 Good afternoon. I'm delighted to welcome you to today's meeting of the McLean Center professionalism series. As I told you last week, we're delighted that today professor Andy Abbott can join us. You may recall that he and Dr. Ross made this switch of their time timing because Professor Abbott was called away to Versailles to accept an honorary degree in the fall and Dr. Ross kindly stepped in and gave her talk at that time five months before I told her we needed to talk ready. But today today we will hear Professor Abbott speak on sociologist as moralist, Elliot Freidson, and the concept of professionalism. As many of you know, Dr. Abbott is the distinguished service professor, the Gustavus and Anne Swift distinguished service professor of sociology. He's been a master of the collegiate social science division, chairs chaired the Department of Sociology here, widely published many books including Chaos of Disciplines, Time Matters, and a book entitled The Systems of Professions. So it's with a special delight we don't we don't have an academic robe to give you today and to welcome Professor Abbott to our seminar. Thanks very much. Get out the correct set of glasses here. Thanks, Mark. I'd like to say first again for myself thanks to Lani Ross for kindly switching places with me in order to deal with my scheduling difficulties. She told me earlier she'd be happy to go to France next time. So it rained, you'll be. At least I got that. But in any case, professionalism is shown not only in the big gestures and the moral dilemmas, it's also shown in small things and this is a fine example. So thanks. More broadly, I'd like to thank Mark Sealer for inviting me to speak to the seminar and that for several reasons for three really. First, it brings me back for a talk in hospital buildings in which I undertook my first ethnographic efforts. Second, it provides an occasion to write about the late Elliot Frydson who shaped the study of professions decisively. And third, it allows me to address an important topic that's quietly clamored for my attention like a child overlooked while one dealt with a troublesome sibling. So let me expand on those three avenues of thanks. They provide kind of different routes into my central topic of concern. First of all, the return to Billings Hospital. 40 years ago when I arrived at Chicago as a graduate student, I was vaguely interested in psychiatry as a knowledge system. My advisor, Morris Janowitz, immediately put me into the field observing life in the outpatient psychiatry clinic, some Bob's three here, at which as it happened, four members of the Department of Sociology were then patients. That's the days before IRBs. So I sat in the waiting room coding patient data and observing waiting room. He's gonna like that one all night. I attended staffings. I talked with the Morris Chattie residents and attendings. And as I got to know people better, I began to sit in on diagnostic interviews and supervision sessions. Later that year, I observed the clinic's special therapy sessions for the victims of one of Chicago's great trauma events, the Illinois Central train wreck of 30 October 1972, 45 fatalities, 300 or 400 injuries. So often happens, I was unable to see what was important about the events in front of me. And so to clarify my thinking, I decided to compare the use of psychiatric knowledge in the clinic to the use of psychiatric knowledge in what was then the largest mental hospital in the state of Illinois, Mantino State Hospital about 40 miles south of here. In the event, the contrast between the ambitious, brilliant, and successful professionals at Billings and the often unlicensed defrocked or disbarred professionals at Mantino could not have been more marked. Indeed, it may well be that my disattention to professionalism as a topic originated in this intense contrast for the mantino world with its desperate realities of psychosis and senility, crime and corruption seem somehow more authentic than the delicate hot house here at Billings where gifted people treated equally gifted patients where professionalism meant subtle moral decisions rather than deciding who was responsible when a mantino patient when we gave a home visit, chopped up his wife in pieces, put the pieces in the trunk of the car and sank the car in late Calumet. A return to Billings is then a return for me to a world before that kind of ugliness to a world in which the morality of his true professionalism seems a near possibility rather than an impossible luxury. Second, a few words about my personal need to honor Elliot Frydson. I encountered Frydson's work soon after the beginning of my field research at Billings. I read his wonderful book, Professional Medicine, one day in the Old Chicago Public Library, and I realized as one so often does in the early days of graduate school that someone had already written one of the books that I had imagined I would someday write. Throughout my years at Mantino and afterwards while I wrote my dissertation on the history of American psychiatry, Frydson remained for me the most important sociologist of professions. Eventually I wrote a book about professions myself and inevitably Elliot was one of the referees. Now the other referee was a younger man who spent most of his comments correcting this and belittling that. But Elliot, who was then in his early 60s and struggling to synthesize his own thoughts about professional life, wrote comments that were unfailingly supportive even when they were critical. I can still remember reading his comment that the book was not so much a theory of professions per se as a theory of the division of labor. I felt just like Monsieur Joudin. Gosh, I've written a book about the division of labor. Wow. It cannot have been easy for Elliot to read a book giving a general theory of something that he was himself at that time in the midst of theorizing, but he did it with a grace and warmth that proves that he not only studied professionalism, but lived it as well. It's an example one does not forget. This brings me to the third of my reasons for thanking Mark that he's provided me with an occasion to address that quiet but troublesome topic that is the moral theory of professionalism. We can enter upon that topic by fleshing out the last comment I just made about Elliot Friedson that he not only studied professionalism, but lived it as well. That sentence presumes a distinction between professionalism as an object of analysis, and professionalism as a personal commitment, and the quiet but troublesome topic that it raises is precisely the relation between professionalism understood as an