by Owen Whooley
When professionalization and epistemic contests do overlap, as they did in the case of nineteenth-century medicine, we ignore epistemology at our peril. In these cases, actors must negotiate a confusing hodgepodge of competing knowledge claims. They are forced to deal with epistemological issues that, though ever present, are normally taken for granted. To navigate uncertainty in knowledge, we have institutionalized epistemic standards that supply a structure or framework by which actors can discriminate good “truth” from false “belief.” These ever-present criteria for assessing beliefs inform and determine the manner in which individuals make sense of reality. In most cases, for most people, these criteria remain unarticulated. An individual does not need to explicitly know justificatory arguments to employ them in the pursuit of knowledge (BonJour 1978). Rather standards are institutionalized in the social practices of knowing.
The concept of the epistemic contest is intended to shed light on those moments of crisis when epistemological standards break down and become contested. It seeks to sort out how certain ways of knowing (“habits of reasoning” [Peirce 1955,123]) become socially established, how actors wage struggles over epistemology, how epistemic closure is realized, and how emergent epistemologies become institutionalized in organizations. Epistemic contests are a particular type of knowledge dispute, in which actors, advocating competing understandings of reality and the nature of knowledge, struggle in various realms to achieve validation to their approach of knowing. They involve questions such as what constitutes a fact; by what standards can true knowledge be distinguished from false belief; what are the conditions by which claims could be said to be justified; what is the relationship between the observer and the external world; and who can be considered a legitimate knower. Thus, rather than debating the merits of particular knowledge claims vis-à-vis a system of agreed-upon standards—as most knowledge debates do—epistemic contests engage with the standards themselves.
Put differently, rather than playing in a game with established rules, those involved in epistemic contests are fighting over the rules themselves. In this sense, epistemic contests are more encompassing, more fraught, and more open-ended than typical knowledge disputes, like credibility contests (Gieryn 1999). They are not just about drawing cultural boundaries between science and nonscience; they are about establishing the parameters for truth and falsity. In turn, the logic of action that epistemic contests compel is different from other forms of knowledge struggles. Actors in epistemic contests must do double work; they must find ways to justify both their particular truth claims and the epistemic assumptions embedded in those claims. In the case of nineteenth-century medicine, competing medical sects not only had to promote their ideas regarding cholera but also had to fight for the assumptions about the nature of medical knowledge that undergirded their ideas. Rather than fighting for credibility within an established, shared system of epistemic values, medical sects engaged in fundamental debates, whose contours were ill-defined.
The openness of epistemic contests results in a wider array of strategies deployed. One of the striking elements of the history of the epistemic contests in the United States is the extent to which the various medical sects deployed organizational strategies to promote and solidify their epistemological positions. The sociology of science downstream focuses on cultural strategies like boundary work (Gieryn 1983, 1999), performance (Hilgartner 2000), and rhetoric (Gilbert and Mulkay 1984), which are certainly but by no means sufficient in waging epistemic contests. Epistemic contests are not waged by cultural means alone. Indeed, because epistemic contests occur in a densely populated organizational terrain, organizational strategies become very important as actors try to harness organizations to legitimate their epistemological systems. One way stakeholders adjudicate knowledge claims in epistemic contests is through organizations, which stamp some knowledge as legitimate and others as outside of the realm of consideration. This is most evident in chapter 2, which discusses how the establishment of the AMA and the institutionalization of a no consultation clause represented an attempt to address the problem of adjudication via organizational practices in an environment bereft of epistemic standards. Organizational formation, in this case, represented an epistemological strategy. The upshot of this analysis, therefore, is that the nature and trajectory of epistemic contests can only be understood as emerging from the interaction between cultural and organizational practices.
These strategic interactions are always embedded in particular contexts, or arenas, that affect their outcomes and the trajectory of epistemic contests more generally. In considering different epistemologies, it is important to avoid the tendency to reify them as free-floating intellectual systems. Rather, they are arguments that arise in particular institutional settings, settings that influence the degree to which they are embraced or rejected. For example, the context of the state legislatures affected the epistemic contest over medical knowledge in that legislatures were more sympathetic to the democratized epistemologies of alternative medical sects. In a sense, the entire epistemic contest over nineteenth-century medicine can be read (without doing much damage to the nuance of the analysis) as a failed struggle for regulars to achieve a privileged position in government institutions that were committed to democracy in knowing and therefore suspicious of regulars’ professional aspirations.
The metaphor of a contest is therefore intentional. Epistemological systems do not originate fully formed. Rather they arise through competition and the strategic interaction among actors. This book offers an account of the development of medical knowledge through conflict. Poked and prodded by alternative medical movements, regulars were forced to provide an epistemological justification for their authority. Recognizing the problems with rationalism, reformers adopted first radical empiricism, and later an epistemology based on the laboratory. Alternative medical movements responded to these reforms and the strategies that followed from them. Epistemic change followed the give-and-take strategic dance between competing actors. The concept of the epistemic contest is thus situated in a broader call for sociology to take seriously the analysis of embedded strategic action (Jasper 2006).
