by Owen Whooley
In this book, I elevate epistemology to the center of my analysis, building my analysis of the professionalization of medicine in the United States upon the basic recognition of the historical nature of epistemologies. My analytical approach was born from an empirical observation made early on in my archival research—namely, that the debates between allopathic medicine and alternative medical movements during the nineteenth century were fundamentally and persistently waged on the level of epistemological claims. No matter the manifest issue, there was always a latent epistemological controversy at work. The professional politics of nineteenth-century American medicine were subsumed into an epistemic struggle that had its own rules and dynamics.
In doing so, I address a sociological puzzle: if epistemological standards change, how does this happen? A little historical imagination shows that the common answer to this question—the appeal to scientific discoveries—does not suffice. Given that epistemological standards must be in place before an idea is embraced, the whole notion of self-evidently true discoveries is exposed as an impossibility. Outside of historically emergent epistemological systems, ideas have no authority, no truth. The dissemination and acceptance of ideas as discoveries—as well as the professional authority that accompanies ownership of such ideas—requires an explanation beyond the ideas themselves. Nor can it be explained by appealing to the cultural authority of science, at least in this case. Science was not yet privileged in the nineteenth century. Indeed, there was widespread hostility toward science during the Jacksonian era (Hofstadter 1963). To consolidate professional power under the mantle of scientific medicine, reformers not only had to promote specific knowledge claims; they also had to construct the promise of science as the foremost way of knowing. The question becomes, how was this accomplished?
FROM IDEAS TO EPISTEMOLOGY
The professionalization of U.S. medicine is best understood as revolving around fundamental debates over who has the authority to speak truth and on what grounds. To develop an analysis attuned to epistemology, I marry insights from the sociology of the professions and the sociology of scientific knowledge (SSK). It is a curiosity that these two fields, so obviously related, have had little interaction over the last few decades. And while we may be able to chalk up this lack of dialogue to the idiosyncratic development of these subfields, it has created confusion about the nature of professional power and misconstrues the role of ideas in the achievement of professional authority. I seek to integrate insights from both these traditions, as they provide important concepts and points of departure to explain the rise of bacteriology and of professional authority. I focus on the important practices, or work, needed to bring about the new epistemological commitments integral to the acceptance of the bacteriological definition of disease and, in turn, professional power for the AMA. In the process, I offer a conceptual framework to understand the politics of epistemological change generally.
While previous sociological accounts of the professionalization of U.S. medicine have paid scant attention to the role of knowledge disputes in the emergence of the medical profession, this is not to suggest that the sociology of professions is bereft of tools for the examination of the role of knowledge in professional politics. In proposing an ecological model of professions, Andrew Abbott (1988) has sought to reorient the sociology of professions toward knowledge disputes, recognizing the overwhelming importance of interprofessional struggle in the development and decline of professions. Professions exist in an interdependent system, or “ecology” (Abbott 2005), of competitors that vie for control over certain “jurisdictions” of work. Central to these “jurisdictional disputes” are conflicts over knowledge. Knowledge is the “currency of competition” among professions, as changes to—and developments in—abstract knowledge shape a profession’s jurisdiction and the system of professions generally (Abbott 1988, 102). Abbott ’s focus on the competition between actors reintroduces contingency and particularity into the study of professionalization. Every profession has its own unique history, its own unique struggles, and, in turn, assumes its own unique organizational form and place within the system of professions.
Because the definition of reality and the production of knowledge are central to the ability of a profession to gain control over a jurisdiction, exploring developments in a profession’s knowledge base is crucial in accounting for professionalization. And while Abbott does not address epistemology directly,8 it is easy to see how his model, focused as it is on the dynamic struggle between collective actors over knowledge, could be extended to accommodate epistemological debates. Yet, while Abbott developed his ecological model with great historical sensibility, it works best for periods in which a system of professions already exists.9 The situation for nineteenth-century physicians, aspiring to professional authority, was much different. Not only were they struggling over professional plums; they were struggling to justify professions as a legitimate organizational form during a period when such an idea was highly suspect. In the preprofessional world, knowledge struggles revolved less around professional jurisdictions and more around basic concerns of how to organize knowledge.
