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PROFESSIONALISM REBORN

Theory, Prophecy, and Policy

Eliot Freidson

Polity Press

Copyright © Eliot Freidson 1994.

The right of Eliot Freidson to be identified as author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.

First published in 1994 by Polity Press in association with Blackwell Publishers.

Reprinted 2004

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For Molly

Contents

Acknowledgments

Introduction

PART ICLARIFYING THE ISSUES

1The Theory of Professions: State of the Art

2How Dominant are the Professions?

PART IIELEMENTS OF A THEORY OF PROFESSIONALISM

3The Division of Labor as Social Interaction

4Professions and the Occupational Principle

5Occupational Autonomy and Labor Market Shelters

PART IIIPROPHESYING THE FUTURE OF THE PROFESSIONS

6Professionalization and the Organization of Middle-Class Labor in Post-Industrial Society

7The Futures of Professionalization

8The Changing Nature of Professional Control

PART IVCHOOSING PROFESSIONALISM AS SOCIAL POLICY

9Are Professions Necessary?

10Professionalism as Model and Ideology

11The Centrality of Professionalism to Health Care

12Nourishing Professionalism

References

Index

Acknowledgments

The essays in this volume appear as originally printed, though in some cases text and references were cut to minimize repetition, and brief text added to link papers to one another. Their original substance (as well as the references they relied on at the time) has been preserved.

“The Theory of Professions: State of the Art,” appeared in Robert Dingwall and Philip Lewis (eds), The Sociology of the Professions: Lawyers, Doctors and Others (London: Macmillan, 1983), pp. 19–37. © 1983, Eliot Freidson. Reprinted by permission of The Macmillan Press Ltd.

“How Dominant are the Professions?” appeared in Frederic W. Hafferty and John B. McKinlay (eds), The Changing Medical Profession: An International Perspective (New York: Oxford University Press, 1993), pp. 54–66. © 1993 Oxford University Press. Reprinted by permission.

“The Division of Labor as Social Interaction” is reprinted from Social Problems, 23, 3 (1976), pp. 304–13, by permission. © 1975 by the Society for the Study of Social Problems.

“Professions and the Occupational Principle” is reprinted from Eliot Freidson (ed.), The Professions and Their Prospects (Beverly Hills: Sage, 1973), pp. 19–38. © 1973, Sage Publications. Reprinted by permission.

“Occupational Autonomy and Labor Market Shelters” is reprinted from Phyllis L. Steward and Muriel G. Cantor (eds), Varieties of Work (Beverly Hills: Sage, 1982), pp. 39–54. © 1982 Sage Publications. Reprinted by permission.

“Professionalization and the Organization of Middle-Class Labor in Post-Industrial Society” originally appeared in Sociological Review Monographs, no. 20 (1973), pp. 47–59. Reprinted by permission.

“The Futures of Professionalization” originally appeared in Margaret Stacey, Margaret Reid, Christian Heath, and Robert Dingwall (eds), Health and the Division of Labour (London: Croom Helm, 1977), pp. 14–38. Reprinted by permission.

“The Changing Nature of Professional Control” is reproduced from the Annual Review of Sociology, 10 (1984), pp. 1–20. © 1984 by Annual Reviews. Reprinted by permission.

“Are Professions Necessary?” originally appeared in Thomas L. Haskell (ed.), The Authority of Experts: Studies in History and Theory (Bloomington: Indiana University Press, 1984), pp. 3–27. © 1984 Indiana University Press. Reprinted by permission.

“Professionalism as Model and Ideology” is reprinted from Robert L. Nelson, David M. Trubek, and Rayman L. Solomon (eds), Lawyers’ Ideals/Lawyers’ Practices: Transformations in the American Legal System (Ithaca: Cornell University Press, 1992), pp. 215–29. Copyright © 1992 by Cornell University. Used by permission of the publisher, Cornell University Press.

“The Centrality of Professionalism to Health Care” is reprinted by permission from Jurimetrics: Journal of Law, Science and Technology, 30 (summer, 1990), pp. 431–45.