RETHINKING AMERICAN MEDICAL PROFESSIONALIZATION
The benefit of examining the epistemological foundation of the professionalization of medicine in the United States is that it leads to empirical findings that help flesh out our understanding of the U.S. medical system and the precarious place it finds itself in today. The proof of a framework’s usefulness is in its explanatory pudding. What does looking at this case of professionalization through an epistemological lens tells us empirically that we would not have seen otherwise?
First, and most broadly, the analysis in this book specifies the mechanisms that undergird the macro-cultural account of U.S. medical professionalization. It eschews the analytical laziness of labeling an era and calling it an explanation. By focusing on practice, it allows for the identification and explanation of the human action that comprises such macro-cultural shifts. Certainly the cultural changes that accompanied the Jacksonian era played a role in creating an environment conducive to the epistemic challenge mustered by alternative medical movements. And undoubtedly the burgeoning acceptance of expert knowledge during the Progressive period was favorable to the reform of American medicine through the laboratory, exemplified in the Flexner Report. But these general shifts are not sufficient enough to tease out the nature of professionalization, or even to understand its course. Macro-cultural arguments may provide some basic contours of the narrative, but their lack of specificity leaves much of the story untold. By moving to a meso-level analysis, this book shows how large-scale cultural shifts operate through specific practices in specific settings. Rather than making a broad appeal to the culture of the Jacksonian period, it shows the ways in which the types of epistemological visions proffered by homeopaths and Thomsonians resonated in certain government institutions. Culture, in turn, is no longer conceived as something external, hovering above soc
ial action that sets the context, but as something produced and reproduced in practice.
Second, this book stresses the essential role of alternative medical movements in the development of medical knowledge. Rather than mere curiosities or, worse, repositories of errors, alternative medical movements emerge from this analysis as crucial. In addition to any specific intellectual influences they had (e.g., convincing regulars to discard heroic therapies like bloodletting), by forcing regulars to legitimate their professional claims in epistemological terms, these movements drove changes in medical knowledge. In other words, because epistemological positions arose from contentious struggle, the influence of alternative medical movements was manifest in the outcome of the epistemic contest. The crucial role played by alternative medical movements has been woefully underestimated in the dominant histories; alternative medical movements drove developments in medical knowledge through their dynamic, magnetic relationship with regulars. This case, then, points to the potential of social movements to play a more substantial, if more subtle, role in influencing knowledge than is typically recognized. Research on “scientific and intellectual movements” reveals the important influence of movements in scientific-knowledge-producing institutions, like research universities and scientific disciplines (Frickel 2004; Frickel and Gross 2005). However, because it largely restricts its analyses to autonomous scientific fields in which activists are forced to conform to scientific epistemic standards so as to portray themselves as credible knowers (see Epstein 1996), this body of research overlooks the potential influence of social movements in fundamental epistemological debates. In less autonomous fields, like medicine, or in fields experiencing epistemological flux, social movements like homeopathy can engage in “knowledge advocacy” on fundamental epistemological grounds (Whooley 2008), offering “epistemic challenges” as they are less pressed to debate the issues on the field’s own terms (Hess 2004). In other words, the analytical frame here allows for a wider recognition of the “cognitive praxis” (Eyerman and Jamison 1991) of social movements, one that penetrates to the level of epistemology.
Third, this book clarifies the nature of the alliance between elite philanthropies and medicine by revealing the epistemological affinity between the bacteriological laboratory and Standard Oil’s incorporation of chemistry laboratories in its industrial operations to gain a competitive edge. Typically, the alliance is reduced to simple class terms. For example, according to the account offered by E. Richard Brown (1979), Rockefeller adopted medical science as his philanthropic cause both to improve his public image in the wake of damaging labor disputes and because the laboratory portrayed problems as technical issues amenable to expert intervention, rather than general social problems of inequality. These dimensions undoubtedly were at play, but they do not explain why Rockefeller chose medicine specifically, and they overstate the degree to which the alliance was forged on the basis of crass class politics. By illuminating corporate scientific practices, long neglected in the sociology of science (Penders et al. 2009; Shapin 2008), this analysis transforms Rockefeller from a mere cunning capitalist into a cunning capitalist who pioneered the integration of laboratory sciences in industrial practice. His efforts to integrate the laboratory mirrored the efforts of bacteriological reformers, with whom Rockefeller shared an epistemic affinity. And it was upon this affinity that a mutual alliance between the AMA and private interests was built.
