Eliot Freidston Profissão de médico

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EDITORS INTRODUCTION

VII

THE first paragraph of Eliot Freidson's book invites our attentionto the fact that the word "profession" has a dual meaning. It is, in

the first place, a species of a generic concept, namely, "occupation,"and, in the second, an avowal or promise. ln the first sense we have

a semantic problem, the problem of articulating, in the Aristotelian

manner, thespecies difJerentia which distinguishes a profession from

other activities and endeavors which belong to the genus occupation.

This, of course, is a serious sociological problem, and many efforts

have been directed to its solution. We are alI inclined to think that

there is a difference, let us say, between those who practice surgery

and those who fill prescriptions at the comer pharmacy, those whoargue a case at law and those who serve as notaries, those who lecture

on the history of philosophy and those who teach the multiplication

table. ls there a continuum here, or can genuine discontinuities

be discemed? The answer belongs to logic and to language,

and is of considerable interest to sociologists.The second meaning of "profession," however, is of concern to

everyone. It concems everyone who has ever consulted a physician,

engaged the services of a lawyer, solicited the advice of a minister,or sat in a college classroom. These people-and it is a group to

which we all belong-can always ask whether the avowal or promise

has been fulfilled. Does the profession do what it promises to do?

Does it accomplish what it professes? These are the kinds of questions

to which the author is especially sensitive as he writes on the

profession of medicine. lt may be a profession which, like other professions

as well, contains endemic defects, defects that can be atv

VII

tributed not to its practitioners but to its organization and structure.One may, in conforming to the norms of his profession, perform at

tbe same time a disservice to tbe public whose interests tbe profession

supposedly supports and satisnes.

The self-regulatory process, for example, often used as one criterion

of a profession, is intended to guarantee tbe competence of

its members and to protect its clients from tbose, in the medical

profession, who have less than complete respect for tbe Hippocratic

Oatb to which tbey have all subscribed. The self-regulatory process,however, may not be working in a satisfactory manner. Expected

standards of performance may not be meto The sanctions appliedby the profession to errant and negligent members may not suflice

because of errant and negligent utilization. Furthermore, tbe processof professionalization itself may introduce a narrow and parochial

view of the community the profession is designed to serve. The

doctor may indulge in a misplaced-or possibly exaggerated-emphasis

upon therapy, tbe lawyer upon property, tbe professor upon

learning, the cleric upon sanctity. Thus, a certain "ethnocentrism"

may arise, a tendency to view and to evaluate tbe community ofclients in terms of a professional rather than a more universal criterion.

A professional is a specialist by dennition, but the more be

specializes in the pursuit of his profession tbe more be may be induced


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to sacrmce the larger point of view and reb:eat, in turn, from

the highest of etbical standards. ln every profession, as Freidson

wisely observes, there is an ineradicable moral elemento And he

would doubtless agree with George Bernard Shaw tbat "Every profession

is a conspiracy against the laity."

The problem of promise and avowal is only one of a number of

questions to whicb Eliot Freidson addresses bimself in this booka

book that is remarkable botb for its cogency and for its penetration.Anotber is the character of illness, the degree to which it is

susceptible to social rather tban physiological dennition, the degree,

in sbort, to wbicb it is an artifact of a doctor-patient relationsbip

rather than a fact of a patient's organic condition. There is a difficult

and complex problem bere, one tbat would elude those who are

sociologically unsophisticated and those-to say tbe same tbingwho

are unaware of the Baconian idols of the tribe, cave, marketplace,

and theater. The autbor of tbis book is neither unsophisticated

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nor unaware. He offers us a cIose and comprebensive discussion oftbis problem, a discussion tbat wilI almost certainly provoke tbe

medical profession into disagreement and response.

The profession of sociology, in sbort, bas sometbing to say to tbe

profession of medicine. ln tbis book it is tbe doctor, so to speak, wbo

is tbe patient or, more precisely, it is tbe entire organization of medical

care tbat receives a diagnostic treatment by an eminent sociologist.

