The Rise of the Medical Profession

A Study of Collective Social Mobility

Noel Parry, José Parry

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9780367001759
• eBook ISBN: 9780429684142
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

Originally published in 1976 The Rise of the Medical Profession combines a sociological and historical approach to the rise of the medical profession in England. Sociologically it offers a theoretical framework which for the first time links the study of social mobility and professionalism with the theory of stratification. Historically, it examines the movement which led to the unification of the medical profession arising from effective social organisation among the surgeon-apothecaries in the early nineteenth century. It demonstrates that through the successful pursuit of the occupational strategy of professionalism the doctors have been able to raise their income and status in the community and to dominate the institutions and organisations of medical care. In their relationship with the state, they have been generally successful in securing a recognition of their privileged position. The future of the medical profession and of professionalism is discussed in the context of the changing balance between state power and that of free private occupation associations, whether of the type based on professionalism or unionism. The ideal-type conception of the middle class as essentially individualistic is challenged by the exploration of middle class collective action, particularly professionalism.

PART I

1. SOCIAL MOBILITY AND CLASS STRUCTURE – THE ORTHODOX APPROACHES

Collective social mobility, a term used by Everett Hughes, (Hughes 1971:368) has been a neglected aspect of social stratification in Western countries, though sociologists have often noted its significance in the traditional caste system of India (Srinivas 1967:552). Collective social mobility it will be argued is an important feature of Western societies. The study of this phenomenon will assist in deepening our understanding of our own society and throw light on debates in sociology — such as the one about embourgeoisement. This debate, together with the study and measurement of individual mobility, has been one of the larger areas of research interest in sociology in the last twenty-five years. It has been of the greatest moment in defining the scope of the subject in terms of an established tradition of research not least in Britain.

In 1954 a book was published, edited by David Glass, reporting on a major set of related research projects. In his introduction (Glass 1954:3) Glass says:

‘the programme as a whole is concerned with the processes of social selection and differentiation which are at work in Britain, with the formation of social strata and with the nature, composition and functions of those strata. Such problems are central to the study of social structure; they are of direct concern both for the development of sociological theory and for the formulation of social policy.’

The object of the study was to be the ‘middle classes’ because as he said ‘save in respect of their early history “the middle classes” of Britain have not been much exposed to investigation’. He went on to say that ‘the core of the general investigation is the study of social mobility in Britain — of the extent of movement in social status or social position by individuals of diverse social origins’ (1954:5).

The method was modelled on demography and used statistical techniques, in particular the index of association, to measure intra-generational social mobility. Valuable information was provided about the extent of self-recruitment in the various social classes and in certain occupations i.e. medicine. The social class index used was the Hall-Jones scale. It may be observed that among the possible items for research cited in the aims only some have actually been investigated. In such an ambitious programme this is not surprising, but what is interesting is the selection of items which have actually been researched as opposed to those which were left out. These give an indication of the purposes and priorities of the researchers.

Glass himself explicitly states further on in his introduction what his preconceptions and priorities were when he decided to ‘step outside the frame of the studies contained in the present volume and put forward personal views which are explicitly “loaded” in that they have a value basis’ (1954:22). ‘Certainly’, he said, ‘it is one of the postulates of a democratic and egalitarian society that ability, whatever its social background shall not be denied the chance to fulfil itself (1954:25). He states that there are two primary reasons for wishing to see a higher degree of social mobility in the community. These are to increase economic and social efficiency and to improve the lot of the individual by making sure that there are fewer square pegs in round holes and thus greater personal fulfilment. Rather than stepping outside the frame of the study, as Glass puts it, these remarks point up the reasons why it took a particular form. Reflected there are the assumptions of liberalism and social democracy which was the established radicalism of the day. The doctrine of equality of opportunity was embodied in the 1944 Education Act and the idea of the ‘career open to all the talents’ was an accepted objective. The removal of barriers preventing access to education would, it was hoped, assist in the achievement of this aim.

