These minorities already see that they – and all autochthonous cultural life – are threatened by mega-tools which systematically expropriate the environmental conditions that foster individual and group autonomy. And so they quietly determine to fight for the usefulness of their bodies, memories, and skills. Because the rapidly increasing multiplication of imputed needs generates ever new kinds of dependence and ever new categories of modernized poverty, present-day industrial societies take on the character of interdependent conglomerates of bureaucratically stigmatized majorities. Among this great mass of citizens who are crippled by transport, rendered sleepless by schedules, poisoned by hormone therapy, silenced by loudspeakers, sickened by food, a few form minorities of organized and active citizens. Now these are barely beginning to grow and coalesce for public dissidence. Subjectively, these groups are ready to end an age. But to be dispatched, an age needs a name that sticks. I propose to call the mid-twentieth century the Age of Disabling Professions. I choose this designation because it commits those who use it. It exposes the anti-social functions performed by the least challenged providers: educators, physicians, social workers, and scientists. Simultaneously, it indicts the complacency of citizens who have submitted themselves to multi-faceted bondage as clients. To speak about the power of disabling professions shames their victims into recognizing the conspiracy of the life-long student, gynaecological case, or consumer, each with his or her manager. By describing the sixties as an apogee of the problem-solver, one immediately exposes both the inflated conceit of our academic élites and the greedy gullibility of their victims.
But this focus on the makers of the social imagination and the cultural values does more than expose and denounce; by designating the last twenty-five years as the Age of Dominant Professions, one also proposes a strategy. One sees the necessity of going beyond the expert redistribution of wasteful, irrational, and paralyzing commodities, the hallmark of Radical Professionalism, the conventional wisdom of today’s good guys. The strategy demands nothing less than the unmasking of the professional ethos. The credibility of the professional expert, be he scientist, therapist, or executive, is the Achilles’ heel of the industrial system. Therefore, only those citizen initiatives and radical technologies that directly challenge the insinuating dominance of disabling professions open the way to freedom for non-hierarchical, community-based competence. The waning of the current professional ethos is a necessary condition for the emergence of a new relationship between needs, contemporary tools, and personal satisfaction. The first step toward this emergence is a sceptical and non-deferential posture of the citizen towards the professional expert. Social reconstruction begins with a doubt raised among citizens.
When I propose the analysis of professional power as the key to social reconstruction, I am usually told that it is a dangerous error to select this phenomenon as the crux for recovery from the industrial system. Is not the shape of the educational, medical, and planning establishments actually the reflection of the distribution of power and privilege of a capitalist élite? Is it not irresponsible to undermine the trust of the man in the street in his scientifically-trained teacher, physician, or economist precisely at the moment when the poor need these trained protectors to gain access to classroom, clinic, and expert? Ought not the industrial system’s indictment expose the income of stockholders in drug firms or the perquisites of power-brokers that belong to the new élites? Why spoil the mutual dependence of clients and professional providers, especially when increasingly – as in Cuba or the United States – both tend to come from the same social class? Is it not perverse to denigrate the very people who have painfully acquired the knowledge to recognize and service our needs for welfare? In fact, should not the radically socialist professional leaders be singled out as the most apt leaders in the ongoing task of society of defining and meeting people’s ‘real’ needs in an egalitarian society?
The arguments implicit in these questions are frequently advanced to disrupt and discredit public analysis of the disabling effects of industrial welfare systems which focus on services. Such effects are essentially identical and clearly inevitable, no matter what the political flag under which they are imposed. They incapacitate people’s autonomy through forcing them – via legal, environmental, and social changes – to become consumers of care. These rhetorical questions represent a frantic defence of privilege on the part of those élites who might lose income, but would certainly gain status and power if, in a new form of a market-intensive economy, dependence on their services were rendered more equitable.
A further objection to the critique of professional power drives out the devil with Beelzebub. This objection singles out, as the key target for analysis, the defence conglomerates seemingly at the centre of each bureaucratic-industrial society. The developed argument then posits the security forces as the motor behind the contemporary universal regimentation into market-dependent discipline. It identifies as the principal need-makers the armed bureaucracies that have come into being since, under Louis XIV, Richelieu established the first professional police: that is, the professional agencies that are now in charge of weaponry, intelligence, and propaganda. Since Hiroshima, these so-called services appear to be the determinants for research, design production, and employment. They rest upon civilian foundations, such as schooling for discipline, consumer training for the enjoyment of waste, habituation to violent speeds, medical engineering for life in a world-wide shelter, and standardized dependence on issues dispensed by benevolent quartermasters. This line of thought sees state security as the generator of a society’s production patterns, and views the civilian economy as, to a large extent, either the military’s spin-off or its prerequisite.