object of sociological study, and professionalism understood as a form of moral commitment. Now this problematic relation is quite recognizable in my own work on professions. After all, I've written a book on professions of which it's been said that quote, anyone seeking to study the professions after reading Abbott's book had difficulty imagining they could say anything new that had not already covered. Yet I've never addressed a professional association on the subject of how that profession ought to behave. I've explained professional history to social workers and librarians, I've given strategic advice to occupational therapists, I've predicted the future to information scientists and to military officers. But I have never addressed a professional association about the moral obligations and duties of professions. Indeed, the only talk I've ever given about professional ethics in 1983, debunked professional ethics as a monopoly strategy and a largely symbolic purity ritual. Yet this is not because I do not myself believe in professionalism as a moral phenomenon far from it. I not only believe in professionalism, I live it on a daily basis. At the American Journal of Sociology where I've just come from, I expect my reviewers to tell me if they've read a submission before or if they know it's author or if they gave him advice on the paper. When supervising students, I make them undertake detailed research that will never appear in print merely to teach them that readers have to be able to trust them to have done such things. When I submit my own work to journals, I expect colleagues to set aside their professional prejudices as I do when I read theirs. All of these are moral aspects of professionalism that I not only expect in others but undertake for myself. I don't think them symbolic purity rituals at all. They're not only the way I expect my professional world to work, they're the way I think my professional world ought to work. Now to a medical audience, this disjunction between what I say about the professions in my writing and how I live as a professional may not seem to matter all that much. After all, a doctor aims first and foremost to treat patients' illnesses, not to say something which will be regarded as warrantable knowledge by a community of scholarly colleagues. If one treatment succeeds in one case and a quite different treatment succeeds in another, the doctor chucks the result up to chance or good clinical judgment and goes on to the next patient. But for a sociologist with the ambition to produce a cohesive and ultimately coherent body of work, such a disjunction is a major embarrassment, as if he were a clergyman preaching one gospel and living another. Now my label for this particular disjunction is going to be the phrase knowledge alienation. Knowledge alienation is endemic in the social scientists, sciences. As social scientists, we're in the business of explaining other people's behavior. But as humans, we live our own lives as if we were free moral beings, Kantian individuals. We don't explain our lives, we live them. It's other people's lives that we explain. Explanation plays no role in our own living, except in the Machiavellian sense. We use our skill at explanation to predict what may result from this or that act that we plan. But those predictions don't determine whether we feel we ought to do such an act or not. For social scientists, that latter question belongs to the realms of politics or morals or whatever else, all of them areas that we've agreed to separate from academic inquiry. Political science, which has a subdiscipline of political theory, is the only exception in the social sciences to this separation of morality from empirical investigation. The rest of us make a very sharp separation between objectivity and advocacy. Now, a cursory glance at the literature on professionalism as an ethical system, i.e. stuff written by ethicists, reveals a quite equivalent phenomenon on that side of the fence. Books by ethicists on professional ethics contain only the most grudging references to scholars like Elliot Friedson and myself, who are dismissed as unworthy cynics. Changes in university discipline, Cain tells us, quote, especially in history and sociology, also have played a part in displacing the notion that professional practice serves the public interest, end quote. In the views of such scholars, she tells us, quote, professions have no inherent legitimacy. They're only a dominant ideology, ideology to be replaced when infers by institutions or practice that truly aim at the public good. But the fact that the moralists are as one-eyed as the sociologists doesn't change much. It remains the case that the world is both moral and empirical. And so we require a social science that can be systematically moral as well as definitively empirical. The question is how to do that. In the next half hour, I'm going to examine exactly how Elliot Friedson himself addressed this conundrum, which is central for every working social scientist. Perhaps by studying his example, we can learn something important. But before I analyze Friedson, it's perhaps useful to restate the usual method for resolving the problem of knowledge alienation, as I've called it. It's a resolution that's implicit in the phrase objectivity and advocacy. Objectivity comes first, then advocacy after. First, we undertake empirical analysis to discover what is actually going on in the world. Then that knowledge becomes input to some political or moral debate. Empirical results are deployed in those debates to justify assertions about the causes of morally or politically problematic states of affairs and to sustain inferences about predicted effects of various kinds of actions and policy interventions. Thus, psychological studies of children were deployed in Brown versus Board of Education. Thus, studies of occupational discrimination support the policies of the EEOC. Thus, focus groups of California teenagers inform the decisions of the fashion industry. Objective analysis comes first, then it's deployed as advocacy to influence policy debates. Now in practice, this supposed separation of objectivity and advocacy is nothing like complete. After all, the topics of social scientists are themselves shaped by the needs of advocacy. For example, inequality is only one of many properties of social systems, but American political needs, as well as scholars own political preferences, have made it the topic of well over half of the literature in my field for many decades. Or again, juvenile delinquency is a classification invented by the political and legal system, but sociologists