“Nourishing Professionalism” is reprinted from Edmund D. Pellegrino, Robert M. Veatch, and John P. Langan (eds), Ethics, Trust, and the Professions: Philosophical and Cultural Aspects (Washington: Georgetown University Press, 1991), pp. 193–215. Reprinted by permission.

Introduction

This book brings together a selection of the essays I have written about the professions over a period of twenty years. Both my preoccupation with the topic and my writing about it extend back even further, however, for when I undertook intensive study and analysis of the medical profession during an earlier decade, the larger problem of understanding professionalism1 as a general phenomenon was never out of my mind. But with the exception of a recent paper that argues an important policy issue for the professions in general by analyzing efforts to control the cost of American health care in particular, nothing of what I have written about medicine and health care is included here.2

The papers address a number of different topics and are arranged in several broad categories. The articles in Part I are concerned with appraising the state of the field, the reasons for some of its inadequacies, certain of the methodological issues it must face, and the complexity of the phenomenon it addresses. In Part II I advance some of my own efforts to develop a theory, beginning by establishing my choice of occupational control of work as the guiding concept for the theorizing, and then elaborating its implications. The essays in Part III turn to the more topical matter of evaluating the present position of professions in advanced industrial society in the light of recent shifts in public opinion and state policy. I analyze forecasts of professional decline in the light of available evidence, and indicate what I believe is happening to the professions today. In Part IV the tenor of the essays shifts from descriptive analysis to an attempt to inform social policy, which must inevitably judge and choose among alternatives and cannot be neutral. I argue that, on balance, professionalism is preferable to alternative modes of organizing the work of professionals (and others) and suggest how its virtues can be reinforced.

THE EARLY POSTWAR PERIOD

At any given time, much of what is chosen to write about reflects not only the stage of development of one’s own thinking but also a response to contemporary issues and interests. Thus, these essays must be seen in part as a product of the development of the field of the sociology of professions during the second half of the twentieth century. Let me briefly sketch that development in order to provide a context for them.3

As I note in Chapter 1 and other essays in this book, the professions have been considered worthy of special attention in the English-speaking world for at least a century. Herbert Spencer dwelt on their special importance in English society, as did Beatrice and Sidney Webb, R. H. Tawney, A. M. Carr-Saunders, and T. H. Marshall, each for different reasons. But the concept of profession was largely taken for granted, and there was little systematic thinking about it until academic sociology in the United States expanded after World War II. The most widely known American theorist, Talcott Parsons, had been perhaps the earliest to address the professions in theoretical terms. In a prewar essay (Parsons, 1939) he sought to make sense of the ostensible contradiction between the idea that professions manifest altruistic rather than self-interested behavior and the assumption on the part of economic theory and utilitarianism that all behavior is self-interested. In postwar work (Parsons, 1951, 1964, 1968) he theorized about both the medical and the legal professions, and claimed special importance for the professions in advanced industrial societies. In a lower key, outside the then-dominant functionalist tradition, Everett Hughes (1958) wrote a series of provocative essays that cut through the mystique with which professions attempt to surround themselves, analyzing both what they had in common with far more humble occupations, and what distinguished them.

In addition to those pre-eminent sociologists, many other well-known writers made self-conscious efforts to develop a concept of profession that would distinguish it from other occupations, and to discover regularities in the historic process by which an occupation attains professional status (e.g., Wilensky, 1964; Goode, 1969; Moore, 1970). By the 1960s,4 a number of British sociologists had joined in the enterprise (e.g., Jackson, 1970; Elliott, 1972). A literature of considerable size had begun to accumulate.

