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The Emergence of the Modern Mode of Medical Production, "The Emergence of the Modern Mode of Medical Production," Humanity and Society, Vol. 9, No. 4 (November 1985), pp. 371-387 by Gordon Welty Wright State University Dayton, OH 45435 USA [//371] Reflexive Statement The impetus to this study came about a dozen years ago when I had a series of abscesses in my left hand. During one of the operations I underwent, the local anaesthesia wasn't effective. The nurse gave me a rolled gauze bandage to bite on, and they proceeded. Afterwards I asked the surgeon what it was like before anaesthesia. He replied "This is pretty much the way it was." So I was motivated to study the development of surgical anaesthesia. I was dissatisfied, however, when I looked into the social scientific literature, The opportunity for this study presented itself a few years later, when I lived in Philadelphia, and had access to the excellent historical holdings of the libraries of the College of Surgeons and the University of Pennsylvania. But my dissertation -- painful in a different way -- and other projects have delayed the completion of this research until now. Introduction Health care in the United States has become a topic of increasing controversy in recent years. The enormous increase in the cost of health care has fueled the controversy, but issues more profound than those of cost are involved. The relative constancy of the adult life span during the last half of the Twentieth Century has called into question the wisdom of vast aggregate expenditures on health-related research, or at least the orientation of that research. Moreover, the particular critiques of health care in the United States by members of the medical profession (e.g. Mendelson, 1979), by traditional critics (such as the Health Policy Advisory Council; cf. Ehrenreich and Ehrenreich, 1970), as well as by 'competitors' (such as homeopaths; cf. Coulter, 1973, esp. Vol. 3), provide detailed evidence that the medical-health industry, as currently constituted and directed, is either unable or unwilling to serve the health care needs of the vast majority of Americans./1/ Dr. Robert Mendelson's reference to himself as a "medical heretic" is significant; in the scientific study of sacred and secular ideology the heretic is the opponent of the orthodox on existing terrain of contention and would replace the orthodox within the dominant social form. Another instance in the medical-health industry is the homeopath who would replace the presently hegemonic allopath. Thus heresy is to be understood as [371/372] social change by substitution. Heretic and orthodox are to be contrasted to the revolutionary who seeks to sublate this contention and to transcend this terrain by carrying the struggle to a broader terrain or to a higher level of emancipation. Thus revolution is to be understood as social change by structural transformation. This can be formulated as a question. Can the problems of health care in the United States be resolved within the existing political and economic context, or does the resolution of health care problems implicate structural and totalistic social change? In attempting to answer this question, I will outline the nature of the modern mode of medical production and will sketch the historical lines of its development during the Nineteenth Century. This mode of medical production is the internal relations of today's medical-health industry if we examine the organic structure beneath the myriad of institutional forms, medical-surgical practices, and particular personalities which make up the everyday world of health care in the United States. Only by such a study of the underlying mode of medical production can we address our question and come to apprehend the possibilities of long-term social change in the medical-health industry because such possibilities are constrained if not determined by that modality. This essay has four parts. First, we will engage in a brief analytic sketch of the nature of modes of medical production. This discussion is based on the Marxian categories of the reproductive labor process. Next, we will consider the development of one crucial constituent of the modern mode of medical production, that of surgical anaesthesia during the first half of the Nineteenth Century. Then, we will consider the development of another constituent of the modern mode, antiseptic surgery, during the same century. Finally, we will indicate how these elements were constituted into the modern mode of medical production, as this mode was itself integrated into the capitalist social formation in its highest stage. Section I: The Analytics of the Modes of Medical Production. Marx distinguished productive labor from reproductive (or "unproductive") labor. The former labor produces surplus values while the latter does not, rather reproducing the everyday world which is necessary to the production of surplus value (Marx, 1963:392-3). It is of interest to us that reproductive activities are either coextensive with or specializations of the domestic or