often study it as if it were a natural category of social life. It is in fact impossible to avoid this confusion of the moral and the empirical, because the empirical topic of social science, human behavior, is itself largely constituted of congealed social values and moral activity. But because of this inevitable contagion between the world of is and the world of ought, the vaunted separation of objectivity and advocacy is always something of a mirage. Every social scientist has to find his way past that mirage, and perhaps by studying Freidson's approach, we can learn something important about the possible roots. So next bit, Freidson on professionalism. Elliot Freidson's analysis of this problem shifted drastically over his professional life, as Stephen Brent has noticed. Early in his career, Freidson focused on professional dominance. In those years, he regarded professional pretensions to transcendent values as so much ideology. Yet by the end of his life, Freidson had become an explicit defender of precisely those claims. He did this by adopting, but gentling, the position of Terrence Johnson, another early power theorist of professions. Johnson had argued that there were three modes of control of service work. Collegial, clientelistic, or mediative, depending on whether the work was controlled by service providers themselves, by clients, or by third parties. Johnson had seen all three of those as modes of simple exercise of power in the producer-consumer relationship. Now in his last book, Elliot Freidson argued somewhat similarly that there are three modes of control of work, which he called occupational, market-based, and bureaucratic. But he held that an essential part of the first form, occupational control, was a connection to transcendent authority, that is to an authority grounded in claims that are explicitly moral. This was what he called professionalism, a third logic, as the title of the book has it. Now before we go further, we need to be very clear about two rather different senses of the word moral. As anyone will know who's taken sociology 101, among the founding books of the field is Emile Durkheim's Division of Labor in Society. And you may recall, if you took that course, that Durkheim claims in the book to have turned moral activities of men into so much sociological data. Indeed, throughout his work, Durkheim claimed that he had discovered how to measure the moral life of a people. But this claims, this claim depends upon the customary French use of the word moral, to refer not only to what we would call in English, morality, the judgment of rights and wrongs, but also to denote that social spirit for which English speakers now use the French word moral. That is, the moral world that Durkheim measured was less morality than what we call moral, and the notion that we take from him that morality can be causally determined and be sociologically measurable inevitably involves a slide between two quite different French meanings of the word moral. So let's agree that for purposes of this presentation, I mean by the word moral, those things which are to be judged under the sign of right and wrong, that is, morality. I take it for granted that these things cannot be determined by antecedent social causes, that is, I take it for granted that in some sense any individual action always has some part that is judgeable in moral terms, but yet another way, no human action other than that which is physically coerced can be said to be without any component of free activity subject to moral judgment. So I'm taking some level of freedom to be inherent in human action and I agree that we judge that free action in moral terms. That much it seems to me is an empirical fact. Now whether those moral terms are transcendent in some special sense is quite another story. So far as we can tell, morality is simply a premise of human activity. As a symbol using species we simply happen to have deployed one symbolic register which we call oughtness or something like that, which we use to judge actions. Men have expanded or shrunk that register in different societies and cultures in which they've lived, but we've always had ideas of oughtness and we have always separated them from concepts of determination. It's just like right and left. It's a premise of difference that can't be explained in terms of some other combination of other things. It's just a primitive fact in human experience. Now it was this specifically moral register towards which Freyzen changed his view over his professional lifetime. As I noted earlier in his forties, Freyzen saw professional claims to transcendent moral legitimacy as claptrap. They were intentional, to be sure, but intended for the reason of professional dominance. They were moral, to be sure, but morally questionable because their intent was self-serving. They were not transcendent, but determined by obvious causal forces and to the extent that they were moral, they were dubious if not simply wrong. Now I took much the same view in my own early writing about professional ethics code. It seemed clear to me 30 years ago, as it does today, that the AMA Ethics Code originated in the 1840s in some sense to facilitate competition with the homeopaths, the botanicals, and the other medical personnel who were causing so much trouble for American allopaths in the Jacksonian era's free competition over treating people's ills. It certainly had that protective function and no doubt some allopaths must have seen it in just that light. But no doubt many more allopaths were quite genuinely persuaded of the moral evil of homeopathy, even if we now know that the homeopaths had a better record than the allopaths with respect to eatrogenic mortality. It's perfectly possible to have been morally committed in good faith to a policy whose main functions turned out to be self-serving. It's this kind of conundrum that over his career Freidson came to recognize and rethink. He was in part driven to this view by the spectacular decline of medical dominance. The proud aristocratic medical profession of the middle of the 20th century, which had decried Medicare as socialized medicine and bristled at the faintest hint of extra professional regulation, had become by the latter days of Freidson's career a shadow of its former self. Most doctors were employees, often of non-medical corporations. The length and type of treatment were dictated by medical criteria set by external bodies. The profession was overawed by the collective might of the government's pension plans and health plans who were the collective payers of America's medical bill. The national