THE CRITICAL PERIOD

Until the 1960s, the tenor of writings by scholars on the professions was, by and large, neutral. If it was not critical of the professions, neither was it laudatory. Only Talcott Parsons (who was himself hardly an apologist for the professional status quo) singled them out for a position of special importance in his vision of modern society. As for other fields, however, the 1960s were an intellectual watershed for the study of the professions. Under the ideological influence of that period, historians and sociologists began producing “revisionist” histories of the professions and their institutions, emphasizing their economic self-interest and concern for their status in the policies they pursued, and analyzing how their activities facilitated control of the poor, the working class, and the deviant (e.g., Platt, 1969; Rothman, 1971; Auerbach, 1976). Influential sociological essays warned against the adoption of the professions’ own self-advertisements and, denying the possibility of neutrality, urged both a more critical stance and taking the side of the deviant and the client.

By the early 1970s, two writers reflected the intellectual ferment of the previous decade and shifted the emphasis of subsequent theorizing about the professions away from their role in holding society together and toward issues of conflict and power. My books Profession of Medicine (1988 [1970a]) and Professional Dominance (1970b) were focused on the medical profession and the organization of health care, while keeping in sight the implications of the analysis for understanding professions in general. They emphasized the ideological character of professional claims, unjustified aspects of monopolistic privilege, and the way organized professional institutions create and sustain authority over clients, associated occupations, and the very way we think about deviant or undesirable behavior. Shortly afterwards Terence Johnson (1972) defined profession as a method of controlling work – one in which an occupation, rather than individual consumers or an agent or agency mediating between occupation and consumer, exercises control over its work. And he emphasized the role of power in establishing and maintaining such control. Subsequent literature from both the United Kingdom and the United States was described by commentators as taking a “power approach” rather than the “trait approach” of earlier structural-functional writers. Later in the decade, Larson’s The Rise of Professionalism (1977) brought both Marxist and Weberian theory to the fore in her analysis of professions, studying them as interest groups linked to the class system of capitalist societies and analyzing professionalization as a “collective mobility project” in which occupations seek to improve not only their economic position but also their social standing, or prestige. The broad historical orientation of her work also stimulated greater interest in historical studies of professionalization, which I shall discuss shortly.

The revival of Marxist analysis in the United Kingdom and the United States from the 1960s on also made its mark on studies of professions. Marxism, of course, emphasized the ultimate importance of economic relations. But so, too, does economic liberalism, which was also revived. The intellectual consequence was that those otherwise mutually hostile ideologies joined in attacking the social standing and economic privilege of professions, arguing that professionalism represents unjustified elitism that reinforces the class system, and that its exclusionary “social closures” limit opportunity (Collins, 1979) and interfere with the operation of a free and putatively efficient labor market. Similar criticism was implicit in the more neutral-sounding academic work of those adopting the “power approach.” It remains the dominant theme in evaluating professionalism today, perhaps because in virtually all capitalist democracies the high cost of health, legal, education, welfare and other professional services has become a critical policy issue.

In the early 1970s, the primary target of most of the British and American writers criticizing the professions was medicine – how it dominated social policy, the other occupations in the health-care division of labor, the institutions in which its members work, and patients or consumers, and how it has “medicalized” personal and social problems (e.g., Berlant, 1975; McKinlay, 1973). But later in the decade, under the influence of Marxism, the emphasis on medicine’s power (and the power of the professions) began to shift. The literature turned to predicting the decline of medicine, law, and professions in general. A considerable literature has since grown up that speculates about the consequences for the professions of financial and administrative policies being undertaken both by private corporations and by the state. In addition, attention has focused on the possible consequences of changes within the professions themselves, such as increasing numbers of practitioners and greater internal stratification and fragmentation into specialties, not to speak also of the influence of consumer movements. All analysts agree that in virtually every industrial nation the professions are going through important changes. Marxist analysts predictably forecast proletarianization; others prophesy considerable reorganization of the professions, if not actual loss of their status.

THE EMERGING COMPARATIVE APPROACH

Until the 1980s, medicine served as the primary model for conceptualizing professionalism. An early essay by Rueschemeyer (1964) pointed out that there are major differences between law and medicine even though both are recognized by everyone as true professions, and he warned against generalizing from medicine alone. But since it was medicine and paramedical occupations that were familiar to most writers, his warning fell on deaf ears and had little influence at the time. By the 1970s, sociologists in Canada, Australia, and New Zealand had joined British and American sociologists in studying the professions – concentrating on medicine and related occupations in the English-speaking countries (e.g., Larkin, 1983; Willis, 1989), but beginning to pay some sustained attention to the legal profession (e.g., Dingwall and Lewis, 1983).