If an argument constructed around these notions were valid, how could such a society forego atomic power, no matter how poisonous, oppressive or counter-productive a further energy glut might be? How could a defence-ridden state be expected to tolerate the organization of disaffected citizen groups who unplug their neighbourhoods from consumption to claim the liberty to small-scale use-value-intensive production that happens in an atmosphere of satisfying and joyful austerity? Would not a militarized society soon have to move against need-deserters, brand them as traitors, and, if possible, expose them not just to scorn but to ridicule? Would not a defence-driven society have to stamp out those examples that would lead to non-violent modernity, just at the time when public policy calls for a decentralization of commodity production reminiscent of Mao, and for more rational, equitable, and professionally supervised consumption?
This argument pays undue credit to the military as the source of violence in an industrial state. The assumption that military requirements are to blame for the aggressiveness and destructiveness of advanced industrial society must be exposed as an illusion. No doubt, if it were true that the military had somehow usurped the industrial system, if it had wrenched the various spheres of social endeavour and action away from civilian control, then the present state of militarized politics would have reached a point of no return; at least of no potential for civilian reform. This is in fact the argument made by the brightest of Brazil’s military leaders, who see the armed forces as the only legitimate tutor of peaceful industrial pursuit during the rest of this century.
But this is simply not so. The modern industrial state is not a product of the army. Rather, its army is one of the symptoms of its total and consistent orientation. True, the present industrial mode of organization can be traced to military antecedents in Napoleonic times. True, the compulsory education for peasant boys in the 1830s, the universal health care for the industrial proletariat in the 1850s, the growing communications networks of the 1860s, as well as most forms of industrial standardization, are all strategies first introduced into modern societies as military requirements, and only later understood as dignified forms of peaceful, civilian progress. But the fact that systems of health, education, and welfare needed a military rationale to be enacted into law, does not mean that they were not thoroughly consistent with the basic thrust of industrial development which, in fact, was never non-violent, peaceful, or respectful of people.
Today, this insight is easier to gain. First, because since Polaris it is no longer possible to distinguish between wartime and peacetime armies and second, because since the War on Poverty, peace is on the war-path. Today, industrial societies are constantly and totally mobilized; they are organized for constant public emergencies; they are shot through with variegated strategies in all sectors; the battlefields of health, education, welfare, and affimative equality are strewn with victims and covered with ruins; citizens’ liberties are continually suspended for campaigns against ever newly discovered evils; each year new frontier-dwellers are discovered who must be protected against or cured of some new disease, some previously unknown ignorance. The basic needs that are shaped and imputed by all professional agencies are needs for defence against evils.
Today’s professors and social scientists who seek to blame the military for the destructiveness of commodity-intensive societies are people who, in a very clumsy way, are attempting to arrest the erosion of their own legitimacy. They claim that the military pushes the industrial system into its frustrating and destructive state, thereby distracting attention from the profoundly destructive nature of a market-intensive society which drives its citizens into today’s wars. Both those who seek to protect professional autonomy against citizen maturity, and those who wish to portray the professional as victim of the militarized state, will be answered by a choice: the direction free citizens wish to go in order to supersede the world-wide crisis.
The waning of the professional age
The illusions that permitted the installation of professions as arbiters of needs are now increasingly visible to common sense. Procedures in the service sector are often understood for what they are – Linus Blankets, or rituals that hide from the provider-consumer-caboodle the disparity and antipathy between the ideal for the sake of which the service is rendered, and the reality that the service creates. Schools that promise equal enlightenment generate unequally degrading meritocracy and life-long dependence on further tutorship; vehicles compel everyone to a flight forward. But the public has not yet clarified the choices. Projects under professional leadership could result in compulsory political creeds (with their accompanying versions of a new fascism), or experiences of citizens could dismiss our hubris as yet another historical collection of neo-Promethean but essentially ephemeral follies. Informed choice requires that we examine the specific role of the professions in determining who in this age got what from whom and why.