medical situation was embarrassing no matter whether you looked at it in terms of cost, distribution of care, patient satisfaction, or even some of the basic mortality and morbidity measures. In this world of powerful actors mostly dedicated to the bottom line, the medical profession's interest in its patients must have seemed to Freidson a basic resource for improvement. He must have felt that he and those of us who'd followed him had in our judgment of the medical profession thrown out the baby with the bathwater. This feeling led Freidson to found his later work on a question that my own book had done its best to demolish, the question of what is a profession. Now I had thought this question worthless because from the sociological point of view it was a purely ideological question. It was asked only by professions themselves and only in order to judge life worth claims to status eminence. We are a profession you aren't. The real question for sociologists was not what is a profession but how is expertise institutionalized in society? A question to which I said there were three answers in things, in organizations, or in people. The sociology of professions is concerned with the last and in the book System of Professions I'd set myself the task of explaining all the dynamics by means of which such occupational control of work grows, changes, and dies. That this sometimes involved the claim of being a profession was merely one of many contingencies. So I rejected the term profession and tried to focus on expert occupations, a term with no special connotations, no political and status power, and hence nothing to disturb its definition in purely sociological terms. Freidson however returned to the what is a profession question a sign of his insistence on directing, directly addressing the moral claims of professions. He answered this question with what Max Weber would call an ideal type. That is he defined professions by an abstraction, a thing never exactly observed, but created by raising the qualities or characteristics of numerous observed cases to some kind of definitional strength. Throughout the book he compares his ideal type of professionalism to the celebrated ideal types of his two other forms of control of work, managerialism in Max Weber's ideal type of bureaucracy, and consumerism in Adam Smith's ideal type of a free market. In Freidson's view professions had five characteristics. Number one specialized work in the officially recognized economy that's grounded in a body of theoretically based discretionary knowledge or skill, and that's accordingly given a special status in the labor force. Number two, exclusive jurisdiction in a particular division of labor that is created and controlled by occupational negotiation. Three, a sheltered position in both external and internal labor markets based on qualifying credentials created by the occupation itself. Four, a formal training program lying outside the labor market which produces the credentials which is controlled by the occupation and which is associated with higher education. And five, an ideology that asserts greater commitment to doing good work than to economic gain and to quality rather than economic efficiency. Now this ideal type was ideal in both senses. First it was an ideal in the empirical sense that such an occupation is almost never observed and certainly it was an ideal type in that this was more or less a thinly veiled idealization of mid-century American medicine and law. It was an abstraction created quite simply by extending the characteristics of well-known and obvious cases. But it was also an ideal type in the moral sense of the word ideal for it used explicitly moral language. Thus in the first characteristic we have the phrase officially recognized economy and given a special status in the labor force both of which are descriptions of moral political states of affairs not empirical ones. In the second characteristic we have the idea of exclusive jurisdiction, an idea that took me 400 closely argued pages to turn from a loose moral phrase into a defensive and specified empirical one. In the third characteristic we had sheltered position, a term used with strong negative moral overtones throughout the labor market literature. And finally in the fifth quality we have his uncompromising statement of ideological commitment, a statement whose accuracy as an empirical description of American medicine has been debated since the first arguments of biomedical specialization in the 1930s. It's at once clear then that this definition is not an empirical ideal type at all but a moral specification, an ideal of how an occupation called the profession ought to be organized. Having set out this moral ideal in his first five chapters, Frydson takes two chapters to discuss what he calls the contingencies of professionalism. Here he speaks of the effects on professions of state intervention. He first distinguishes activist and reactive states, states that initiate professionalization versus states that respond to efforts by rising professions themselves. He also distinguishes hierarchical and coordinating states as he calls them, states that develop administrative structures to manage professions versus states that simply legitimate and coordinate the affairs of the professions themselves. A second chapter in this contingencies part of the book conducts a similar analysis of professional knowledge, looking at the vicissitudes of that knowledge under the influences of changes in labor markets, divisions of labor and changing training institutions. But we don't find in these contingencies chapters an analysis of the moral world of the professions. Rather, they list a set of causal effects coming from outside medicine that Frydson feels surround and determine the profession. It's in his last two chapters that Frydson takes on what he calls the assault on professionalism and the soul of professionalism. That is, he tries in these chapters to give an account of the moral damage done to the professions and medicine in particular by particular versions of these external causal forces reaching in that he's discussed in the two preceding chapters. Now for Frydson, the idea of an assault on profession lies in the domination of professionalism as a way of being by consumerist and bureaucratic modes of control, which have led both to professionals excessive pursuit of self-interest, consumerism, and to the excessive rationalization of professional work about presumably I have no need to tell anyone in this room. He uses the cause the case of medicine again is ideal typical. In the labor force we see a