The professions dominate our world. They heal our bodies, measure our profits, save our souls. Yet we are deeply ambivalent about them. For some, the rise of professions is a story of knowledge in triumphant practice. It is the story of Pasteur and Osier and Schweitzer, a thread that ties the lawyer in a country village to the justice on the Supreme Court bench. For others it is a sadder chronicle of monopoly and malfeasance, of unequal justice administered by servants of power, of Rockefeller medicine men. Beneath the impassioned contradictions of these interpretations lie some common assumptions. Most authors study professions one at a time. Most assume that professions grow through a series of stages called professionalization. Most talk less about what professions do than about how they are organized to do it.
These assumptions seem to emerge from our central questions about professions. Why should there be occupational groups controlling the acquisition and application of various kinds of knowledge? Where and why did groups like medicine and law achieve their power? Will professionalism spread throughout the occupational world? To answer such puzzling questions, it seemed necessary to adopt simplifying assumptions. The complexities of the individual professions forced case by case study. The fact that professions like medicine and architecture seemed more similar in organizational pattern than in actual work made organizational pattern the focus of analysis. The focus on pattern implied in turn a search for its origins and led to the idea of a common process of development, the idea of professionalization. But professionalization was at best a misleading concept, for it involved more the forms than the contents of professional life. It ignored who was doing what to whom and how, concentrating instead on association, licensure, ethics code. In fact, not only did it miss the contents of professional activity, but also the larger situation in which that activity occurs.
By focusing on parallels in organizational development, students of the professions lost sight of a fundamental fact of professional life—interprofessional competition. Control of knowledge and its application means dominating outsiders who attack that control. Control without competition is trivial. Study of organizational forms can indeed show how certain occupations control their knowledge and its application. But it cannot tell why those forms emerge when they do or why they sometimes succeed and sometimes fail. Only the study of competition can accomplish that.
The professions, that is, make up an interdependent system. In this system, each profession has its activities under various kinds of jurisdiction. Sometimes it has full control, sometimes control subordinate to another group. Jurisdictional boundaries are perpetually in dispute, both in local practice and in national claims. It is the history of jurisdictional disputes that is the real, the determining history of the professions. Jurisdictional claims furnish the impetus and the pattern to organizational developments. Thus an effective historical sociology of professions must begin with case studies of jurisdictions and jurisdiction disputes. It must then place these disputes in a larger context, considering the system of professions as a whole. It must study such evolving systems in several countries to assess exogenous factors shaping systems of professions. Only from such portraits can one derive an effective model for understanding and predicting professional development in modern societies generally.
The movement from an individualistic to a systematic view of professions organizes this book. I begin by evaluating the idea of professionalization and move on to theorize the systematic relations of professions. I then analyze external forces bearing on the system and close by discussing three important examples of contested jurisdictions. Throughout, I addresss the familiar questions about professions. How do professions develop? How do they relate to one another? What determines the kind of work they do?
But this summary slights a methodological theme that accompanies the substantive one as harmony does a melody. My substantive questions all involve generalizing about stories, such as stories of professionalization. My methodological concern is with how this generalization takes place. Traditional theories of professionalization argue that professions follow a certain sequence of development. This "careers" model is one way to generalize about sequences of social events. My theoretical scheme, particularly in Chapter 4, illustrates a different way of generalizing about sequences, one that makes them interdependent. Since jurisdiction is the defining relation in professional life, the sequences that I generalize are sequences of jurisdictional control, describing who had control of what, when, and how. Professions develop when jurisdictions become vacant, which may happen because they are newly created or because an earlier tenant has left them altogether or lost its firm grip on them. If an already existing profession takes over a vacant jurisdiction, it may in turn vacate another of its jurisdictions or retain merely supervisory control of it. Thus events propagate backwards in some sense, with jurisdictional vacancies, rather than the professions themselves, having much of the intiative. This simple system model shows how a set of historical stories can be analyzed without assuming a common career pattern, as in the concept of professionalization.