If not alI pbysicians and surgeons will agree witb it, neitber

wilI alI sociologists. But no one wilI doubt tbat we bave in tbese

pages a careful and diligent examination of a profession, a professiontbat enjoys a prestigious position not only in modern societies

but in primitive societies as well. Tbose wbo are privileged to read

tbis book will regard it not only as a contribution to tbe sociology

of medicine, and not only as a contribution to tbe sociology of tbeprofessions in general, but as a contribution, in addition, to tbe sociology

of knowledge.

ROBERT BlERSTEDT

--------------------------XI

PREFACE

NO baak can fail to reHect the time in which it is written, and thisbaak is no exceptian to the rule. In aur day we seem to be turning

away fram an uncritical aptimism abaut the role af specialized

knawledge in ardering human affairs. We have nat yet arrived at a

satisfactary new pasitian, hawever, and in the meantime we are

treated to despairing vialence and self-defeating anti-intellectualism

an the part af laymen and their champians, self-interested elitism

an the part af the intellectual classes, and dawnright autharitarianisman the part af even thase palitical leaders with humanitarian


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intentians. Markedly absent fram thase reactians is an attempt to

deal with the issue empirically and analytically. Knawledge and

expertise, whether accepted ar rejected, tend to be seen as things

existing in and af themselves rather than as abstractians which are

realized by the activities af men arganized inta accupatianal careers

and graups.

In this baak I try to shaw that the accupatianal arganizatian af

the wark af ane learned professian canstitutes a dimensian quiteas distinct and fully as impartant as its knawledge, and that the

social value af its wark is as much a functian af its arganizatian as

it is af the knawledge and skill it is said to passess. Sacialagical

analysis af accupatianal arganizatian can, I believe, aid greatly in

the farmulatian af an intelligent palicy taward the role af the professianal

expert in public affairs. But in arder to be saund, such

analysis must attend as closely to empirical detail as to canceptual

clarity. Unfartunately, most af the capiaus literature an the prablem

is very general. Here I trY to pravide just such needed detail in as

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sessing the social role of one of the major professions. That detail,

however, should be viewed in the light of two important issues of

freedom in our time.

One is raised by the fact that professions characteristicalIy seek

the freedom to manage their knowledge and work in their own way,

protected from lay interference. Indeed, they celebrate the ideal of

men who may be trusted to control their own affairs responsibly

and in the public interest. In this book I shalI comment on both the

nature of professional freedom and the manner in which it is exercised.The second issue lies in the problem of the proper role of

the knowledgeable man, or expert, in governing the affairs of laymen.

Insofar as the inB.uence of the expert is strong, and his jurisdietion

far-ranging, the layman's freedom to govem his own affairshowever he chooses is restrieted. Part of the analysis in this book

attempts to assess the justineation for increasing the inB.uence of the

man of applied knowledge at the expense of the freedom of others.

In writing this book the opportunity to obtain critical reactions toearly drafts has been very valuable to me. I have been fortunate to

have had aid from a number of people. I am especialIY indebted

to Judith Lorber for her detailed criticism of several drafts of the

entire book, and to Howard S. Becker, Robert Bierstedt, and Paul

J. Sanazaro for their many comments on most draft chapters. Others

have commented on specinc chapters closely related to their own

interests: they are Peter L. Berger, Vem L. and Bonnie BulIough,

Joel R. Davitz, Mark G. Field, Blanche Geer, Irwin Goffman, HerbertKlarman, DonaId Mainland, David Mechanic, Derek L. Phillips,

Richard Quinney, Thomas J. Scheff, George A. Silver, Erwin

O. Smigel, Merwyn Susser, Kerr L. White, and Irving K. Zola. These

friends and colIeagues have been far more helpful to me than they

know, and I thank them alI.ELIOT FREIDSON

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XV

INTRODUCTION

This book presents an extended analysis of a profession. As its

title implies, emphasis is on both sides of the meaning of the word-"profession" as a special kind of occupation, and "profession" as

an avowal or promise. As 1 shall try to show in the chapters that

follow, it is useful to think of a profession as an occupation which

has assumed a dominant position in a division of labor, so that it

gains control over the determination of the substance of its own

work. Unlike most occupations, it is autonomous or self-directing.