The focus of attention was on the individual and on his talents and his fulfilment. The measurement of the opportunities and achievements of individuals was done by a process of aggregation. The methods employed neatly match the objects of the study. A shrewd observer may notice that the methodological tool, the index of association, is in fact a logical analogue to the classical economic notion of the perfect market. The liberal assumption that talented people may be born in any stratum of society was also basic to the study. It is the reason why statistical randomness is equated with ‘perfect mobility’. The index of association is a measure of the extent of self-recruitment in any actual society. or to put it round the other way, it is a measure of the extent to which there is deviation from the standard of perfect mobility. Glass and his co-workers claimed that this is purely a methodological device with heuristic value only. Value-neutrality as a precept guiding the work of the sociologist was then regarded as both more feasible and more desirable than it is today. However, the reader will notice that Glass’s methodology is at least not inconsistent with his stated values. It is clearly his belief that a society which approximates most closely to perfect mobility is a better society than one in which the incidence of mobility is small. We contend that Glass’s approach is limited by the individualism which arises from his ideological assumptions and it is not surprising therefore that in setting the scene for much future work on social mobility, the movement of groups was left out of account.

American studies have also been influenced by the same starting assumptions and have defined their conception of the problems of social mobility and methods of investigating it in a similar way. Pitirim Sorokin’s magnum opus on social mobility was published in the United States in 1927, although the author was in fact a distinguished Russian émigré. Introducing the subject in the preface he says ‘our society is a mobile society par excellence. An intensive shifting of individuals from position to position and a great circulation of social objects in horizontal and in vertical directions are probably the most important characteristics of contemporary Western society. To them is due its dynamic character.’ In an earlier book The Sociology of Revolution he studied the abnormal forms of social mobility. However, in Social Mobility he states his intention ‘to give a general theory of vertical mobility of individuals and social objects’ (Sorokin 1927:preface).

He defines social mobility as follows:

‘by social mobility is understood any transition of an individual or social object of value — anything that has been created or modified by human activity — from one social position to another. There are two principal types of social mobility, horizontal and vertical. By horizontal mobility or shifting, is meant the transition of an individual or social object from one social group to another situated on the same level. Transitions of individuals, as from the Baptist to the Methodist religious group, from one citizenship to another, from one family (as a husband or wife) to another by divorce or remarriage, from one factory to another in the same occupational status, are all instances of social mobility. So too are transitions of social objects, the radio, automobile, fashion, Communism ... within the same social stratum’(1927:133).

Sorokin is aware also of changes in geographical location as an aspect of social mobility. He explains that ‘shifting’ of these kinds may take place without an individual changing his social position in the vertical direction. He goes on

‘by vertical social mobility is meant the relations involved in a transition of an individual (or a social object) from one social stratum to another. According to the direction of the transition there are two types of vertical mobility: ascending and descending, or social climbing or social sinking. According to the nature of the stratification, there are ascending and descending currents of economic, political, and occupational mobility, not to mention other less important types. The ascending currents exist in two principal forms; as an infiltration of the individuals of a lower stratum into an existing higher one; and as a creation of a new group by such individuals and the insertion of such a group into a higher stratum instead of, or side by side with, the existing groups of this stratum’ (1927:133–34).

There are processes of downward mobility, which correspond with these but in addition there is the possibility of the ‘disintegration [of a group] as a social unit’.

Sorokin is well aware of the importance of collective social mobility. He suggests that the question ‘of social ascending and descending, the rise and fall of groups, must be considered more carefully’ (1927:134). He gives some historical examples — the Indian caste system is one case where the superior caste of Brahmins did not always hold the position of indisputable superiority which it has maintained during the last 2,000 years. He points out that if ‘the group as a whole being is elevated, all its members, in corpore through this very fact, are elevated also’ (1927:134). Other cases he mentions are those of the social ascent of the Christians during and after the reign of Constantine the Great and, in the Middle Ages, the elevation of the communal bourgeoisie and the Gilda Mercatoria. Referring to the question of social descent, he cites both the Romanoffs and their ruling class and the Hapsburgs. He suggests as a contrary example the case of those members of the Communist Party in Russia who, after the revolution, were elevated en masse into the place of the former Czarist aristocracy. In Western industrial societies, he mentions the rise of the groups associated with the oil and automobile industries.