Throughout the book, then, run two levels of analysis. Substantively, the book answers some questions about the evolution of professions. Methodologically, it considers the difficulties of generalizing about sequences of events and proposes a new way to address them. It both does historical sociology and asks how historical sociology ought to be done.
The Professions Literature
Although the professions derive from medieval or in some cases ancient origins, the first systematic attempts to study them came in this century. In part this reflected the rise of the social sciences, but it reflected more importantly a great change in the professions themselves. The nineteenth century saw the first development of professions as we know them today. In England the merging of apothecaries with surgeons and physicians, the rise of the lower branch of the legal profession, and the appearance of the surveyors, architects, and accountants signaled the change. In America the triumphs of regular medicine over its various sects, the growth of the university professional schools, and the host of would-be professions all testified to the new form of occupation.
The nineteenth century professions were important but peculiar social creatures. With the exception of accounting, they stood outside the new commercial and industrial heart of society. They were organized in a collegial manner that was distinctly anachronistic. On the Continent, to be sure, the professions were more hierarchical. But this hierarchy came not from the new capitalist forms of organization, but rather from the Old Regime, from which it acquired a civil servant quality quite peculiar in the modern occupational world. The professions, and in particular the Anglo-American variety, were therefore a great puzzle for social theorists. Weber spent many embarrassed pages confronting the wanton irrationality of the English Bar. Durkheim simply ignored the Anglo-American professions altogether and looked to more familiar French occupations for his neocorporatist future.
It was the English themselves who perforce first analyzed these unusual occupations. Carr-Saunders and Wilson's The Professions, published in 1934, was the first such attempt. The book gave historical background on every group that could then be considered a profession in England. Its theoretical discussion systematized a view of professions that had by then come to dominate the writings both of the professions themselves and of the social scientists examining them. Professions were organized bodies of experts who applied esoteric knowledge to particular cases. They had elaborate systems of instruction and training, together with entry by examination and other formal prerequisites. They normally possessed and enforced a code of ethics or behavior. This list of properties became the core of later definitions.
The Carr-Saunders and Wilson volume epitomized two methodologies characteristic of writing on professions, combining naturalism and typology. Early articles on the professions would summarize the life history of their particular case, review the then- current essential traits of a true profession, and decide whether social work or nursing or whatever really was a profession. Work in this genre rapidly built the stock of case studies, fitting each case into the procrustean bed of essential traits. But that bed was so often refinished as it passed from hand to hand that the case studies were never very comparable. By 1964, when Geoffrey Millerson attempted a new general analysis of professions, he had to treat earlier work as merely advisory and build on new data in a new framework. Millerson recognized that trait-based definitions had often reflected political concerns. If one disliked social work, one easily found some trait excluding social work from the prestigious category of "professions." He himself avoided this by identifying only very general traits of professionalism (e.g., organization, education, ethics) and then permitting wide variation within them.
Other authors confronted this empirical diversity more directly. An early and parsimonious answer came from the theorists of professionalization. The diversity of the would-be professions arose because professional status was an end state that few had yet achieved. Diversity would disappear with time, as groups gradually acquired all the marks of true professions. The concept of professionalization thus consummated the marriage of naturalism and typology. Professionalization was a natural process, as in the case study literature, but that process entailed a series of types. In 1964 Harold Wilensky published an article that demonstrated such a regular sequence in the American professions. Professionalization seemed an established fact. The new conceptualization meant in turn a new theoretical question. Why did professionalization follow the sequence it did?
