Framing a Profession: Meaning and Autonomy in Medicine

Research has stressed the importance of autonomy to professional identity. Autonomy, scholars have said, grants professionals the license to use their unique skills and esoteric knowledge on behalf of clients. The growth of constraints upon professional autonomy in the last several decades has been predicted by some scholars to herald a proletarianization of the professional class. Existing work also suggests that people turn to culture to reconcile themselves to challenges to their worldviews.

This dissertation examines professionals’ use of cultural logics to organize their work experiences into coherent landscapes of meaning. By using culture in this way, they manage the experience of declining autonomy and link their work to a vision of the good. Cultural logics do not exist solely in professionals’ minds; rather, they exist in dialectical tension with the institutional infrastructure in which professionals work.

As professionals for whom autonomy has been particularly emphasized but who face extensive intervention from external forces, doctors represent a highly appropriate group with which to analyze the use of culture in managing professional constraint. I identify and outline three cultural logics doctors use to make sense of and adapt to infringements upon their autonomy. Each logic places a special emphasis on one particular form of autonomy and encourages doctors to defend or pursue it. Sardonic pragmatism directs doctors’ ambitions toward small victories and cultivates indifference toward the decline of autonomy. It stresses negative autonomy and encourages doctors to withdraw (emotionally if not physically) from that which is seen as distracting or counterproductive. Progressive planning fosters a tentative embrace of the structural changes as a means of directing the field toward the conservation of scarce resources and away from the preservation of exceedingly medicalized life. It emphasizes a form of hierarchical autonomy in which the peopling of the hierarchy is determined by insight rather than simply tenure. Neoclassical professionalism resists structural changes through a combination of denial and conflict, stressing the importance of preserving human connections between doctors and patients. It asserts interpersonal autonomy, through which doctors are empowered to make the connections to others that are, in this view, essential to optimal medical care.

The larger implications of this research speak to the sociology of culture, the study of professions, and the contested organizational and moral visions underlying contemporary medical care. Through the use of culture, individuals can accommodate themselves to constraints that might seem intolerable when viewed through an economic or institutional logic. It is shown that action can, in fact, be driven by cultural models and not merely by practical consciousness. Additionally, the stakes of the cultural contestation at work in the medical field inform discussions regarding the meaning and value of life and the role of the medical field in managing it.