In 1970 the sociologist Eliot Freidson took the American medical profession to task for its lack of self discipline.1 Looking back at the erosion of professional autonomy since then, Freidson recently wrote that “it was the profession's own failure to regulate itself in the public interest that created the legal, economic, and political pressures of the past twenty- five years.”2

Freidson now worries that professionalism in American medicine and “the flexible discretionary judgment that is necessary to adapt services to individual [patients'] needs” may be crushed between the forces of government regulation on one side and the market forces of competition on the other. He accepts that “both market and bureaucratic methods should be used to reduce cost and control performance, but only elements of those that do not destroy or seriously weaken what is desirable in professionalism.”3

The bureaucratic oppression under which the British medical profession now labours seems considerably greater than that in the United States. As employees of the NHS, and therefore of the government, doctors are inescapably and directly subject to managerial control; and they are also inevitably, willingly or unwillingly, …