To see the present clearly, let us imagine the children who will soon play in the ruins of high-schools, Hiltons – and hospitals. In these professional castles turned cathedrals, built to protect us against ignorance, discomfort, pain, and death, the children of tomorrow will re-enact in their play the delusions of our Age of Professions, as from ancient castles and cathedrals we reconstruct the crusades of knights against sin and the Turk in the Age of Faith. Children in their games will mingle the uniquack which now pollutes our language with archaisms inherited from robber barons and cowboys. I see them addressing each other as chairman and secretary rather than as chief and lord. Hopefully adults will blush when they slip into managerial pidgin with terms such as policy-making, social planning, and problem-solving.
The Age of Professions will be remembered as the time when politics withered, when voters guided by professors entrusted to technocrats the power to legislate needs, the authority to decide who needs what and a monopoly over the means by which these needs shall be met. It will be remembered as the Age of Schooling, when people for one-third of their lives were trained how to accumulate needs on prescription and for the other two-thirds were clients of prestigious pushers who managed their habits. It will be remembered as the age when recreational travel meant a packaged gawk at strangers, and intimacy meant training by Masters and Johnson; when formed opinion was a replay of last night’s talk-show, and voting an endorsement to a salesman for more of the same.
Future students will be as much confused by the supposed differences between capitalist and socialist school, health-care, prison or transportation systems as today’s students are by the claimed differences between justification by works as opposed to justification by faith in the late Reformation Christian sects. They will also discover that the professional librarians, surgeons, or supermarket designers in poor or socialist countries towards the end of each decade came to keep the same records, use the same tools, and build the same spaces that their colleagues in rich countries had pioneered at the decade’s beginning. Archeologists will periodize our life-span not by potsherds but by professional fashions, reflected in the mod-trends of United Nations publications.
It would be pretentious to predict whether this age, when needs were shaped by professional design, will be remembered with a smile or a curse. I hope, of course, that it will be remembered as the night when father went on a binge, dissipated the family fortune, and obligated his children to start anew. Sadly, it will more probably be remembered as the time when a whole generation’s frenzied pursuit of impoverishing wealth rendered all freedoms alienable and, after first turning politics into the organized gripes of welfare recipients, extinguished it in expert totalitarianism.
Professional dominance
Let us first face the fact that the bodies of specialists that now dominate the creation, adjudication, and satisfaction of needs are a new kind of cartel. And this must be recognized to outflank their developing defences. For we already see the new biocrat hiding behind the benevolent mask of the physician of old; the paedocrat’s behavioural aggression is shrugged off as perhaps silly, overzealous care of the concerned teacher; the personnel manager equipped with a psychological arsenal presents himself in the guise of an old-time foreman. The new specialists, who are usually servicers of human needs that their speciality has defined, tend to wear the mask of and to provide some form of care. They are more deeply entrenched than a Byzantine bureaucracy, more international than a world church, more stable than any labour union, endowed with wider competencies than any shaman, and equipped with a tighter hold over those they claim than any mafia.
The new organized specialists must, first, be carefully distinguished from racketeers. Educators, for instance, now tell society what must be learned and can write off as useless what has been learned outside of school. By this kind of monopoly, which enables tyrannical professions to prevent you from shopping elsewhere and from making your own booze, they at first seem to fit the dictionary definition of gangsters. But gangsters, for their own profit, corner a basic necessity by controlling supplies. Educators and doctors and social workers today – as priests and lawyers formerly – gain legal power to create the need that, by law, they alone will be allowed to serve. They turn the modern state into a holding corporation of enterprises that facilitate the operation of their self-certified competencies.