Sorokin recognises that there may be a type of immobile stratified society in which vertical social mobility is nil. This means that within such societies there is no ascending or descending, no circulation of its members so that every individual is for ever attached to the social stratum in which he was born.

‘Such a type of stratification may be styled as absolutely closed, rigid, impenetrable or immobile. The opposite theoretical type is that in which vertical mobility is very intensive and general... Such a type of stratification may be styled open, plastic, penetrable or mobile. Between these two extreme types there may be many middle or intermediary types of stratification’

(1927:137–138). Sorokin argues that although democratic societies are believed to be characterised by more intensive vertical mobility compared with that of non-democratic ones, they are in fact not necessarily more open in this sense than autocratic societies; the channels of mobility may simply be different. Extensive social mobility is not guaranteed simply by the existence of democratic elections or the widespread belief that the social position of the individual ought not to be ascribed at birth. Neither of these, nor the idea of equality of opportunity or freedom from prejudice occasioned by judicial or religious obstacles necessarily produce high rates of individual mobility. No society in fact is absolutely closed, or conversely, free from transition from one social stratum to another.

Sorokin discusses channels of vertical circulation such as the army, the church, the school, governments and political groups, professional organisations, wealth-making organisations and the family. Questions which have been much researched and debated since his day concern the mechanisms of social testing. One of these — the school — he chooses to discuss in some detail from the point of view that it is a selective and distributing agency (1927:188). He argues that the school is an agency which leads not so much to an obliteration of mental and social differences as to their increase ... [it] is a machinery [for] the stratification of society, not of “levelling” or “democratisation” ’ (1927:189-190).

Returning to the subject of vertical mobility in Western societies, Sorokin sets an example for later studies, such as that associated with David Glass, by focussing on the extent of inter-occupational and intra-occupational mobility and in particular he asks the question, to what extent does the occupational status of the father determine that of his children. In caste society, Sorokin says, there is an established set of privileges adhering in caste groups which confers the right to the performance of a definite occupation on an hereditary basis. In modern Western society, by contrast, the occupational status of parents plays a more modest part in determining that of their children. Sorokin states that the transmission of occupational status seems to be much less in Western societies than a hundred per cent. In his view contemporary occupational groups are far from rigid. He notes the probability that the transmission of occupational status is not equal in all occupational groups. He also seeks to show with such evidence as is at his command, that there is a considerable fluctuation of inheritance of occupations in different social groups. He further suggests (1927:419), quoting F. Chessa,¹ that ‘hereditary transmission of occupation is stronger in those occupations which demand a greater technical experience and specialisation or a more or less large amount of money for their performance than in the occupations which do not demand either of these conditions’.

On the subject of the liberal professions, (again following Dr Chessa) Sorokin proposes that hereditary transmission of occupations tends to be higher in those professions which are connected with social honour and privilege and which are also characterised by stability and durability, or again those which require intensive intellectual work. He makes the point that these conclusions are tentative and need to be tested by further studies. Following up the evidence he has presented, Sorokin suggests some ‘tentative inferences’ (1927:426–7). He says

‘other conditions being equal, first, within the same occupation the more qualified and better paid strata shift less intensively than the less qualified and more poorly paid groups; second, members of occupations which disappear shift more intensively than members of occupations which develop and prosper; third, unskilled labour is more mobile than skilled labour; business and professional groups (their higher strata) are likely to be still more stable even than the group of skilled labour’ (1927:427).

Another interesting proposition put by Sorokin is that ‘the closer the affinity between occupations, the more intensive among them is mutual interchange of their members; and vice versa ...’ (1927:439).