The occupation sustains this special status by its persuasive professionof the extraordinary trustworthiness of its members. The

trustworthiness it professes naturally includes ethicality and aIso

knowledgeable skill. ln fact, the profession claims to be the most

reliable authority on the nature of the reality it deaIs with. When

its characteristic work lies in the attempt to deaI with the problems

people bring to it, the profession develops its own independentconception of those problems and tries to manage both clients and

problems in its own way. ln developing its own "professional"approach, the profession changes the dennition and shape of problems

as experienced and interpreted by the layman. The layman's

problem is re-created as it is managed-a new social reality is

created by the profession. It is the autonomous position of the profession

in society which permits it to re-create the layman's world.

From these observations it is possible to identify two major

problems for analysis presented to the sociologist by the profession.

First, one must understand how the profession's self-direction orautonomy is developed, organized, and maintained. Second, one

XVImust understand the relatian afthe prafessian's knawledge andpracedures

to professional arganizatian as such and to the lay warld.

The first is a problem afsocial arganizatian; the secand a prablem

of the saciology of knawledge.1 These are the prablems I shalI

attempt to deal with in my analysis ofane afthe major prafessiansof madern saciety-medicine.

Medicine, however, is natmerely ane afthe major prafessians af

our time.Amangthe traditianal prafessians established in the

Eurapean universities af the Middle Ages, it alane has develaped

a systematic connection with science and technalagy. Unlike law

and the ministry, which have no impartant cannectian with madern

science and technolagy, medicine has develaped into a very camplex

divisian af labor, arganizing an increasingly large number aftechnical and service warkers around its central taskafdiagnasing

and managing the ills af mankind. Too, it has surpassed the athers

in prominence. Since the praduction afgaads and ather farms af

real praperty are far less afa prablem topastindustrial sacieties

than is the welfare af their citizens, since welfare has come tobe

defined in wholly secular terms, and since the natian af illness has

itself been expanded to include many more facets af human welfare

than it did in earlier times, medicine has displaced the law and the

ministry fram their once daminant pasitians. Indeed, in ane way ar


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anather, the profession afmedicine, natthat af law ar the ministry

arany other, has come tobe the pratotype upan which accupations

seeking a privileged status taday are madeling their aspirations.

The better we understand medicine, then, the better we will

be able to understand the problems that may be pased by the

prafessianalizatian af the key service workers afthe welfare state.

My intent in this baakis to cantribute to our understanding af

prafessians by making a clase analysis af the prafessian af medicine.Obviausly, this is a treacherous undertaking, for as Rueschemeyer

has painted aut,2 there are such important differences between

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merely the twaprafessians af law and medicine that accurate

generalizatian fram one to the ather, let alane fram ane to alI

athers, is very difficult. But since no man can gain cammand aver

much af the relevant data on more than ane afthe established

prafessians, the chaice is between camparison af several prafessians

by a few oversimple variables, and dose examinatian afane in ali

its camplexity with an eye taward the many. I have chasen to dothe latter.

