While writing my last book, Remaking the American Patient, I became fascinated by the 1970s and the new demands for physician accountability that arose in that decade. After roughly fifty years of enjoying an unprecedented degree of respect and autonomy, American doctors felt compelled to explain and defend their actions in new ways. “What does society really want from doctors? Greater accountability,” announced a 1978 article in Medical Economics, the most widely read medical journal in the United States. This accountability movement came from within, as physicians debated how to conduct scientific research and translate it to the bedside. It also developed outside the medical profession, as politicians, policy makers, and patient-consumerists pressured doctors to justify their methods, outcomes, and fees. The demand for accountability covered many different aspects of the medical profession’s performance: research ethics, clinical efficacy, bedside manner, and perhaps most painfully, cost-benefit analysis.
These dynamics were of course not unique to the U.S.; many developed nations, including the Netherlands, experienced similar developments and dilemmas. The rising demand for accountability, as well as its paradoxes, paralleled the rapid growth of Western biomedicine and capitalist economies. The new “medical industrial complexes” that grew up in postwar Western Europe, the United States, and the Commonwealth nations proved fertile ground for their development. While addressing local problems, these postwar accountability regimes were anchored in seemingly universal principles of scientific rigor, patients’ rights, and “free” markets that transcended national boundaries. Hence new ways to “improve” medicine generated in one country were often adopted by others; examples include the randomized clinical trial (Great Britain), the Cochrane collaboration (Canada), and the diagnosis-related group (the U.S.) At the same time, national and regional cultures still mattered enormously in how problems were (and are) defined and acted upon.
Thus, historians of medicine have much to gain by comparing accountability regimes across time and place. By studying their origins and implementation, fundamental assumptions about both biomedicine and “medical capitalism” become apparent. We see what is similar and what is not. In my talk, I will highlight some of the ways that this comparative perspective has helped me to understand the accountability “revolution” in the United States and invite the seminar participants’ suggestions for how to go forward with the larger project.