From our point of view, it is important to notice that all of these statements which anticipate much of the later research on social mobility do not deal adequately with the question of group mobility, but always focus on the transposition of individuals from occupation to occupation. It is very relevant to our argument to notice that in his section on professional organisations as channels of vertical circulation, there is no conception of the possibility of collective mobility via professionalism. On the contrary, he argues that

‘as the entrance to these organisations (professional organisations) has been relatively free to all who displayed a corresponding ability, regardless of the status of families, and as an ascent within these institutions has been followed by ... elevation in the social position of a corresponding individual, therefore, many scientists and scholars, lawyers and literary men, artists and musicians, painters and architects, sculptors, physicians, and players, dancers, and singers, born in humble families, have climbed up through this channel’ (1927:174).

This quotation underlines the fact that Sorokin holds the long accepted view that the professions are vehicles through which individuals obtain upward social mobility. There is no conception in his work of the idea we are advancing, namely, that professionalism is itself an important type of collective action which may be used as a strategic mechanism to elevate the social position of a whole occupational group.

Speaking of what he regards as ‘the Golden Rule of distribution of individuals’, he says,

‘in the ideal mobile society individuals must be distributed according to their capacity and ability, regardless of the position of their fathers. Such a social distribution where everybody is placed at his proper place, seems to be the best. At least since ancient India and China, through Plato and Aristotle, up to the present democracies, this type of social distribution of individuals has been recognised as the most desirable. And, it seems, only an ideal mobile society can realise it. In an immobile society, only extremely fortunate racial purity may to some extent approach such a type. But such purity cannot prevent the appearance of children dissimilar to their parents, [therefore] even an exclusively fortunate immobile society has to deviate from the ideal rule. In an ideal society, such children are at once shifted to the positions corresponding to their ability’ (1927:530).

Sorokin takes the view that within mobile societies, since there is a system of open positions and greater competition for the higher places among candidates... ‘the relatively weaker individuals are eliminated or ousted by the relatively stronger ones’. This process by which the weak posterity of prominent parents is forced downward and stronger men of humbler origin climb up, ensures that ‘the whole social structure is permanently cleansed from the inappropriate dwellers of its different storeys’ (1927:532).

He distinguishes between this form of ‘normal vertical mobility’, which facilitates a more appropriate social distribution of individuals and an alternative form, which occurs in anarchical or revolutionary times and which, in his view, is quite blind and unselective.

Sorokin is well aware of the arguments for and against an open society which maximises opportunities and chances for social mobility. Indeed, he rehearses the arguments in his book. His position is, however, different in some respects from many of the liberal or social democratic writers on social mobility. These hold the view that the maximisation of social mobility is desirable as a means of achieving a more egalitarian and less class-ridden society. For Sorokin, social mobility is important precisely because it is a defence of social order. Thus potential revolutionaries who are given the opportunity to rise and are incorporated in the ruling group are transformed from leaders of revolution into protectors of social order. In this way ‘mobility permanently robs the revolutionary factions of their possibleand capable leaders’ (1927:533–4). This, then, appears to be the principle reason why Sorokin supports the ‘open society’.

Sorokin suggests two important conditions for the creation of such a society. They are ‘an equality in the starting point of children and an equality of chance’. He goes on to argue that

‘as we cannot know a priori who are talented and the nature of those talents, we must test them. In order that the testing be fair it is necessary that children start from the same point, equipped more or less equally, and given equal chances in “their life race”. Only under such conditions of equality may be determined those among them who are “good runners”’ (1927:530).

Another condition he lays down is that the testing institutions and methods be adequate. Sorokin’s difficulty in attempting to marry his conservatism with American liberalism is apparent in the following quotation:

‘it is somewhat difficult to decide whether mobile or immobile societies have been nearer to their ideal rule of social distribution of individuals. We know some mobile socities, and the United States of America may serve as an example, in which the social distribution of individuals has been very satisfactory. But we know also some immobile societies, like India, where social distribution has been not altogether bad. The objective fact of an unquestionable supremacy of the Brahmins during 2,000 years is a very convincing test of their adequacy for their social position regardless of whether we like the caste-system or not. Surely, stupid men, without m...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Dedication
• Contents
• Acknowledgements
• Introduction
• Part I
• Part II
• Part III
• Bibliography
• Index