By then, however, an increasing number of historians were undertaking studies of professions that began appearing in print in the 1980s. Indeed, histories of professions became, in the words of one review-essayist (Ramsey, 1983), a cottage industry for historians. Furthermore, they did not restrict themselves to health-related professions in English-speaking nations (e.g., Geison, 1983a, 1983b; Frieden, 1981; Peterson, 1978; Gawalt, 1984; Cocks and Jarausch, 1990; Ramsey, 1988). Typically, they turned to sociology for concepts and theories to use either as a guide or as rhetorical straw men for organizing their exposition. Many of those studying professions on the continent found those concepts wanting (e.g., Gispen, 1988). But sociologists had also become dissatisfied with concepts that were developed more for analyzing medicine than other professions, and, even then, in English-speaking countries with relatively decentralized and passive governments.

Strong interest in the professions grew on the continent as well as in English-speaking countries during the 1980s. Previously, European scholars had seemed to consider the concept of profession to be of little pertinence to their own societies. This is not to say that they ignored medicine, law, and other educated, middle-class occupations, or that they were unaware of the increasingly conspicuous role of experts in their societies. But they did not use the Anglo-American concept of profession to organize the way they dealt with those topics. Their neglect of the concept was no doubt due to a number of causes, such as their intellectual propensity to think in terms of class rather than occupation, the absence of a term with similar implications in their own languages, and, perhaps most important, the fact that European professions in general are more closely bound to the state than their English-speaking counterparts.

For whatever the reason, during the 1980s French, German, Swedish, and other historians undertook studies of physicians, lawyers, engineers, secondary school teachers, and others (e.g., Burrage and Torstendahl, 1990; Torstendahl and Burrage, 1990). Stimulated primarily by the work of Larson, they sought to analyze how the modern professions emerged in Europe during the nineteenth and twentieth centuries – that is, the process of professionalization. In doing so, they were quite critical of the way the process had been conceptualized by earlier Anglo-American writers and sought to distinguish the different paths of different professions in different nations with different cultural and political traditions. In most, the state played an active role in initiating the institutionalization of some professions and reorganizing others. Furthermore, in many cases it served as the professions’ prime employer. This obviously made for a different course of professionalization than occurred in the English-speaking countries and will no doubt lead to new theories in the future.

Interest in comparative studies of the position of contemporary professions also developed during this time. Medical sociologists (Hafferty and McKinlay, 1993), sociologists of education (Clark, 1987), and scholars concerned with the bearing of public policy on the various professions (Freddi and Björkman, 1989; Jones, 1991) brought together volumes comparing the position of a number of different professions in the same nation, or comparing the position of the same profession in different nations. Abel and Lewis (1988a, 1988b) published a massive compendium of studies of lawyers in both civil and common law countries, as well as a volume of essays (1989a) exploring some of the theoretical implications of that comparative study. By now a considerable literature of comparative transnational studies has begun to accumulate, with many more likely to come well before the end of the century.

Parallel with growing interest in transnational comparative studies has been the growth of a marked emphasis on the role of the state in the affairs of the professions. No doubt this is due in part to having to explain the position of professions in nations on the European continent (and elsewhere), which had different kinds of state traditions, but it also reflects an intellectual shift in emphasis and interest that has taken place in the larger disciplines of political science and political sociology. Elements of that shift have begun to appear in the literature, as in my own exploration of the legal and other state-supported institutions that sustain professionalism in the United States (Freidson, 1986a), Rueschemeyer’s proposal (1986) to compare professions by adopting a state-centered rather than profession-centered approach, and Halliday’s invaluable appraisal (1989) of the pertinence of corporatist theory to understanding the position of professions in various nations.