Although Abbott ’s ecological model has become central in the professions literature—it is widely cited, its terminology extensively employed—its analytical potential has not been fully realized. No one has attempted to revisit the history of the American medical profession through a similar analytical lens. And while Abbott’s heavy focus on knowledge would suggest a close working relationship between the sociology of the professions and the sociology of knowledge, there has been almost no dialogue across these subfields. Lamentably, Abbott’s call for a deeper engagement in knowledge struggles—echoed in Eliot Freidson’s (2001, 27) argument that an adequate sociology of work and professions “must also be a sociology of knowledge”—has gone unheeded.
SSK has much to offer the study of professionalization, especially on how actors struggle to win recognition for their ideas. Scientific practice, and by extension scientific knowledge, is shaped by the local context, cultures, and contingencies (see Collins 1992; Knorr-Cetina 1999; Kohler 2002; Latour and Woolgar 1986; Pickering 1984). Extra-scientific factors operate in the production and validation of science both within the laboratory, where facts are not “discovered” but produced, and outside it, in public disputes over science. Of particular relevance for the purposes of this analysis is research in what Thomas Gieryn (1999, ix) calls the “sociology of science downstream” that attends to the interpretation and consumption of science in the public sphere, “downstream” from the laboratory. To win the status of scientific truth in the public realm, scientists engage in advocacy work to capture authority and legitimacy for ideas through practices like boundary work (Gieryn 1999), network formation (Latour 1987, 1988), appeals to cultural norms of trust (Shapin 1994), the deployment of formal empiricist discourse (Gilbert and Mulkay 1984), and specific performances of expertise (Hilgartner 2000). Scientific truth is therefore not simply a status produced internally in the lab; it is created out of the dynamic struggles between actors in the public arena over how to interpret particular ideas.
While SSK deals with scientific knowledge struggles extensively, it offers less guidance in theorizing issues of epistemology.10 This is not to suggest that SSK has been silent on epistemology. In an important sense, the entire subfield can be viewed as a direct epistemological challenge to science by showing how science does not develop by the application of procedures ratified by the type of epistemological norms that philosophers take seriously. And insofar as SSK examines struggles over science, it addresses issues of epistemology—how people achieve scientific knowledge and how disputes over scientific interpretation get adjudicated. Still, SSK rarely takes up epistemology and epistemological struggle directly as an object of analysis.11 This oversight results from its focus on scientific forms of knowledge. Though contested and continuously defined (Gieryn 1999), claims to science share a core set of epistemological assumptions (e.g., a co
mmitment to the scientific method, a notion of objectivity, the elevated status of facts, etc.) that remain unquestioned in scientific practice and even scientific disputes. Although there is some heterogeneity in how science is framed and understood (Knorr-Cetina, 1999), the underlying ideals of science constrict these divergences, and shared valuation of these ideals remains. Put differently, much of the literature of scientific disputes revolves around whether what one observes can be considered legitimate scientific evidence; epistemological disputes involve something deeper, more fundamental, namely what evidence is. The theoretical insights gleaned from analyses of empirical cases in which the core epistemological assumptions of science are taken for granted are limited for examining cases in which epistemological assumptions are contested, like debates over nineteenth-century medicine.
Epistemic Contests
Epistemological struggle was decisive in shaping the process of American medical professionalization. Therefore, I embed my analysis in epistemological change, investigating the practices by which actors advocated for—and struggled over—competing epistemological visions, so as to obtain a full account of how professional medical politics unfolded during this period of confusion and flux in medical knowledge and to ultimately understand the exceptional result that emerged from this political/epistemological conflict.