Legalized control over work has taken many different forms: soldiers of fortune refused to fight until they got the licence to plunder; Lysistrata organized female chattels to enforce peace by refusing sex; doctors in Kos conspired by oath to pass trade secrets only to their offspring; guilds set the curricula, prayers, tests, pilgrimages and hazings through which Hans Sachs had to pass before he was permitted to shoe his fellow burghers. In capitalist countries, unions attempt to control who shall work what hours for what pay. All these trade associations are attempts by specialists to determine how their kind of work shall be done, and by whom. But none of these specialists are professionals in the sense that doctors, for instance, are today. Today’s domineering professionals, of whom physicians provide the most striking and painful example, go further: they decide what shall be made, for whom, and how it shall be administered. They claim special, incommunicable knowledge, not just about the way things are and are to be made, but also about the reasons why their services ought to be needed. Merchants sell you the goods they stock. Guildsmen guarantee quality. Some craftspeople tailor their product to your measure or fancy. Professionals however, tell you what you need. They claim the power to prescribe. They not only advertise what is good, but ordain what is right. Neither income, long training, delicate tasks, nor social standing is the mark of the professional. Their income can be low or taxed away, their training compressed into weeks instead of years; their status can approach that of the oldest profession. Rather, what counts is the professional’s authority to define a person as client, to determine that person’s need, and to hand that person a prescription which defines this new social role. Unlike the hookers of old, the modern professional is not one who sells what others give for free, but rather one who decides what ought to be sold and must not be given for free.
There is a further distinction between professional power and that of other occupations: professional power springs from a different source. A guild, a union, or a gang forces respect for its interest and rights by a strike, blackmail, or overt violence. In contrast, a profession, like a priesthood, holds power by concession from an élite whose interests it props up. As a priesthood offers the way to salvation in the train of an anointed king, so a profession interprets, protects, and supplies a special this-worldly interest to the constituency of modern rulers. Professional power is a specialized form of the privilege to prescribe what is right for others and what they therefore need. It is the source of prestige and control within the industrial state. This kind of professional power could, of course, come into existence only in societies where élite membership itself is legitimated, if not acquired, by professional status: a society where governing élites are attributed a unique kind of objectivity in defining the moral status of a lack. It fits like a glove the age in which even access to parliament, the house of commons, is overwhelmingly limited to those who have acquired the title of master by accumulating knowledge stock in some college. Professional autonomy and licence, in defining the needs of society are the logical forms that oligarchy takes in a political culture that has replaced the means-test by knowledge-stock certificates issued by schools. The professions’ power over the work their members do is thus distinct in both scope and origin.
Towards professional tyranny
Professional power has also, recently, so changed in degree that two animals of entirely different colours now go by the same name. For instance, the practicing and experimenting health scientist consistently evades critical analysis by dressing up in the clothes of yesterday’s family doctor. The wandering physician became the medical doctor when he left commerce in drugs to the pharmacist and kept for himself the power to prescribe them. At that moment, he acquired a new kind of authority by uniting three roles in one person: the sapiential authority to advise, instruct, and direct; the moral authority that makes its acceptance not just useful but obligatory; and the charismatic authority that allows the physician to appeal to some supreme interest of his clients that not only outranks conscience but sometimes even the raison d’état. This kind of doctor, of course, still exists, but within a modern medical system he is a figure out of the past. A new kind of health scientist is now much more common. He increasingly deals more with cases than with persons; he deals with the breakdowns that he can perceive in the case, rather than with the complaint of the individual; he protects society’s interest rather than the person’s. The authorities that, during the liberal age, had coalesced in the individual practitioner in his treatment of a patient are now claimed by the professional corporation in the service of the state. This entity now carves out for itself a social mission.
Only during the last twenty-five years has medicine turned from a liberal into a dominant profession by obtaining the power to indicate what constitutes a health need for people in general. Health specialists as a corporation have acquired the authority to determine what health care must be provided to society at large. It is no longer the individual professional who imputes a ‘need’ to the individual client, but a corporate agency that imputes a need to entire classes of people, and then claims the mandate to test the complete population in order to identify all who belong to the group of potential patients. And what happens in health care is thoroughly consistent with other domains. New pundits jump on the bandwagon of the therapeutic care-provider: educators, social workers, the military, town-planners, judges, policemen, and their ilk have obviously made it. They enjoy wide autonomy in creating the diagnostic tools by which they then catch their clients for treatment. Dozens of other need-creators try: international bankers ‘diagnose’ the ills of an African country and then induce it to swallow the prescribed treatment, even though the ‘patient’ might die; security specialists evaluate the loyalty risk in a citizen and then extinguish his private sphere; dog-catchers sell themselves to the public as pest controllers, and claim a monopoly over the lives of stray dogs. The only way to prevent the escalation of needs is a fundamental, political exposure of those illusions that legitimize dominating professions.
Many professions are so well established that they not only exercise tutelage over the citizen-become-client, but also determine the shape of his world-become-ward. The language in which he perceives himself, his perception of rights and freedoms, and his awareness of needs all derive from professional hegemony.
