Knowledge in the Time of Cholera (41 page)

This distinction becomes evident when comparing the process of medical professionalization in the United States to that of other national contexts. While claims to American exceptionalism are often rife with exaggerations and normative assertions, the American medical profession has in fact departed from its peers in other Western democracies. The most obvious—and politically contentious difference—is its approach to health insurance, where “the United States stands out for the virulence of its political battles over health care” (Starr 2011, 1). Prior to the passage of the Patient Protec
tion
and Affordable Care Act (PPACA) in 2010, the United States was the only advanced country to lack a government-mandated system for universal health care. And even the mechanism by which PPACA seeks to achieve universal coverage is unique in that it does so largely through the private sector. The country's approach to medical insurance is in great part a reflection of the profession's adamant opposition to government intervention in medicine.

The absence of some sort of government-backed mechanism to achieve universal health care coverage is not the only way in which the U.S. medical system diverges from other developed countries. The American medical profession is also exceptional in its focus on technologically intensive medical services, its commitment to specialization, and historically, its embrace of the germ theory. To an extent unusual in the early twentieth century, American medicine was built around the promises of technological fixes, a tendency that has been exacerbated over the years by the structure of U.S. medical economics, which favors expensive technological interventions (see Birenbaum 2002, Clarke et al. 2003).

I have labored to show that the U.S. medical profession's embrace of the epistemology of the laboratory and its suspicion of government institutions—the source of much of its exceptionalism—resulted from the specific trajectory of the epistemic contest. This argument raises a critical question when teasing out the relationship between epistemological change and professionalization: if all Western countries eventually embraced the laboratory sciences, why did this epistemic shift yield such different organizational/professional outcomes in the United States? Doesn't it undermine the significance of the relationship between professionalization and epistemic change if similar epistemic outcomes lead to different professional ones?

The answer, I argue, is not really. While it is beyond the scope of this book to offer a comprehensive comparative account of professionalization in different contexts, a few comments are in order. First, as the status of the United States grew in the world, so too did its medical influence over other countries. It became a major exporter of the epistemology of the laboratory, and its doctors global emissaries for the lab. The worldwide adoption of this epistemology resulted in part from the U.S. epistemic contest, which created a profession whose very identity hinged on the laboratory and offered a vision that was exported to other countries via philanthropic projects. Second, the epistemological similarity between different countries
leads
many to gloss over real differences in the
extent
to which physicians in other nations embraced the epistemology of the laboratory. My argument vis-à-vis the exceptionalism of the U.S. case is a matter of degree, not kind. All Western countries eventually adopted the epistemology of the laboratory, but none with as much fervor as the United States. The germ theory became “gospel” in the United States (Tomes 1998) to an extent unrealized elsewhere. This degree of commitment reflected the particular nature of the epistemic contest in the United States. The identity of the medical profession in the United States came to be built on the laboratory; this was simply not the case in other countries (e.g., England), where professional political dynamics differed. While other countries demonstrated a greater emphasis on public health, general medicine, and prevention, the U.S. medical profession poured its energies and optimism into scientific medicine, as the laboratory justified the profession's power. Therefore, while there was overlap between national contexts (partially due to the fact that they were not isolated from each other), the trajectory of professionalization in each country contained its own idiosyncrasies that subsequently became inscribed in their medical systems.

Ultimately, the relationship between epistemic contests and professionalization is a historically contingent one, not a necessary one. The exceptionality of the U.S. medical system emerged out of (and can only be understood as resulting from) the unique history of its epistemic contest. This epistemic contest—with a strong democratic culture resistant to professions, active challenges by alternative medical movements, and eventual consolidation through the unique system of U.S. philanthropy—meant that the epistemology of the lab became linked to a suspicion of government intervention. But this was a specific outcome, contingent on a specific confluence of factors.

The professionalization of medicine in other countries did not involve epistemic challenges of the same nature or intensity. Context matters. The way in which different constellations of actors intersected in the political, social, and cultural systems of various countries affected the degree to which bacteriology mattered for the organization of medicine.
⁴
For example, in Great Britain, the medical profession evolved along class lines (Shortt 1983). Elite physicians shared a background with government elites and always had their support. Although initially questioned for geopolitical reasons, the germ theory was folded into the existing professional hierarchy that had long-standing support from the state. In France, the germ theory was em
braced
first by a strong central government, which, given its reach, brought reluctant doctors along (Latour 1988). Indeed, the process of medical professionalization in France was carried out
through
the state, occurring much earlier than in the United States (see Ellis 1990; Geison 1984; Goldstein 1990; Weisz 1978). In other words, the adoption of bacteriology and the epistemology of the lab in England and France did not have the professionally trans-formative character that it had in the United States. In fact, of the developed Western European countries, only Germany had a medical profession that demonstrated a similar wariness toward working with the state. This reluctance, however, was resolved during the nationalistic run-up to World War I (Kater 1985). In the end, although rigorous comparative research on the professionalization of medicine in different countries is needed to tease out the nuances of these differences and similarities, the history presented in this book demonstrates the unusual extent to which the professional politics of U.S. medicine were animated by basic epistemological issues. In no other country did medical professionalization involve either the same epistemic dimensions present in the United States and/or the same hostility from state institutions.

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 con
tests
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?