decline in medicine's prestige and confidence. In the division of labor we see a proliferation of subspecialties and non-medical techniques and technicians beyond the power of medicine to coordinate much less control. In the labor market we see a massive invasion of bureaucratic control stemming from Medicare and the increasing power of the payers. Moreover the Supreme Court struck down crucial professional restrictions on advertising and other similar practices. The pharmaceutical and hospital industries abandoned their traditional alliance with doctors and sought new political and economic foundations. Ideological changes in favor of consumerism along with neoliberal attempts to free the market, damaged professional control, even as consumer advocates demanded increased medical care. As for professional schooling, medical schools Frydson felt have moved increasingly towards a research environment heavily dominated by capitalist concerns steering research towards short run and patentable payoffs rather than long-term basic research. Now Frydson's analysis in this assault on professionalism chapter is purely causal. It's not yet moral. That is while he clearly sees the ways in which these various changes threaten the moral being of the medical profession he does not trace those changes to alternative moralities only to alter external causes. His account of these particular contingencies is quite morally unsympathetic. Thus he tells us for example that neoconservatism quote denigrates the capacity of the state to deal effectively with social problems of health welfare education and living conditions and emphasizes instead the apparently beneficent income of the efforts of individuals and localities to manage their own affairs when free from state interference or again neoliberal economics he says quote asserts that individual competition in a free market freed of state regulation will lead to a better or at least a more affluent society or third he argues that corporations advocacy of consumer choice is merely quote a reflection of their assurance that if we are they are freed from regulation their enormous advertising resources can determine what consumers will choose. So despite Frydson's efforts at even handedness these paragraphs events are very pejorative view. He sees the effects of neoconservatism neoliberalism and consumer advocacy but he has no sympathy with any of these as moral positions. It's hard to escape the conclusion that he considers them as do many or even most sociologists simply to be ideological screens for quite traditional greed. As for the professional as for the sorry bureaucratic and managerial side of the assault on professionalism he doesn't engage its moral foundations at all. Although he speaks at one point of the quote economically self-interested actions of the profession and its failure to undertake responsibility for assuring the quality of members work and quote he nowhere addresses the larger moral failure of the medical profession to develop what we might call a social compact for health. Yet the fact is that when the state began to assume responsibility and direction for the medical care of the elderly and the indigent the medical profession far from developing any utopian model of a healthy society through its very considerable energy into self-protection. Indeed the arguments of the doctors against Medicare and the various earlier moves for government insurance were one long blast of neoliberalism and neoconservatism avant la lettre. An ironic fact indeed. In short while Frydson saw the damage caused to the medical profession's morality by the rise of managerialism and consumerism he analyzed neither the moral foundations of those managerialism and consumerist ideas nor the moral failures of the medical profession itself which themselves then causally contributed to the rise of the managerial and consumerist ideologies by failing sort of to fill a gap a gap a vacuum. As he presents it the story is simply that causal forces came from outside medicine which undermined the conditions of medical's moral medicine's moral being. In his final chapter Frydson aims to reject the standard ideological arguments he calls them chivalrous that are urged against the professions in general and again very much against medicine in particular. Thus he says quote in attacking professionalism critics use the word monopolies stereotypically the implication being that it serves only one purpose and is dominated by only one motive. They ignore the fact that the institutions of professionalism are grounded not only in an economy but also in a social enterprise of learning advancing and practicing a body of specialized skill. He argues that monopoly is required not so much for economic protection as it is to guarantee a quality of work and to permit the development of the knowledge system itself. Indeed he argues more generally that no knowledge discipline can survive without active boundaries of some kind. He also quite rightly ridicules the argument long champion by Milton Friedman and his predecessors going back to the Jacksonian era that any public can effectively judge for itself the quality of medical care on offer in the market. Now all of this is fairly persuasive if rather ironic given that Frydson was rejecting all the arguments that he himself had made many years before. But it is striking that here too Frydson does not confront the moral arguments that lie behind the admittedly contemptuous monopoly critique of professionalism. If the public is unable to distinguish high quality medical care who has failed to educate them. If there is no general vision of a healthy society beyond a society that goes to a credentialed doctor when it's ill whose fault is that. If the society spends almost 20% of personal consumption expenditures on health why should it not debate that question in the language of rights and costs and justice rather than in the narrow language of professionalism. That is, Frydson does not accord to the other realms of society the moral respect that he accords to professionalism. One admires his sympathy for the fallen mighty but a full complete picture requires that we see the moral basis of consumerism and of managerialism as well as those of professionalism and that we also see the deleterious causal effects of past moral decisions by the profession as well as the present deleterious causal results of consumerism and managerialism on the profession. In his closing pages however Frydson becomes both more subtle and more credible. He argues persuasively that the attack on professions hasn't really weakened the institutions