THE STUDY OF PROFESSIONS IN THE FUTURE

It is far too early to tell where growing interest in comparative studies and in the state will take us. We can assume that historians’ interest in professionalization will continue if only because the study of how institutions develop over time is intrinsic to their discipline. Nor can there be any doubt that Abbott’s recent (1988) brilliant analysis of the role of jurisdictional claims and disputes in the changing fortunes of professions will force us to pay closer attention in the future to the interaction between occupations in contiguous positions in a division of labor. In both cases, the role of the state is almost certain to be explored more thoroughly than was the case in the past. My guess is that the emphasis on professional monopoly that has dominated the literature for many years is in decline, due partly to its own intrinsic limitations, and partly to a shift in intellectual interest that has little to do with the limitations of what is abandoned. Similarly, “revisionist” histories are likely to decline, and it may be that greater attention will be paid in the future to aspects of professionalization that cannot be explained easily by reference to material self-interest. Who knows? Whig history may yet return! Whatever else, I have little doubt that cross-national comparisons of particular professions will thrive, and I hope that the systematic comparison of different professions will also do so.

In addition, I hope that sociologists will answer Abel and Lewis’s call (1989b) to study the work that professions do and to make greater efforts to grapple with conceptualizing the influence of differences in the kind of knowledge and work on the process of professionalization (see Halliday, 1985; Abbott, 1988, pp. 33–58 and 177–211). And certainly more can be done to trace the influence of professional knowledge on both social policy and everyday life. One intellectual current that has already contributed to that topic, though not always in a comprehensible fashion, stems from the writings of Michel Foucault (e.g., 1975, 1979). While neither he nor his French followers appear to have examined closely the institutional forms through which those disciplines are exercised (see Freidson, 1986a), it is clear that he was in fact concerned with professionalism, for the professions are the agents which create and advance the knowledge embodied in disciplines, and their members project that knowledge into human and state affairs. By and large, the major exception being Magalí Larson (1989, 1990), the question of the influence of the knowledge and concepts of professions on human consciousness and state policy has been given too little attention by sociologists.

Finally, I might mention the most serious deficiency of the field today – namely, its lack of an adequate theoretical foundation. At present, the sociology of professions stands as a topical field, loosely affiliated with class theory by some, but essentially without any clear theoretical roots. I believe it should be grounded in a theory of occupations, for a profession is generically an occupation, and certainly not a class. What distinguishes occupations from each other is the specialized knowledge and skill required to perform different tasks in a division of labor. This is a distinctly different criterion than location in a class system or in a firm. As I note in Chapter 5, neither class theory nor organizational theory can account adequately for the self-organizing potential of occupations. What is needed to ground theorizing about professions is the development of a genuine sociology of work that deals in a systematic fashion with such topics as the nature and varieties of the specialized knowledge and skill that are embodied in work, the role of that specialized knowledge and skill in the differentiation of work into occupations, and the varied ways by which that differentiation becomes organized.

Apart from developing a theoretical foundation for a true theory of professions, it is essential to establish a guide for their empirical study. As I note in Chapter 2, the more comparative studies there are, the more likely is it that they will be incomparable if they are based on different conceptions of profession. I believe that a fixed standard is most useful for that purpose – namely, an ideal type. But an ideal type that can serve as a standard cannot merely define the substantive essence of some historic form of occupation. As European criticism of Anglo-American efforts to define profession has correctly shown, there is no single, invariant historic form. Success in creating a standard that can guide a wide variety of comparative studies can come only from an ideal type that is constructed systematically out of basic concepts of work, the ways by which it can be organized and controlled, and the institutions necessary for gaining and maintaining that organization.