But just as professionalization became an established concept, the study of professions was suddenly reshaped by the new political climate of the 1960s. Early work on professionalization had rested on the functional assumptions characteristic of postwar sociology. It attributed the collegial organization of professions to their position as experts. The "asymmetry of expertise" required the client to trust the professional and the professional to respect both client and colleagues. These relations were guaranteed by various institutional forms—associations, licensure, ethics codes. But theorists rejecting functional assumptions disputed the whole picture. In a lucid analysis of professionalism as a form of control, Johnson argued that the professions did not serve disembodied social needs but rather imposed both definitions of needs and manner of service on atomized consumers. Writing on American medicine, Eliot Freidson argued that dominance and autonomy, not collegiality and trust, were the hallmarks of true professionalism. Another student of medicine, Jeffrey Berlant, attributed the structures of professionalism directly to the goals of economic monopoly. Berlant's work was the more striking in that the feature of professionalism whose monopolistic function he most carefully analyzed was ethics codes, whose altruistic nature had been assumed by earlier workers.
By seeing monopoly rather than control of asymmetric relationships, the new theorists moved the focus of debate from the forms of professionalization to its functions. For the new theorists, the regularity of professionalization was not the visible regularity of school, then association, then ethics code, but rather the hidden one of successive functions for these professional forms. Ethics codes came late in professionalization not because they were a culmination of natural growth, but because they served the function of excluding outsiders, a function that became important only after the professional community had been generated and consolidated. Since ethics codes did not serve these earlier functions, they came late.
The new power literature thus unmasked earlier work as ideological. This unmasking reached its final form in Magali Larsons The Rise of Professionalism (1977). Here professions were explicitly market organizations attempting the intellectual and organizational domination of areas of social concern. Yet even while it reversed the traditional images of profession and professional, Larson's book drew on themes and assumptions standard throughout the Anglo-American study of professions. The old model was accepted for new reasons. Since she cast professions as market dominating organizations, Larson ruled out the professions of the Continent, where expertise was never formalized independent of the state. Like her predecessors in the power tradition, she explicitly excluded the organization-based professions—armed and civil service and clergy—that continue in the Anglo-American world the institutional forms of the Continent. Through her focus on dominance she ignored professions like nursing that had accepted subordination. The exclusions should come as no surprise. By accepting professionalization as the thing to be explained, the new power theorists accepted the assumptions behind the concept. These included not only the idea of a fixed sequence of events or functions, but also assumptions about the best examples of professionalism (American medicine and law), about its essential qualities, and about the character of the interprofessional world.
The split between the functionalists and the monopolists was thus not total. It was also not one-dimensional. First, the two groups emphasized different consequences of professionalism. Berlant and Larson were interested in the consequences of medical professionalism not for health, but rather for the status and power of the medical profession. These were external, social consequences that derived from professional status or activity; sickness was of little interest. Other writers emphasized internal consequences of professionalism, consequences affecting the area of professional work itself—healing, auditing, and so on. To Parsons, for example, the impact of professionalism on sick individuals was of central importance. Yet it was also central for Freidson, whose critical stance otherwise identifies him with Larson and Berlant. This contrast between Parsons and Freidson indicates the other dimension of the split, which concerns the locus of analysis; like Larson but unlike Parsons, Freidson aimed his analysis at the social level. He asked how the overall social handling of illness was affected by the existence and nature of professional groups. Similarly, Larson's concern with the external consequences of professionalism extended to the profession as a whole. She asked what professions got out of professionalism and how. Parsons and other functionalists, while concerned, like Freidson, with internal consequences, saw them at the individual level. How, they asked, does a social relation between client and professional have to be structured for healing (or some other individual professional act) to occur?
Of course, the crossing of these two dichotomies implies a fourth approach, one examining external consequences, as do Larson and Berlant, but at the level of individuals. This view has been argued at length by Joseph Ben-David and Burton Bledstein. Both emphasize the function of professionalism in protecting certain individuals—the professionals themselves—from the structured, rigid employment that emerged with nineteenth century capitalism. Beyond this independence, they both argued, professionalism also provided both an ideal metaphor for vertical mobility and the means with which to attempt it. This argument defines the chief implications of professionalism as its external consequences (status, money, power), but at the individual level. Professionalism was a matter of individual choices and corporate action taken to protect or extend them.