of professionalism itself. Credentials, schools, salaries, relative prestige and so on seem surprisingly healthy. There's no real attack on those institutions in particular he feels so much as an attack on the ideological preeminence of the professions and he notes perspicuously that this ideological attack has decisively weakened the profession's ability to fend off capital and the state. We thus have the worst in his view of both worlds on the one a continuing dominance of credentialism without the offsetting ideologies and commitments of true professionalism. As he points out the new ideologies have in fact corrupted the professions again, quote, they have liberated many individuals from the ideology of service freeing them to devote themselves to single-minded efforts to maximize their own incomes, end quote. He then goes on to predict the likely results first and foremost a gradual decline of the professions towards a purely technical if still elite status, serving goals set by others and exercising discretion within limits that are externally specified. Beyond that lie three things he believes. First, increasingly bureaucratized service with a consequent loss for clients. Second, a loss of the spirit of free inquiry and purely theoretical development within the profession's knowledge systems. And third, a loss of what he calls the spirit of professionalism, by which he means an intense focus on intellectual development and a sense of the custody of a knowledge whose values transcend time and place. The professions he feels will remain privileged but will no longer have a real soul. Freyton's remedy such as it is, is moral renewal, founded on a renewed commitment to codes of ethics. He particularly urges in expansion of institutional ethics. He thereby begins to move in the direction of the kind of social moralizing that I've implicitly suggested earlier as crucial in both the past and the future of medicine. But Freyton focuses really on the ethical defense against bureaucratism, which may or may not succeed, but more importantly against commercialism. He decries the emergence of patenting of knowledge insisting on the freedom in which knowledge flourishes. He tells us that, quote, professional ethics must claim an independence from patron, state, and public that is analogous to what is claimed by a religious congregation. End quote. These are strong words and one can see that behind his concern for the medical profession lies Freyton's equally great concern for the one profession that has to this point defeated both managerialism and commercialism, academia itself. That battle with for-profit education on the one hand and bureaucratic standards of learning on the other will clearly be fought in coming decades throughout the middle and lower tiers of the higher education system. Indeed, Freyton's prediction of sharply increased status differentials within professions is already becoming true in academia. Let me conclude. I began this paper discussing the problem of knowledge alienation, the puzzle that many social scientists analyzed social life one way and live it another. As I noted, most social science addresses that problem by separating the empirical analysis of objectivity from the moral and political analysis of advocacy. But the flow of the social process involves both causal and moral events irretrievably interwoven. So separation doesn't work. Perhaps I thought a careful reading of Freyton would show us a new way to approach this problem. I think Freyton's example teaches us several things. The first, of course, is that this diagnosis is correct. My original diagnosis is simply echoing a conclusion that Freyton and no doubt many others had reached long before. Freyton's own life trajectory shows clearly his recognition of the centrality of moral life in the social process. Having said it aside for purely causal analysis as a young man, he returned to make morality central in his last work. But he did so in a way that was clearly incomplete. I think this was for want of an abstracting impulse. Deep down, Freyton was committed not to all of the professions, but deep down to medicine. He wrote almost nothing about professions that was truly general. His preferred examples, his theories, his ideal types, all came from medicine. We might say in Levy Strauss's fortunate phrase that Freyton found medicine good to think with. But this meant that he was hostage to the medical example as the prime instance of his central category of profession. That's why he chided me for, as he put it, going well past the conventionally defined professions to include many specialists who have attained considerably less prestige leaving aside the question of their status. So for him, if a form of institutionalizing expertise in persons wasn't like medicine, he just set it aside. Yet those examples have much to tell us about the causal and the moral worlds of expertise. Moreover, Freyton's devotion to medicine also made him hostage to the vagaries of the history of medicine, the triumphant success of mid-century, and then the fall before the assembled powers of state, commerce, and consumers. But this was not the experience of many other professions. Law flourished in the late 20th and early 21st centuries as also did accountancy. Well, most of the time. This is why I continue to feel that a much more general approach is preferable. But if Freyton's approach was incomplete, it was nonetheless substantively profound. By engaging the medical case deeply, he shows us how causal forces well beyond a profession can lead not only to a decline of morale, which should be familiar enough, but also of morals. Since I think he and I would both agree that the moral realm itself cannot be determined by any antecedent causes, this change could only occur because a new causal order presents new moral challenges to which the profession did not rise. So Freyton forces us to begin to theorize the ways in which causality can shape the preconditions for moral behavior, even though it can't determine that behavior itself. For me, however, the most important lesson in rereading Freyton lies in seeing how his abiding love of the medical profession led him to overlook the larger moral case against it. Freyton saw the fall of medicine as in part moral, but he did not see the moral hubris of mid-century medicine. It's almost childlike faith that all it was necessary for a healthy society was a public that would patronize only credentialed physicians. Freyton saw only the causal nemesis that came from the rising tides of managerialism and commercialism, and he did not see the moral and political