1.2 The shifting balance of power

Doctors were not always powerful. In the 19th century their social status was low, lower than that of the clergy or the legal profession. They were, of course, able to have a reasonable social status, but only if they were well connected, as was Mr Lydgate, the surgeon in George Eliot's Middlemarch, who was 'one of the Lydgates of Northumberland, really well connected', although, as Lady Chettam pointed out, 'one does not expect it in a practitioner of that kind. For my own part I like a medical man more on the footing of a servant, they are often all the cleverer'. Middlemarch (now available in its entirety online, thanks to the wonderful Project Gutenberg) was published in 1871, and describes perhaps better than any other book the ambivalent, but rising, status of the doctor in Britain during its first phase of modernisation.

1.2.1 In the 19th century, patients had more power

Jane Austen's Emma was written more than fifty years earlier in 1816, and describes the hypochondriacal Mr Woodhouse making use of the apothecary, Perry, who was clearly the social inferior of the valetudinarian. Between 1820 and 1870, the social position of the doctor had begun to improve, partly because, as a result of the railway revolution which started about 1850, even rural England was in the process of rapid change by 1870. Science and technology were in the ascendant and the Church, although not yet in decline, was being challenged as never before by new wealth and new ideas.

1.2.2 By the end of the 20th century, physicians had more power

At which point in time did the balance of power swing from patient to doctor? There is no specific answer to this question, but it occurred after the Second World War when scientific medicine was starting to have an impact. Science alone, however, is only one factor in determining the relative balance between doctor and patient.

What factors affect the power balance between clinician and patient? Obviously there are many, and generalisations are fraught with difficulties, but there are a few obvious determinants of where the power lies.

Knowledge. As science provided more knowledge for clinicians, their authority increased - what sociologists call 'sapiential authority'. This is not to say that patients gave up their beliefs, but they certainly deferred overtly to the power of authority of the doctor, even though his science was often flawed, as beautifully depicted in J. G Farrell's book The Siege of Krishnapur.

The changing financial contract between clinician and patient. Until the advent of the National Health Service, patients really were consumers or customers and shopped around, if they could afford it. The provision of services by the State which removed the financial dependence of the doctor on the patient was undoubtedly a relief to many patients, but it did shift the balance of power towards the clinicians, particularly as the clinician was virtually a monopoly supplier of medical care to patients who had, in the United Kingdom at least, great difficulty in changing the general practitioner on whose list they had been placed.

The rise of the meritocracy. During the second half of the twentieth century Britain experienced what the sociologist Michael Young called 'the rise of the meritocracy', and the medical profession, like other knowledge-based professions, became more powerful and more respected. Doctors acquired more authority, derived not only from their public commitment to medical self-regulation and high standards, but also from their self-avowed claim to act always and only in the patient's best interests.

1.2.3 All professions are losing power in the 21st century

It is not just medicine that is losing power. The Death of the Guilds is the title of a monumental work by Elliott Krause in which he studied the decline in power of a number of professions, including medicine, in the United States, France, Germany, Italy and the United Kingdom. The subtitle of the book is 'The state capitalism, and the decline of the professions, 1930 to the present day' and Krause demonstrates that even while doctors were increasing their power to control disease, which understandably increased the awe in which they were held by many patients, the medical profession as a whole was losing autonomy and its powers of self-determination and self-regulation. The decline of the power of the medical profession was occurring while the clinical power of the individual doctor was waxing.

Obviously these generalisations do not take into account variations between different groups within society, for example different ethnic groups or the differences between men and women. Nor do they take into account individual factors relating to both the doctor and the patient, for there is a wide range of different styles within all of the groups mentioned above.

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