In order to illuminate all professions by the dose examinatian

of one, hawever, it is necessary to remain at a leveI of abstraction

that prevents canfusing the unique with the general. This means

that one's guiding concepts may natstem fram the peculiarities af

the concrete prafessiart one is studying. It means that ane must in

some sense stand apart fram and autside of the specific prafession

one is studying. In the case of medicine ar law or the ministry, one

must use analytical cancepts that allaw camparisons af one with theothers. Such cancepts cannot come fram any single prafessian, for

each prafession has its special preoccupatian, its view of the warld,

and its "science." Thus, in order to study medicine in such a way

as to clarify and extend aurunderstanding of prafessians in general,one must natadopt medicine' s own cancepts af its missian, its

skill, and its "science." Since prafessians are callective human enterprises

as well as vehicles for special knawledge, belief, and skill,

sociology can focus an theircamman organizatian as graups quiteapart fram their different cancepts,praviding the general concepts

by which they may be made individually comparable. It is to this

task that I hape to cantribute. By detailed analysis afmedicine I

hope to demanstrate the. usefulness of seeing the professian as a

kind of occupatianal organization in which a certain state afmind

thrives and which, by virtue of its autharitative pasition in saciety,

comes to transform if not actualIy create the substance of its awn

work.I shall begin the baokwith a discussian of haw a profession

differs fram an ordinary accupation by cantrasting the positian of

healing in saciety at different times in histary and by arguing that,

while the end or aim of healing has natchanged, the position in

society of the accupatians devated to healing has changed. I shalI

point out how medicine has attained its rather special status, how

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it has become dominant in an elaborate division of labor, and how,


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even in circumstances where it is not wholly free of state control,

it is at the very least formally free to control the content if not the

terms of its own work. I shall argue that this special type of occupation

is characteristically autonomous and self-regulating.

Turning to more detailed analysis of American medical institutions,

I shall discuss the varied settings in which medical work is

performed, and I shall look at the manner in which, under the

condition of professional autonomy, medical work is guided or controlledfrom within. Th.is. will lead to a characterization of the

informal organization of the profession, which orders what is known

about variation in work performance, and which shows how individuaIs

in local communities are linked in with the profession's

formal organization.

Finally, the last major section of the book will deal with the

object of the work of medicine-illness. Consonant with my concern

to develop concepts general enough to permit systematic comparison

across individual professions, I shall not make extensive use of

the medical notion of illness. Rather, I shall treat illness as a socialconcept which, like "crime" and "sin," refers to deviation from

social and moral expectations which are embedded in an official

order which the professions come to represento I shall try to showhow the professional frame of mind as well as the organization

of professional work both inHuence the nature of its concepts, and

I shall try to show how the layman also contributes to the process

of constructing the social reality of illness.

Throughout the book my exposition will attempt to present asuggestive model for the analysis of professions in general and consulting

professions in particular. Some exposition must therefore be

addressed to the problem of definition and classification. More importantly,

some must include comments on substantive areas which

are necessary for a logically coherent analysis but about which

little reliable or systematic information is available. For the sake of

the completeness of the logic, I shall have to discuss such areas

anyway, relying more on my own research experience and senseof plausibility than I would like. Those who may disagree with me

about the facts in such obscure areas of professional behaviorshould bear in mind the logical demands of the analysis which

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require me to speculate, for here the analysis is most important.

While I am hardly uninterested in the profession of medicine as

such, which I have been studying for some years, my interest has

heen sustained by the degree to which the study of medicine can

he a proving ground for the development of more adequate waysof analyzing occupations and professions than exist in sociology

today. It is about medicine that I write, but I write of it as species

of occupation first and as medicine itself only second.

1Peter L. Berger and Thomas Luckmann, The Social Construction of Reality(Garden Cit)', New York: Doubledayand Co., 1966), and particularly BurkartHCo.l,z1n9e6r8, ).Reality Construction in Society (Cambridge: Schenkman Publishing2 Dietrich Rueschemeyer, "Doctors and Lawyers: A Comment on the

Theory of the Profissions, " The Canadian Review of Sociology and Anthropology, I (1964), 17-30.


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1

PART I.