hurricane that was propelling those tides, but only the huge determining waves of change that washed over the coastlands of medicine. His example teaches us then that a social science that would combine an analysis of moral and causal forces must be careful indeed. Easy solutions are not possible. We must accord all the various actors in our dramas the same moral respect, even as we hold them all to the same moral standards. And we must much more carefully conceptualize the simultaneously moral and determined nature of events, seeing the two sets of flows coming into them and the two sets of flows going out. We must also recognize the nested and sometimes fractal nature of these events lest we forget that moral issues are of many sizes and that understanding the morality of episodes of professional services is not enough to constitute a true morality for a profession. As I've hinted earlier, I think most of these debates lie very close ahead for most of those of us in academics. I read Freidson's book as a cautionary tale and like him, I see the possibility for a great fall for university professors. We too have been digging our silly foxholes. We too have overlooked new tactics and strategies of learning. We too have forgotten in our own rush of careerism what are the only central values of a scholarly life and of the existence of scholarship. We're lucky then to have had the guidance of this great scholar. He had the courage to look things in the eye, the magnanimity to unsay the harsh words of his youth, the wisdom to bring many different arguments together. He was a great sociologist and as my analysis here shows, we have much to learn from him. In the long run, Eliot Freidson also proved a great friend to the medical profession. May you find another such. And for those in the audience who were here last week when Dr. Winia, who's on our faculty as an infectious disease doctor, but also runs the AMA ethics program, said there's nobody left to speak for the profession. That in the old days, as much as any group, the AMA had such a voice. But today that voice is fragmented among a hundred claimants to offer the kind of message towards a future that you're advocating. There's nobody left whose voice was there. There's nobody in a sense there's too many. I mean, one of the things to remember is that the world that had leaders like William Osler was a world that had 100 or 150,000 physicians. There are a million now in the United States. And they're just different numbers. 150,000 is one thing. A million is a lot, lot more. I wonder if you've got one way of reading what Freidson said and maybe even the development of his own thought, whether he said it or not, is that there's also a sort of ideal type of society in terms of its balance between professionals, managerial and consumerist modes of operating within any sphere of human activity and that we may have had a period in which there was too much emphasis on the professional. He sees it as having slid in sort of an extreme toward the dominance of managerial and too little of the professional without moving towards some sort of ideal type of balance between all of those forces. Well, I think it's really interesting to think about that. I mean, of course, the first thing will be it'll never stop. It's the same as, you know, even that will never shift. The odd, so I don't have a quick answer to that, that there's not going to be, you're just going to keep moving around as each one of them sort of moves ahead and push gets pushed out. One of the odd aspects of this entire approach to things is if you were to ask what's the sort of high point of managerialism in America would not be now. It's a period right after the Second World War. There's a period of giant organizations, a period when more than one percent of the labor force worked for one company, AT&T. I mean, it's just absolutely giant. This is the era of giant bureaucracies. The war produces that as an experience. Everybody gets used to being in a giant bureaucracy, either this one or some other one. And so the period from 1945 to 1965 or 70 is a period when everything in America is done in this highly bureaucratic way. Grave flammable man, blah, blah, blah. And it's actually there's a high sort of moral notion of this, the moral businessman, blah, blah, blah. It's a very different kind of managerialism than the sort of straight accountancy that we would, most people would think about with that word today. So that's a kind of odd fact. It's hard to, I mean, I'm interested in Freidson's analysis about these three different possible ways of ideals for the society. But I haven't given a lot of thought to how they would balance that kind of thing. It's just interesting to think about. But I don't have a canned answer for that. Yeah. Thank you for your talk. I have two sort of related questions following up on what Dan just asked. So if we think, if you say the ideal of the profession here is to think beyond what we currently are, potentially, to different call, then what is, and you describe when you talk this pushback of where we are boxed in, but what is to say that actually we're not where we are supposed to be? Meaning that the outside of the sphere of health, if you look at sociologists, but if you look at anthropologists, they talk about other sectors of health, the folk, popular domain. And actually, when we went professional, we went and said, our corner of market is this health care interface. And that's what we talk about. Those other sectors are for other people, and they're unprofessional. I mean, the climate sort of mentions that sort of sector. So what is to say that we are actually not where we are, and we should be where we are, and we're doing what we're supposed to be doing. And rather, that trajectory was carefully planned to thought out. And because you touch this education model, I just want to say, so are you advocating like the Oxbridge model, where it's kind of a, your argument is what we do through small tutorials. And that's all it is. So you develop your argument. And would that be what the master clinician sort of back to what Mark's idea is supposed to do in medicine, this idea we rejuvenate this clinician relationship where you learn through virtual, you know, to virtuous mentors to take care of patients or rather the science and the direct portion is less important than the mannerisms of how you're doing what you're doing. There's a lot in there. And I don't, you know, I'm not terribly comfortable in telling professionals what to do, as you can tell. I sort of, I spent my whole life avoiding doing it. So I don't, I'm not sure I