Knowledge in the Time of Cholera (3 page)

Despite these problems, the truth-wins-out narrative has proven obstinately resilient, even as historians have challenged it on a number of
grounds
(see Grob 2002; Warner 1997, 1998). Were it restricted to publications of the American Medical Association (AMA) or the myths doctors tell themselves, it might not be much of a concern. The problem is that its assumptions insinuate themselves into more critical sociological analyses of professionalization. As such, it is not enough to dismiss it as merely “hagiographic” (Warner 1997, 2).

It is not surprising that older functionalist accounts of professionalization embrace the truth-wins-out logic. When professions are viewed as arising to fulfill some preexisting societal need or structural imperative (see Parsons 1964), it is difficult to maintain the critical distance necessary to challenge the science that justifies such a role. But what of the more critical sociological research that arose in opposition to functionalism? These critical accounts depict professionalization not as a functional response to a societal need but rather as a political process that involves winning allies and creating a strong organizational infrastructure to promote professional goals.
³
Still, even this research inadvertently reproduces a version of truth-wins-out logic. Here the issue is reproduction through neglect. In reacting against the truth-wins-out narrative, which gives undo power to ideas, critical analyses tend to ignore ideas altogether, mustering organizational and political explanations for the professionalization of medicine (i.e., Berlant 1975; Freidson 1970, 1988; Larson 1977). Through this silence, they unintentionally reproduce misguided assumptions of the truth-wins-out narrative; focused on the
organizational
infrastructure of professions, they neglect the
intellectual
infrastructure. Ideas come to serve merely as window dressing for the real politicking happening behind the scenes.

The power of the truth-wins-out logic is displayed in the way it insinuates itself into the preeminent sociological treatment of the U.S. medical profession, Paul Starr's
The Social Transformation of American Medicine
(1982). Critical of both functionalism and purely organizational accounts of professionalization, Starr seeks to integrate organizational and cultural factors, recognizing professional authority as dependent upon force and persuasion (Starr 1982, 13). According to Starr, the AMA was able to consolidate professional authority once Jacksonian egalitarianism gave way to the Progressive Era's embrace of scientific expertise. Seizing the zeitgeist, the AMA offered more effective ideas and carried out adroit political strategies to achieve professional power.

Starr's work rightly remains the foremost sociological account of American medical professionalization. However, while Starr's
analytical
approach
of
integrating both cultural and organizational factors is laudable, his
historical
analysis unfortunately reduces culture to an external context (i.e., Jacksonian democracy or Progressivism). He invokes ambiguous phrases to explain these macro-cultural mechanisms (e.g., “on the shoulders of broad historical forces [140]”). Moreover, he reproduces the logic of the truth-wins-out narrative by treating bacteriological discoveries as self-evident, ignoring the ways that its supporters worked to make them appear so. His respect for the cultural authority of science is so firm that his history suggests that once scientists got their facts straight, medicine was ineluctably transformed in ways that allowed physicians to capitalize “naturally” on the latest discovery or breakthrough. In reducing culture to an external context, Starr never turns his critical eye toward the actual production of medical knowledge.
⁴
For Starr, the achievement of professional legitimacy is seen as the outcome of the removal of an external cultural barrier and the elucidation of crucial facts rather than a project to create legitimacy for a particular vision of medical science.
⁵
This is not to pick on Starr; these analytical failings are widespread. If the poverty of the truth-wins-out logic can penetrate good sociological analyses, the oversight is systematic, the blind spot widespread.

Whither Epistemology?

The persistence of the truth-wins-out logic in the professions literature underscores the need for a more rigorous engagement with the sociology of knowledge. The existing accounts of the U.S. medical profession, both the more hagiographic versions and critical sociological analyses, fail to investigate epistemological change as an object of analysis, as a phenomenon in need of an explanation. Absent such a focus, they suffer from a basic misconception as to the nature of knowledge. Epistemological assumptions are seen as somehow timeless and outside of history. But it does not take a verdant historical imagination to see that often what is widely accepted as true in one period is dismissed as false in the next.
Standards
of truth change over time. History is strewn with the carcasses of discarded ideas once embraced as truth. Less apparent, but more significant, is that epistemological systems themselves have histories, waxing, waning, and even disappearing altogether. The life and death of ideas is not merely a matter of better or truer ideas supplanting older ones, but also of the emergence of entirely new ways of thinking.