At its most basic, epistemology explores how we justify the things that we say we know (Kurzman 1994). As Thomas Nagel (1989, 69) points out, “The central problem of epistemology is the first-person problem of what to believe and how to justify one’s belief—not the impersonal problem of whether, given my beliefs together with assumptions about their relation to what is actually the case, I can be said to have knowledge.” Epistemological questions are not just academic; they touch on a core problem of social life—by what standards can individuals adjudicate true knowledge from false opinion?
Despite the real-world implications of epistemological issues, epistemology has traditionally been constrained to philosophy, which focuses on the issue of justification in a particular manner. Committed to the conceit of universal truth, philosophers of epistemology attempt to locate a universal grounding for all knowledge. Given philosophy’s disciplinary goals, philosophic discussions of epistemology assume a prescriptive, normative character, addressing how knowledge ought to be justified (Kim 1988; Longino 2002). They operate on an abstract plane, appealing to thought experiments to score various logical points. Arguments play with reality, asking the reader to conceive of possible worlds, filled with everything from Descartes’s deceiving demons to brains in vats. Such speculation is not unproductive, as it points to logical inconsistencies in commonsense understandings of knowledge. But because philosophy’s “central terrain remains conceptual rather than historical or empirical” (Collins 2000, 880), its theoretical toolkit distorts our understanding of how the epistemological problems are solved in practice,12 as it lacks empirical grounding, is largely normative in nature, and is biased toward an individualistic view of knowledge. I seek to consciously relocate the discussion of epistemology from the rarefied air of philosophy to sociology by identifying the on-the-ground practices through which actors achieve epistemological change.
To do so, I develop the concept of the epistemic contest. An epistemic contest is one in which actors, advocating competing understandings of reality and the nature of knowledge, struggle in various realms to achieve validation for their epistemological systems, or what Ian Hacking (1985) calls “styles of reasoning.” Epistemic contests are a specific intellectual type of debate in the larger “politics of cognition” (Zerubavel 1999, 22). At stake are such questions as: What is the nature of truth? What constitutes legitimate knowledge? How can such knowledge be acquired? How can beliefs about reality be justified, and who can be considered a legitimate knower? While they become manifest in controversies over specific knowledge claims, epistemic contests operate on a more fundamental plane, involving debates over which approach to knowing represents the most promising way to truth, and in turn, demands societal investment.
In this case, allopathic physicians and alternative medical movements not only debated specific knowledge claims (e.g., what is cholera?), but indeed the very nature of medical knowledge (e.g., what constitutes a medical fact?). As such, I use this particular case to explore how collective actors struggle over epistemological claims in an environment bereft of shared epistemological assumptions, identifying a number of strategies and factors that shape the outcome of such a struggle. Not only do I retell the story of U.S. medical professionalization, but I also develop the sensitizing concept of the epistemic contest so that it might be used to examine cases where similar conditions hold.13 Identifying more or less generalizable characteristics of epistemic contests, I establish a framework to attend to the distinctiveness of knowledge disputes that go to the heart of what constitutes legitimate knowing.14
Epistemic contests are unique among knowledge disputes or “cognitive battles” (Zerubavel 1999, 44). Their distinctiveness stems from the depth of the challenge to knowledge they involve. Rather than debating the merits of a particular claim vis-à-vis a system of agreed-upon standards, epistemic contests involve fundamental debates over the standards themselves. Their unique character is evident when compared to Gieryn’s (1999) concept of the credibility contest, to which I am indebted. In his sociology of science downstream, Gieryn examines the cultural and interpretive work performed on an idea in the public arena. His examination of credibility contests focuses on boundary work by which actors discriminate science versus nonscience. In the cases Gieryn examines, there exists a preexisting shared valuation of science—a basic agreement on the epistemic value of scientific knowledge—in which advocates of ideas want to be included.15 In other words, there is epistemic consensus; the disputes in credibility contests revolve around whether particular claims can be said to conform to these agreed-upon standards. While epistemic contests involve issues of credibility, they are broader and more basic, incorporating questions as to what is the legitimate way by which people come to know reality. Preexisting epistemological agreements are absent, and science may be only one of the many epistemological systems involved.16 To clarify this distinction, two experts debating over the interpretation of experimental evidence is not an epistemic contest; two individuals debating the legitimacy of experimentation is. The concept of epistemic contests shifts attention to debates in which more elemental issues of knowledge are at stake, not just who can speak with scientific credibility. Indeed, as epistemic contests involve situations lacking common cultural assumptions, they are waged through diverse strategies that contain both organizational and cultural components. Therefore, in reconstructing the epistemic contest over nineteenth-century medicine, I avoid the false dichotomy between organizational and cultural practices, revealing how the strategies adopted by collective actors in epistemic contests contain elements of both, and by extension, suggest that all knowledge disputes, even those read as solely cultural, do as well.