accept the notion that, well, let's put it this way. You can, a profession can, choose to be a little box, a little thing. The classic example of that is actuaries, right? Very narrow profession, does a very particular thing. Nobody else does what actuaries do. It's good. This is the thing. Veterinarians is another sort of fairly tightly defended. And it used to be dentists, but of course dentists were suddenly then destroyed by fluoridation and had, ah, what are we going to do? Nobody around with teeth rotting, so of course they get into it. Luckily, you guys are keeping everybody alive and even fluoridation doesn't help in the long run. So my 95-year-old mother gets lots of dental care. So you can make a very small box, but, you know, this is a big profession. It's a million people. It's got a lot of different pieces. It can, it can have a greater ambition than that, it seems to me. And if that means having some sort of rapprochement or relation, whatever, with the world of over-the-countercare, all that other kind of stuff, folk, whatever. Yeah, maybe that's something to be thought about. I don't know. I mean, obviously it happens in the, you know, in doctor's offices where they say, well, I use this OTC drug for the, we won't talk about that, right? Okay, so it could be that the depression could do a lot of that, it seems to me. So I don't see any necessary reason why a big and actually quite strong, very heavily institutionalized profession shouldn't have this kind of ambition to, I don't want to say control, but to produce a vision for it. You create a vision of what it means to have a healthy society, what health is for people of the life course. You really think about this. People will be to pass to your door. Rather than having a world where, where people think, I mean, you always see this, people think about health as, health is not having to go to the doctor. So as long as you can avoid, this is not, it's not what you would in control of health, right? What's you in control of the reverse of health and that's kind of not good. So you want to be, in a sense, if you have a positive vision as well. I mean, it's happened in many, many professions. So in fact, this is the way, this is what happens with dentistry. It starts out as a, as a taking care of problems and then moves to prevention, to prevention, to prevention, invents the sort of, you know, the twice yearly cleaning and all that stuff as a way to provide business for itself. Lots and lots of professions get put out of business because they get successful at what they do. And then you have to get into prevention of other kinds. You saw this with psychiatrist, the rise of mental hygiene in the 1920s. It's all, you know, sort of a tooth brushing of your mind every week or you'll turn into a nut. I mean, it really was kind of the way it was. There was this notion that untreated neurosis would turn into psychosis, which is a pretty strange kind of idea. But that's clearly, if you look at the mental hygiene literature from the 1920s, very involved literature. That's sort of the basic theme. So there are a lot of different ways to do it, I think. You know, the master clinician idea, it's an interesting idea, but we have, it's the same kind of debate in education. It's obvious that one-on-one is the best kind of instruction for the most part that exists. It's really expensive. On the other hand, the society is incredibly rich. You know, if you read Gaines's famous essay, Economic Possibilities for Our Grandchildren, the central problem of this world is that our society is so productive that actually, in reality, we only have to work two hours a day to have a very happy society. None of us know what we would do with ourselves for the other time. Kellogg's, just last week, I went to Michigan on the train, of course he goes through Battle Creek. Kellogg's, for 40 or 50 years, had a six-hour day. That's a big experiment to try a six-hour day. And one of the real problems with it was that people found they had time in their hands. They didn't know what to do with themselves. A lot of the women really loved it because it simplified childcare and did a whole bunch of things. But it's not clear that if we actually ran the society and took advantage of the society's unbelievable productivity instead of wasting huge amounts of it in, you know, like, there are 1,500 different kinds of fifths of vodka for sale. In a major Chicago grocery chain. 1,500. You know, if you take all the different sizes and different colors and different whatever, right? This is the world of UPCs. I had a student who studied this. This is, like, bizarre. This large grocery chain, which many of you are probably members of, and card carriers for, you know, has something like 25 million items in its UPC database. It's not the case that we need 1,500 different kinds of fifths of vodka. Let me tell you. Okay, so, you know, if we took that and we didn't waste all this stuff and we just lived in, we could do a lot of stuff in this society. You probably could have one-on-ones of huge amounts. It's a very productive society. It's interesting, because in a sense what you're asking is for medicine to go back to the middle of the 20th century when medicine and public health were more united. Because a notion of health really has to take on the communal notion of health at the society level. And in a sense, that's when we split. At the same time as you're talking about the hubris, which comes because we split and we are the interventionists and the public health are doing those boring things like telling us eat right, exercise and sleep right, which are still probably the three best prescriptions any physician will ever give you. Right, so, well, it could be. I mean, the history of the relation of public health is a long and interesting one. And, you know, I don't actually, I haven't studied it carefully, so I just, I don't know it off the top of my head. It is true that, you know, if you look at declines in mortality, it's public health that's providing most of those until a relatively recent period. And then you have, in relatively recently, you have, you have shifts. But, so I think it is true that in a sense, maintaining that relationship would work and it has to do with sort of, you know, fighting down differentiate certain kinds of differentiation, maintaining a kind of connection. Yeah, it's an interesting argument. So I'll just leave it there. It's obvious we can go somewhere with that. I think all of us have been driven back to reading both the early and the late frights and I want to thank you so much for coming over from the campus. Thanks.