natural economy (cf. Welty, 1978:9). Medical services are explicitly mentioned by Marx as an instance of reproductive labor, as the "cost of repairs for labor-power" (Marx, 1963:163). Genetically, the shaman was the initial specialization to emerge in the segmentary society, the first 'profession' to develop out of the natural economy. Thus both analytically and genetically our discussion of the development of the modern mode of medical production and surgery can for the time set aside the issue of the appropriation and distribution of surplus value and concentrate instead on the process of reproduction. Marx considered production in general as a complex totality, an ensemble of laborer or the subject of labor, the object of labor, the instruments of labor, and the appropriator of surplus labor-product in the an antagonistic social order (Marx, 1954:178; cf also Welty, 1983:289-290). Moreover, for Marx [re]production (production in the antagonistic social order sans appropriator) is historically conditioned by "a definite stage of social development," [372/373] that is development of the forms of social antagonism (Marx, 1971:18; Marx and Engels, 1975, Vol. 6:515). Since we have set aside the issue of appropriation, only the first three of the elements of the ensemble listed are germane to our present discussion. They comprise the moments of the process of the reproductive labor process which is involved in the provision of services, medical-health and surgical services in particular (cf. Fichtenbaum, 1982/83:42). Following Marx, this can be characterized as a labor process where "man's activity, with the help of the instruments of labor, effects an alteration, designed from the commencement, in the material worked upon. The process disappears in the [service]. ." (Marx, 1954:180). That man's activity (in this instance the physician's or surgeon's provision of services) is [re]productive labor is straightforward, except that the physician or surgeon may be more or less skilled, better or worse educated, as we have occasion to note below. Included among instruments of labor are "all such objects necessary for carrying on the labor process." Among these objects is the tool, "a thing, or complex of things, which the laborer interposes between himself and the object [Gegenstand] of his labor" (Marx, 1954:179-180). Among these were also the so-called auxiliary materials, which are entirely consumed in the labor process (Marx, 1962, Vol. 2:159-62). The scalpel, for instance, is a tool, and both the ether of anaesthesia and the carbolic acid of antisepsis are auxiliary materials. In a striking passage on the instruments of labor, Marx states the "laborer makes use of the mechanical, physical and chemical properties of some substances in order to make other substances subservient to his aims" (Marx, 1954:179). In terms of Marx's conception of the object of labor wherein the labor of the physician or the surgeon is materialized (in the present instance that is the patient), it follows that this patient is included with the instruments of labor in the means of [re]production (Marx, 1954:179). The means of reproduction, in contrast to the laborer, are located in the realm of Nature and the interrelationships of these means are those of physical (or natural) laws (Marx, 1954:177-8). Given these natural laws, a limited number of specific ensembles of instruments of production are possible to achieve some planned transformation of the object of labor. Marx comments of instruments of labor and the development of forms of human labor that the instruments are "indicators of the social conditions under which that labor is carried on" (Marx, 1954:180). Now indices of social conditions should not be technologistically confused with social relations themselves. As we will see, it is not possible to take technological development (e.g. the invention of aseptic surgical practices) as anything but an index of social change, since technological developments prove to be most necessary but not sufficient conditions for social change. Scalpel, bone-saw, boiling water, gauze, etc. constituted the instruments of labor or pre-modern medical-surgical practice; in conjunction with the screaming, physically constrained patient these instruments made up the pre-modern means of surgical [re]production (cf. also Fichtenbaum, 1982/83:33). The surgeon's labor was only formally capitalistic; it was in fact a form of petty commodity production (Marx, 54:508ff.). Toward the close of the 19th century the same tools plus anaesthetics and antiseptics [373/374] as auxiliary materials constituted the quite different instruments of labor of the modern mode of medical production; in conjunction with the "patient etherized upon a table," these instruments made up crucial elements of the modern means of medical production and of surgical reproduction (Friedson, 1970:48). This labor has increasingly proved to be capitalistic; the physician and surgeon are becoming (very well rewarded) members of the working class, employees of the medical-health institution.
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