PROFESSIONALISM REBORN

Having provided the historical and intellectual context for the essays in this volume by briefly reviewing the development of the field of the sociology of professions, I wish to note the way in which its title, Professionalism Reborn, is intended to draw them together. My efforts to conceptualize professionalism in these papers owes much to the work of earlier, now often criticized or ignored writers such as R. H. Tawney, T. H. Marshall, Talcott Parsons, Everett C. Hughes, and William J. Goode, Jr. I have tried to use their substantive insights and arguments in a manner intended to avoid the European charge of Anglo-American particularism. I propose professionalism as a logically distinct and theoretically significant alternative to currently received models for conceptualizing the organization and control of work. Thus, in a number of the essays of this volume much of the work of those earlier students of professions and professionalism becomes reborn to shape an analytic concept.

In other chapters I focus on the empirical forms of professionalism, addressing the fact that, in all major advanced industrial nations, the position of professionals and the nature of their practice are changing. My papers discuss others’ efforts to conceptualize those changes as evidence of the decline and future disappearance of professionalism. I argue, to the contrary, that the essential elements of professionalism are not disappearing, but rather are taking a new form. Professionalism is being reborn in a hierarchical form in which everyday practitioners become subject to the control of professional elites who continue to exercise the considerable technical, administrative, and cultural authority that professions have had in the past.

The essays in Part IV of this volume represent my considered response to the torrent of criticism to which professions in the United States have been subjected over the past two decades by both radical and free-market ideologues. My past work on the medical profession has been cited often to support both positions, but I believe that both are ill-considered, especially in light of the practical question “What are the alternatives to professionalism?” I try to redress what is now an extreme imbalance of intellectual opinion. The evaluative tradition of Tawney, Carr-Saunders, and Marshall is reborn in my argument that professionalism is both necessary and desirable for a decent society.

However, that argument, and the analysis of professionalism throughout this book, is grounded in the historic conventions that govern the labor market. Insofar as those who perform complex, discretionary work must gain their living by it, then professionalism represents the more desirable method of organizing their position in the labor market. The connection of professional work with income, however, is a constant stimulus to self-interested exploitation of the sheltered autonomy that professional institutions provide, so we may hardly consider professionalism to be the optimal solution to the problem of organizing work; it is merely the better of the three alternatives I discuss. Are there any other ways of organizing work by which the professional spirit can be reborn in a new and even more desirable form?

Bearing in mind my belief that a truly adequate theory of professions must be rooted in a generic theory of work, a conception of work is required that encompasses all forms of productive labor, not merely those that take place in the conventional labor market. Many kinds of work and workers do not appear in the official statistics of the modern state on which most sociologists rely. Close study of those unofficial forms of productive labor expands our conception of work beyond the official economy. Furthermore, it provides us with resources that can expand our conception of professionalism beyond the historical conventions with which this book is primarily concerned. When we look for productive labor outside the market, we find in fact many empirical circumstances in which skilled, creative work is performed for sustained periods of time largely without pay (see Freidson, 1986b; Stebbins, 1992, pp. 1–19). Such work is performed primarily for its own sake, for the love of it, or for the way it benefits others (see Freidson, 1990). In such circumstances we find a professionalism that is by choice or necessity stripped of the compromising institutions that assure workers a living, a professionalism expressed purely as dedication to the committed practice of a complex craft that is of value to others. To liberate it from material self-interest is the most radical way by which professionalism could be reborn.

NOTES

  1  I use the word “profession” to refer to an occupation that controls its own work, organized by a special set of institutions sustained in part by a particular ideology of expertise and service. I use the word “professionalism” to refer to that ideology and special set of institutions. These usages have evolved over time and are not clearly distinguished in all the essays in this volume.

  2  For a selection of my essays on medicine and health care, see Eliot Freidson, Medical Work in America (New Haven: Yale University Press, 1989).

  3  In what follows I try to provide a brief overview of the development of the sociology of the professions. The references I give are not exhaustive, referring either to key writers, or illustrating a body of writing that is not cited in the essays in this volume.

  4  The careful reader will note discrepancies between the publication dates of my citations, and my periodization. I assume a considerable lag between conception and publication, estimating a delay of between three and five years for an article in a scholarly journal and between eight and ten years for an academic book.

PART I

CLARIFYING THE ISSUES