The difference between craftsman, liberal professional, and the new technocrat can be clarified by comparing the typical reaction of people who neglect their respective advice. If you did not take the craftsman’s advice, you were a fool. If you did not take liberal counsel, society blamed you. Now the profession or the government may be blamed when you escape from the care that your lawyer, teacher, surgeon, or shrink has decided upon for you. Under the pretense of meeting needs better and on a more equitable basis, the service-professional has mutated into a crusading philanthropist. The nutritionist prescribes the ‘right’ formula for the infant, and the psychiatrist the ‘right’ anti-depressant, and the schoolmaster – now acting with the fuller power of ‘educator’ – feels entitled to push his method between you and anything you want to learn. Each new speciality in service production thrives only when the public has accepted and the law has endorsed a new perception of what ought not to exist. Schools expanded in a moralizing crusade against illiteracy, once illiteracy had been defined as an evil. Maternity wards mushroomed to do away with home births.
Professionals claim a monopoly over the definition of deviance and the remedies needed. For example, lawyers assert that they alone have the competence and the legal right to provide assistance in divorce. If you devise a kit for do-it-yourself divorce, you find yourself in a double bind: if you are not a lawyer, you are liable of practice without a license; if you are a member of the bar, you can be expelled for unprofessional behaviour. Professionals also claim secret knowledge about human nature and its weaknesses, knowledge they are also mandated to apply. Gravediggers, for example, did not become members of a profession by calling themselves morticians, by obtaining college credentials, by raising their incomes, or by getting rid of the odour attached to their trade by electing one of themselves president of the Lion’s Club. Morticians formed a profession, a dominant and disabling one, when they acquired the muscle to have the police stop your burial if you are not embalmed and boxed by them. In any area where a human need can be imagined, these new disabling professions claim that they are the exclusive experts of the public good.
Professions as a new clergy
The transformation of a liberal profession into a dominant one is equivalent to the legal establishment of a church. Physicians transmogrified into biocrats, teachers into gnosocrats, morticians into thanatocrats, are much closer to state-supported clergies than to trade associations. The professional as teacher of the current brand of scientific orthodoxy acts as theologian. As moral entrepreneur, he acts the role of priest: he creates the need for his mediation. As crusading helper, he acts the part of the missionary and hunts down the underprivileged. As inquisitor, he outlaws the unorthodox – he imposes his solutions on the recalcitrants who refuse to recognize that they are a problem. This multi-faceted investiture with the task of relieving a specific inconvenience of man’s estate turns each profession into the analogue of an established cult. The public acceptance of domineering professions is thus essentially a political event. The new profession creates a new hierarchy, new clients and outcasts, and a new strain on the budget. But, also, each new establishment of professional legitimacy means that the political tasks of lawmaking, judicial review, and executive power lose more of their proper character and independence. Public affairs pass from the layperson’s elected peers into the hands of a self-accrediting élite.
When medicine recently outgrew its liberal restraints, it invaded legislation by establishing public norms. Physicians had always determined what constitutes disease; dominant medicine now determines what diseases society shall not tolerate. Medicine has invaded the courts. Physicians had always diagnosed who is sick; dominant medicine, however, brands those who must be treated. Liberal practitioners prescribed a cure: dominant medicine has public powers of correction; it decides what shall be done with or to the sick. In a democracy, the power to make laws, execute them, and achieve public justice must derive from the citizens themselves. This citizen control over the key powers has been restricted, weakened, and sometimes abolished by the rise of church-like professions. Government by a congress that bases its decisions on expert opinions of such professions might be government for, but never by, the people. This is not the place to investigate the intent with which political rule has thus been weakened; it is sufficient to indicate the professional disqualification of lay opinion as a necessary condition for this subversion.
Citizen liberties are grounded in the rule that excludes hearsay from testimony on which public decisions are based. What people can see for themselves and interpret is the common ground for binding rules. Opinions, beliefs, inferences, or persuasions ought not to stand when in conflict with the eyewitness – ever. Expert élites could become dominant professions only by a piecemeal erosion and final reversal of this rule. In the legislature and courts, the rule against hearsay evidence is now, de facto, suspended in favour of the opinions profferred by the members of these self-accredited élites.