THE FORMAL ORGANIZATIONOF A PROFESSION

"The system exhibits two principal features, the spontaneous

coming together of the practitioners in associations,

and the regulative intervention of the State .. . . It is the purpose of the professional associations

to achieve, and of the state, where t intervenes, to

grant, some degree of monopoly of function to the

practitioners."

-A. M. CARR-SAUNDERS andP. A. WILSON

3

1.

THE EMERGENCE OF MEDICINE

AS A CONSULTING PROFESSION

In all societies people diagnose sickness and adopt various

methods for managing it. In most societies some individuaIs are

thought to be specially knowledgeable about sickness and its management

and are sought out for help by the sick or their families.

In many cases such healers are compensated for their help: somemerely supplement "their daily living by healing; others develop

sufficient trade to gain their living primarily by the practice ofhealing and so develop a vocation, becoming members of a true

occupation. But all healers are not called doctors or physicians,

nor are they usually considered to be professionals in any other

sense than that of making a living from their work (the opposite

of amateurs). Those occupations which are distinguished from

others by being called professions are considerably more special.The Problem of "Professon"

Beyond being full-time pursuits of some signincance or socialprominence, it is difficult to nnd very much agreement on a dennition

of the word "profession." This is so for a number of reasons.

First, the word is evaluative as well as descriptive.1 Virtually allself-conscious occupational groups apply it to themselves at one

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time or another either to flatter themselves or to try to persuade

others of their importance. Occupations to which the word has been

applied are thus so varied as to have nothing in common save a

hunger for prestige. This state of affairs has led Becker, for one,to claim that it is hopeless to expect the word to refer to more than


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a social symbol which people attach to some occupations but not

to others.2 A second reason for the disagreement surrounding the

meaning of the word lies in the strategies commonly underlying

the process of definition. People frequently draw up definitions fust

by deciding that certain occupations "are" professions and then by

attempting to determine the characteristics these occupations have

in common. Since people do not agree on which occupations "are"

professions-librarians? 3 social workers? 4 nurses? 5-their definitionsvary with the occupations they include (and exclude) or eIse are

alike on such an abstract leveI as to be virtually inapplicable to the

task of distinguishing real occupations. Finally, there is the matter

of purpose or intent underlying definition. As I have already suggested,

some definitions have an intent that is primarily invidious

and only secondarily analytical. Where the intent is analytical,

analytical interest may vary: some focus on cultural values or knowledge;

others focusing on individual commitment and identification.

The outcome of such varied interest is substantive variation in

definitions.For these reasons, it should be clear that it would be folly to be

dogmatic about any definition of "profession" 01' to assume that its

definition is so well known that it warrants no discussion. For myself,it seems necessary to state my essential assumptions. First, I

assume that if anything "is" a profession, it is contemporary medicine.

By examining it carefully, we can learn more about what the

class "profession" includes than we can from examinng less clearcut

occupational cases. Second, I assume that the analytical variables

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of social organization are more useful discriminants than those of

lIorms, attitudes, or ethics and that, in fact, the former has a doser

"olationship to behavior than the latter. My definitions and analysis

Nhnll therefore emphasize more the social organization than the

Nocial psychology of the medical profession.'fiteProfesson Today and Yesterday

Most writers on medicine seem to have in their minds some very

general notion of medicine as being any activity related to diaglIsing

and treating illness. Such a usage is so inclusive as to cover

l)vcrything from individual practices of self-diagnosis and selft

I'catment in simple societies ("folk medicine") to the most esoteric

I'cscarches in biochemistry. Essentially, such usage refers to the

knowledge of a particular occupation. Consonant with my purpose,I am concerned with medicine as an occupation whose members

ollgage in diagnosing and treating the illnesses of those who conIIlIltthem

for such help. Men at work is my interest first, and only

Nccondarily their knowledge, Medicine, then, in this sociological

Ilsage, is an organized consulting occupation which may serve asIllc discoverer, carrier, and practitioner of certain kinds of knowlt:

Eliot Freidston Profissão de médico

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