Every epistemological system contains a working model of what constitutes legitimate knowledge, the method(s) by which such knowledge can be attained, and the general ethos and identity that legitimate knowers should possess in relation to knowledge. They outline the assumptions that guide knowledge production and adjudicate competing claims. Epistemological claims therefore can be made along a number of dimensions. Actors can aver epistemic authority on account of the content of their knowledge, arguing that their possession of a body of knowledge legitimates a privileged epistemic position. Or epistemic authority can be rooted in claims to possess the method by which knowledge is produced. Methods-based claims can represent some sort of abstract ideal, like the scientific method, or more specific forms of technical acumen, like the technical know-how to process certain forms of information. Finally, epistemic authority can be justified along the lines of the orientation or ethos the group assumes toward knowledge. This ethos typically underwrites claims to epistemic au
thority based upon objectivity, where appeals to disinterestedness, trustworthiness, and a “view from nowhere” (Nagel 1989) become common tropes by which actors claim epistemic authority. Naturally, in practice these dimensions overlap, but it can be useful to parse them analytically, as the specific way in which claims are made shapes the strategic choices of actors.
However epistemic authority is framed, the concept of the epistemic contest directs attention toward conflicts among competing epistemological systems. Such conflicts, though not commonplace, are particularly disruptive. Epistemological assumptions form the core of the taken-for-granted world. These ever-present criteria for assessing beliefs inform and determine the manner in which individuals make sense of reality. In most cases, they remain unarticulated. Individuals do not need to be able to articulate justificatory arguments in order to employ them in the pursuit of knowledge (BonJour 1978). Such standards are institutionalized in the social practices of knowing however internalized and unconscious they may become. They are rarely questioned, much less discarded. For this reason, knowledge disputes typically do not operate on the level of epistemology. But when they do, the urgency of the debates is intense.
To overcome the inertia of commonsense thinking, epistemic contests require certain conditions. Crises and major disruptions are often necessary in establishing opportunities for epistemic contests, but they are not sufficient. In the case of American medicine, cholera led to an epistemological crisis; the great influenza did not. Still, even with such exogenous crises, it takes significant work to destabilize epistemological assumptions—work performed by actors competing for recognition as legitimate knowers. The stress on the agency of actors in waging epistemic contests is paramount. Context matters, but it is what actors do that affects the trajectory of epistemic contests. It is true that the epistemic contest over medicine was enabled by certain long-term structural changes in the United States during the nineteenth century. And it is true that the arrival of cholera created a sense of panic and urgency that exposed some fundamental fissures within allopathic medicine. But neither was decisive in creating an epistemic contest. Rather, as I show, alternative medical movements seized the opportunity cholera provided to demand that allopathic physicians give an epistemological account of their authority as knowers. They forced the specific medical debates that cholera elicited onto the level of medical epistemology, thus shaking the foundation of allopathic medicine and giving birth to a nearly century-long struggle over what medical knowledge consists of. Cholera offered alternative medical movements an opportunity to assert themselves vis-à-vis allopathy. They transformed it into an epistemic contest.