But let us not confuse the public use of expert factual knowledge with a profession’s corporate exercise of normative judgment. When a craftsman, such as a gunmaker, was called into court as an expert to reveal to the jury the secrets of his trade, he apprenticed the jury to his craft on the spot. He demonstrated visibly from which barrel the bullet had come. Today, most experts play a different role. The dominant professional provides jury or legislature with his fellow-initiate’s opinion, rather than with factual evidence and a skill. He calls for a suspension of the hearsay rule and inevitably undermines the rule of law. Thus, democratic power is ineluctably abridged.
The hegemony of imputed needs
Professions could not have become dominant and disabling unless people were ready to experience as a lack that which the expert imputed to them as a need. Their mutual dependence as tutor and charge has become resistant to analysis because it has been obscured by corrupted language. Good old words have been made into branding irons that claim wardship for experts over home, shop, store, and the space or ether between them. Language, the most fundamental of commons, is thus polluted by twisted strands of jargon, each under the control of another profession. The disseizin of words, the depletion of ordinary language and its degradation into bureaucratic terminology, parallel in a more intimately debasing manner that particular form of environmental degradation that dispossesses people of their usefulness unless they are gainfully employed. Possible changes in design, attitudes, and laws that would retrench professional dominance cannot be proposed unless we become more sensitive to the misnomers behind which this dominance hides.
When I learned to speak, ‘problems’ existed only in mathematics or chess; ‘solutions’ were saline or legal, and ‘need’ was mainly used as a verb. The expressions, ‘I have a problem’, or, ‘I have a need’, both sounded silly. As I grew into my teens and Hitler worked at solutions, the ‘social problem’ also spread. ‘Problem’ children of ever newer shades were discovered among the poor as social workers learned to brand their prey and to standardize their ‘needs’. ‘Need’, used as a noun, became the fodder on which professions fattened into dominance. Poverty was modernized. Management translated poverty from an experience into a measure. The poor became the needy.
During the second half of my life, to be ‘needy’ became respectable. Computable and imputable needs moved up the social ladder. It ceased to be a sign of poverty to have needs. Income opened new registers of need. Spock, Comfort, and the vulgarizers of Nader trained laymen to shop for solutions to problems they learned to cook up according to professional recipes. Education qualified graduates to climb ever more rarefied heights and implant and cultivate there ever newer strains of hybridized needs. Prescriptions increased and competences shrank. For example, in medicine, ever more pharmacologically active drugs went on prescription, and people lost their will and ability to cope with indisposition or even with discomfort. In American supermarkets, where it is estimated that about 1500 new products appear each year, less than 20 per cent survive more than one year on the shelves, the remainder, having proved unsellable, fadish, risky, unprofitable, or obsolete competitors to new models. Therefore, consumers are forced to seek guidance from professional consumer protectors.
Furthermore, the rapid turnover of products renders wants shallow and plastic. Paradoxically, then, high aggregate consumption resulting from engineered needs fosters growing consumer indifference to specific, potentially felt wants. Increasingly, needs are created by the advertising slogan and by purchases made by order from registrar, beautician, gynaecologist, and dozens of other prescribing diagnosticians. The need to be formally taught how to need, be this by advertising, prescription, or guided discussion in the collective or in the commune, appears in any culture where decisions and actions are no longer the result of personal experience in satisfaction, and the adaptive consumer cannot but substitute learned for felt needs. As people become apt pupils in learning how to need, the ability to shape wants from experienced satisfaction becomes a rare competence of the very rich or the seriously under-supplied. As needs are broken down into ever smaller component parts, each managed by an appropriate specialist, the consumer experiences difficulty in integrating the separate offerings of his various tutors into a meaningful whole that could be desired with commitment and possessed with pleasure. The income managers, life-style counsellors, consciousness raisers, academic advisers, food-fad experts, sensitivity developers, and others like them clearly perceive the new possibilities for management and move in to match packaged commodities to the splintered needs.
Used as a noun, ‘need’ is the individual offspring of a professional pattern; it is a plastic-foam replica of the mould in which professionals cast their staple; it is the advertised shape of the brood cells out of which consumers are produced. To be ignorant or unconvinced of one’s own needs has become the unforgivable anti-social act. The good citizen is one who imputes standardized needs to himself with such conviction that he drowns out any desire for alternatives, much less the renunciation of need.
