Profession of Medicine

The fundamental and consistent criterion that distinguishes a profession from other occupations is its autonomy, a condition that is not absolute but that depends for its existence on the tolerance and protection of the state. Eliot Freidson, a giant of medical sociology, drew this conclusion as the central theme of his comprehensive analysis of the nature of professions.

For those who work regularly with medical professional bodies or with doctors in managed care environments, Freidson’s monograph, now nearly 40 years old, rings so many bells as to be positively deafening.

Freidson argues that the special privilege of considerable freedom from the control of outsiders rests on three claims by professions. Firstly, that there is such an unusual degree of skill and knowledge involved in professional work that non-professionals are not equipped to evaluate it. Secondly, that professionals are responsible and may be trusted to work without supervision. Thirdly, that the profession can be relied on to deal itself with members who behave incompetently or unethically.

Freidson sees medicine as the archetypal profession. He discusses other attributes of the profession and then moves on to its relevance to the sociology of illness. For, he argues, if a profession is entitled to have ultimate control over the content of its work, the medical profession has heavy influence over determining what illness is and in the creation of illness as a social state.

Doctors unfamiliar with sociological thinking and analysis will find Freidson’s arguments very involved, requiring careful study rather than relaxed reading. Yet this is not a book purely for the student or those with an academic interest. Its power is in the ability to explain the culture, attitudes, and values of the medical profession but also to predict its behaviour. In particular, assessing actions that affect the profession (collectively or individually) and reacting to those actions make perfect sense when seen in terms of the potential threat to autonomy.

Having said all this, the medical profession in Britain (and many other countries) has seen its autonomy constrained greatly over the last two decades: more rigorous standards of practice, a wider base of clinical skills, a broader ethical framework, and new responsibilities to corporate goals and targets in managed care environments. The medical profession has largely adopted and accepted these erosions of its traditional freedom from external control, but perhaps the very process of doing so has contributed to lower morale.

It would be fascinating to debate this changed context with Freidson, but he is no more. His ideas, however, remain an inspiration, and they deserve a place in any debate about the medical profession’s future.