which my analysis of professional authority is related to Habermas's and Offe's work. I have not analyzed professional authority in general, but medical and legal professional authority in the United States in particular. One implication of this study is that the prospects for democratic social movements in the United States along the lines Habermas and Offe sketch may depend upon the commodification of professional services more than simply the general intervention of the state into private economic, educational, and family affairs. This peculiar feature of a strong American social movement would be the result of the traditional popular dichotomy between authority and power, the historical role of the professions in needs interpretation in the United States, and the current radical deconstitution of medical and legal authority. Habermas and Offe seem more concerned with the more mature European social movements than with events in the United States. My analysis applies and amends their legitimation crisis thesis, and the repoliticization hypothesis especially, in the U.S. case. But, like a good case study, it also suggests a way in which the general theoretical framework that guided it in turn can be revised. In my analysis it is the concept of needs interpretation that has general theoretical significance for the legitimation crisis thesis. One problem critics have noted in the legitimation crisis thesis is its inadequate account of what motivates or will motivate such as crisis. Habermas's own treatment of the difference between a legitimation crisis and a motivational crisis is notably weak. David Held, “Crisis Tendencies, Legitimation and the State,” 187–189. The case of the deconstitution of professional authority suggests that the motivational basis for a legitimation crisis cannot be deduced from greater state intervention in private domains but that it nonetheless may have its roots in basic changes in the political economy. The commodification of medical and legal services is part of a larger transformation in capitalist political economies that I have not been able to describe here. Although I have called this commodification an “internal” process, it most certainly reflects larger trends and changes, both domestically and internationally. What the deconstitution of professional authority suggests is that 1) it may be possible to gain greater clarity about the motivational basis of a potential legitimation crisis through the concept of needs interpretation, 2) this motivational basis is not a simple function of the macroeconomy, but still 3) how effective professional and political needs interpretation are will depend upon the pace and range of commodification. An earlier version of this article was delivered at the Annual Meeting of the American Political Science Association in New Orleans, Louisiana, August 29–September 1, 1985. I am grateful to Cynthia Negrey, Jay Budziszewski, Mark Kann, and especially Richard Peterson for helpful suggestions. I am also grateful to the Editors of for suggesting revisions in the original argument.