When I was born, before Stalin and Hitler and Roosevelt came to power, only the rich, hypochondriacs, and members of élite unions spoke of their need for medical care when their temperatures rose. Doctors then, in response, could not do much more than grandmothers had done. In medicine the first mutation of needs came with sulfa drugs and antibiotics. As the control of infections became a simple and effective routine, drugs went more and more on prescription. Assignment of the sick-role became a medical monopoly. The person who felt ill had to go to the clinic to be labelled with a disease-name and be legitimately declared a member of the minority of the so-called sick: people were excused from work, entitled to help, put under doctor’s orders, and were enjoined to heal in order to become useful again. Paradoxically, as pharmacological technique – tests and drugs – became so predictable and cheap that one could have dispensed with the physician, society enacted laws and police regulations to restrict the free use of those procedures that science had simplified, and placed them on the prescription list.
The second mutation of medical needs happened when the sick ceased to be a minority. Today, few people eschew doctors’ orders for any length of time. In Italy, the United States, France, or Belgium, one out of every two citizens is being watched simultaneously by several health professionals who treat, advise, or at least observe him or her. The object of such specialized care is, more often than not, a condition of teeth, womb, emotions, blood pressure, or hormone levels that the patient himself does not feel. Patients are no more in the minority. Now, the minority are those deviants who somehow escape from any and all patient-roles. This minority is made up of the poor, the peasants, the recent immigrants, and sundry others who, sometimes of their own volition, have gone medically AWOL. Just twenty years ago, it was a sign of normal health – which was assumed to be good – to get along without a doctor. The same status of non-patient is now indicative of poverty or dissidence. Even the status of the hypochondriac has changed. For the doctor in the forties, this was the label applied to the gate-crashers in his office – the designation reserved for the imaginary sick. Now, doctors refer to the minority who flee them by the same name: hypochondriacs are the imaginary healthy. To be plugged into a professional system as a life-long client is no longer a stigma that sets apart the disabled person from citizens at large. We now live in a society organized for deviant majorities and their keepers. To be an active client of several professionals provides you with a well-defined place within the realm of consumers for the sake of whom our society functions. Thus, the transformation of medicine from a liberal consulting profession into a dominant, disabling profession has immeasurably increased the number of the needy.
At this critical moment, imputed needs move into a third mutation. They coalesce into what the experts call a multi-disciplinary problem necessitating, therefore, a multi-professional solution. First, the proliferation of commodities, each tending to turn into a requirement, has effectively trained the consumer to need on command. Next, the progressive fragmentation of needs into even smaller and unconnected parts made the client dependent on professional judgment for the blending of his needs into a meaningful whole. The auto industry provides a good example. By the end of the sixties, the advertised optional equipment needed to make a basic Ford desirable had been multiplied immensely. But contrary to the customer’s expectations, this ‘optional’ flim-flam is in fact installed on the assembly line of the Detroit factory, and the shopper in Plains is left with a choice between a few packaged samples that are shipped at random: he can either buy the convertible that he wants but with the green seats he hates, or he can humour his girlfriend with leopardskin seats – at the cost of buying an unwanted paisley hard top.
Finally, the client is trained to need a team approach to receive what his guardians consider ‘satisfactory treatment’. Personal services that improve the consumer illustrate the point. Therapeutic affluence has exhausted the available life-time of many whom service professionals diagnose as standing in need of more. The intensity of the service economy has made the time needed for the consumption of pedagogical, medical and social treatments increasingly scarce. Time scarcity may soon turn into the major obstacle for the consumption of prescribed, and often publicly financed, services. Signs of such scarcity become evident from one’s early years. Already in kindergarten, the child is subjected to management by a team made up of such specialists as the allergist, speech pathologist, paediatrician, child psychologist, social worker, physical education instructor and teacher. By forming such a paedocratic team, many different professionals attempt to share the time that has become the major limiting factor to the imputation of further needs. For the adult, it is not the school but the work-place where the packaging of services focuses. The personnel manager, labour educator, in-service trainer, insurance planner, consciousness raiser find it more profitable to share the worker’s time than compete for it. A need-less citizen would be highly suspicious. People are told that they need their jobs, not so much for the money as for the services they get. The commons are extinguished and replaced by a new placenta built of funnels that deliver professional services. Life is paralyzed in permanent intensive care.