The final historical correction that this book achieves relates to this last point. Regular reformers were able to translate this affinity for the laboratory into an alliance that enabled them to circumvent state legislatures to acquire the sufficient funds for their professionalization project. The decision to build the laboratory with private resources allowed regulars to avoid the public institutions that had rejected their professionalizing impulses for decades. Indeed, the desire to circumvent the government institutions was evident as early as the 1870s, when regulars lamented, “Legislative enactments in the various States of this Union clearly show that no reliance can be placed on either the uniformity or permanency of any laws now relating to the practice of medicine” (Medical Society of the State of New York 1870, 39). The “melancholy illustration” (Hutchinson 1867, 56) of continual failures in its legislative agenda led the AMA to seek an alternative route to professionalization, one that skirted government institutions. In its very establishment, the modern U.S. medical profession expressed hostility toward government intervention and wariness of working through state legislatures. This points to an earlier emergence of the AMA’s antigovernment sentiment—and its corresponding embrace of private interests—than is typically acknowledged in historical accounts of the U.S. profession. Most histories of the U.S. debates over health care trace the AMA’s wariness of state intervention to the World War I period (see Numbers 1978); their histories start in 1915 (see Starr 2011). This finding is more than the mere dating of a phenomenon. I demonstrate how the antigovernment sentiment was present in the very founding of the profession and as such, institutionalized in its professional culture. Given that regular physicians achieved professionalization in spite of the state, the hostility toward government intervention was inscribed in the very DNA of the profession. The strategy of achieving their ends through private means became a tried-and-true one postprofessionalization, one with a history of success. Thus, the exceptionalism of the U.S. medical system in its rejection of government intervention, on display most glaringly in the AMA’s persistent campaign against government-run health insurance, has its roots in the manner in which the epistemic contest over medicine played out in the nineteenth century.
To be clear, I am not suggesting that the entirety of the muddled and vitriolic history of health insurance reforms in the United States is solely the result of the epistemic contest; I am not offering a mono-causal account of the decidedly peculiar U.S. medical system. Health care politics in the United States are exceedingly complex, and to attribute the entirety of this complexity to a single factor would be audaciously reductionistic. A number of factors (e.g., a weak labor movement, an impotent socialist political party, the federal system, resistance from insurance companies, a cultural of individualism, etc.) contributed to the long-standing resistance toward government-led health insurance. Indeed, the AMA, with its suspicion of government intervention and its early alliance with private industry, played an important role in shaping this system, but it was only one interest among many (albeit an important one). Furthermore, the U.S. health care system has experienced a number of dramatic organizational changes (Scott et al. 2000), character redefinitions (Light and Levine 1988), and market shifts (Timmermans and Oh 2010) since World War II.
In recounting the “peculiar” history of health care politics, Paul Starr (2011) outlines a two-stage model of the politics of U.S. health care. During the first half of the twentieth century, the politics were driven largely by interests groups, especially the AMA, which rejected government incursion into medicine, often framing such oppositions in terms of anticommunist ideology. This early era established the “script” for health care debates for the rest of the century, as evidenced by the repeating tropes of “socialized medicine.” During the second period, dated roughly from the 1950s, politics were constrained by what Starr (2011) terms a “policy trap.” In other words, the debates of the last half century have been constrained by the original mishmash of policies from the first half. Rather than approaching the issue broadly, the terms of the debate narrowed significantly, making broad reform efforts increasingly impossible. Accepting Starr’s two-stage model of the history of U.S. health care reform efforts, the legacy of the epistemic contest was felt most strongly during the first period, when the AMA established itself as a staunch opponent to government-led health insurance.5 It was during this time that the AMA’s wariness of the state—the legacy of the epistemic contest—dominated the rationale of the AMA. Only a few decades removed from the wide open medical market of the nineteenth century, allopathic pract
itioners were unwilling to cede any of their hard-won professional authority, especially to government entities that had repeatedly denied the legitimacy of this authority on democratic grounds. Of course the politics of the new era were different; the more sedate politics of the Progressive Era had supplanted the woolly democratic experiments of the Jacksonian period. But the wounds remained for regulars, and having achieved epistemic closure in spite of the state, the AMA was unwilling to let it back in and fought tooth and nail against such a fate.
Insofar as the AMA was one of the most powerful stakeholders that successfully defeated early reforms efforts (Quadagno 2005), which later set the script for health care debates, and insofar as this oppositional stance was born of the epistemic contest, we can see the long shadow cast by nineteenth-century epistemological debates inscribed in the modern U.S. health care system. By attending to issues of epistemology and investigating the professionalization of U.S. medicine as a case of an epistemic contest, this book offers a more exacting account of the history of the American medical profession—one that tells us as much about the present as the past.