The notion of a general linear progress of knowledge, derided by sociolo
gists
of science and challenged by historians, is undermined by the historical plurality of assumptions regarding the standard of truth against which ideas are judged. Ideas are promoted (and demoted) against the backdrop of basic assumptions about the nature of knowledge. To say an idea is accepted as true is to point out that it meets the standards of good knowledge of a particular epistemological system that develops out of social networks of thinkers (Collins 2000). Absent some basic agreement as to what constitutes legitimate knowledge, no such assessment is possible. When these assumptions change—when epistemological standards and values are jettisoned for new ones—the previous era's ideas must be translated, accommodated, or discarded. Ideas only make sense—and in turn can only be evaluated—from within an epistemological system. This is not meant to dismiss ideas as socially constructed or to relativize all knowledge claims; it is merely to contextualize truth claims, to embed ideas—and the evaluation of these ideas—within their historical-epistemological context.

But what accounts for the adoption of one epistemology over another? Changes on the level of epistemology cannot be explained away by appeals to truth and falsity. In a fundamental sense, the adoption of one epistemology over another is a matter of collective
agreement
, a typically tacit acceptance of the basic standards for evaluating knowledge claims. Put differently, when the metric for assessing truth claims changes, the ascendancy of one metric over another cannot, by nature, be determined by appeals to truth. It is not a matter of truth versus error, rational versus irrational, but rather of socially mediated choice that arises from the interaction between social actors. It was this matter of acceptance of an epistemological system based on the laboratory—and the conflict out of which it emerged—that was crucial in shaping the professionalization of U.S. medicine during the nineteenth century.

Given the centrality of this epistemological change—and the overwhelming empirical evidence in the historical record of these changes—why has epistemology fallen out of historical accounts of the professionalization of U.S. medicine? Why has the truth-wins-out narrative proven so durable? First, some of the oversight can be attributed to the paradoxical fact that even though epistemological debates are fundamental, they operate subtly. People tend not to discuss epistemological issues; rather they are the background factors that become manifest in specific debates. Doctors rarely fought over the nature of medical knowledge explicitly, but issues of the legitimacy and usefulness of certain forms of knowledge arose consistently in
their
specific debates over cholera. Pay too much attention to these surface knowledge debates and the epistemological subtext goes unnoticed.

Second, even when accounts of the professionalization of U.S. medicine do acknowledge epistemological changes, they commonly reverse the temporal relation between ideas and epistemology. Epistemological change is viewed as following from new discoveries. A microbe is seen; the lab is embraced. This, however, inverts temporal directionality. Before a microbe can be seen or produced in the lab, there must exist a predisposition to seeing it, an adoption of particular epistemological assumptions that would enable physicians and researchers to recognize a discovery as such. Epistemological commitments
precede
facts, not the other way around. Inverting this temporality renders invisible the role of epistemological change in the production of knowledge and the social organization of knowing.

Finally, this oversight stems from a basic lack of a historical imagination when it comes to epistemology. Commonsense, taken-for-granted notions of truth and falsity assume an ahistorical view of knowledge and truth. When one construes the standards of truth as timeless, knowledge is only relevant to the story of professionalization insofar as doctors made new medical discoveries that measured up to these standards. But this assumption is unwarranted, as standards of truth change over time. The dustbin of history is filled with previously recognized true ideas now deemed false, and there is no metaphysical warrant to assume this will not be the case in the future (Putnam 1995, 192). An epistemological system held as universal in one era gets supplanted in the next by another system that sports the same pretenses to timeless universality. From within such systems, standards seem universal, but taking the long view, we see that they are fundamentally historical.

In the past two decades, research in historical epistemology has challenged the timelessness of truth standards, temporalizing many of the attributes of knowledge and, in turn, offering a social and cultural understanding of epistemological shifts (see Biagioli 1994; Daston 1992; Daston and Galison 2010; Davidson 2001; Dear 1992; Fuller 2002; Ginzburg 1980, 1992; Jonsen and Toulmin 1988; Porter 1988; Poovey 1998; Schweber 2006; Shapin 1994; Shapin and Schaffer 1985; Toulmin 1992).
⁶
Historical epistemology starts from the premise that “basic epistemological categories such as cause, explanation, and objectivity are historically variable and can be studied in the same way as other types of scientific claims” (Schweber 2006, 229). Concepts like Foucault's notion of epistemes (2002), Ian Hacking's styles of reasoning
(
1985), and even Kuhn's paradigms (1996)
⁷
serve to highlight the changing standards of truth and falsity. Epistemological units like the “fact” typically perceived as universal are shown to have a history (Poovey 1998).

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.