ARTIGO ORIGINAL

The sociology of prudential activities: from collective commitment to social innovations

A sociologia de atividades prudenciais: de compromisso colectivo a inovações sociais

La sociologie des activités prudentielles: de l’engagement collectif aux innovations sociales

La sociología de actividades prudenciales: del compromiso colectivo a las innovaciones sociales

 

Florent Champy*

* Research Professor, National Centre for Scientific Research, Toulouse, France. E-mail: fchampy@univ-tlse2.fr 

 

ABSTRACT

Former research has drawn attention to the specificities of “prudential activities”, for which irreducible uncertainties require special attention to the concrete cases professionals handle and availability for special deliberations on sensitive cases. Based on empirical research on architects and doctors, this article aims at making it clear what prudential activities are and at presenting three interrelated research programs: on collective commitments of professionals as a consequence of practical wisdom, on increasing barriers to practical wisdom, and on social innovations aiming at overcoming these barriers. New light is being shed on well-known evolutions of work contexts: namely bureaucracy, and demand for objectivity and performance.

Keywords: prudential activities, bureaucracy, social innovation, uncertainty.

 

RESUMO

Investigações anteriores chamaram a atenção para as especificidades de “atividades prudenciais”, cujas incertezas irredutíveis requerem especial atenção nos casos concretos com que lidam os profissionais e a disponibilidade de deliberações especiais em casos sensíveis. Baseado em investigação empírica de arquitetos e médicos, este artigo visa tornar claro o  que são atividades prudenciais e apresentar três programas de investigação interrelacionados: sobre compromissos coletivos profissionais como consequência do conhecimento prático, sobre aumentar barreiras do conhecimento prático, e sobre as inovações sociais feitas para superar estas barreiras. Novas perspetivas estão a aparecer no que toca às evoluções de contextos de trabalho: nomeadamente a burocracia e a procura de objectividade e desempenho.   

Palavras-chave: atividades prudenciais, burocracia, inovação social, incerteza.

 

RÉSUMÉ

Un certain nombre de recherches précédentes ont attiré l’attention sur les spécificités des “ activités prudentielles ”, dont les incertitudes irréductibles requièrent une attention particulière dans les cas concrets dont s’occupent les professionnels et la disponibilité de délibérations spéciales dans les cas sensibles. Basé sur une recherche empirique sur les architectes et les médecins, cet article vise à établir clairement ce que sont les activités prudentielles et à présenter trois programmes de recherche reliés entre eux : sur les engagements collectifs professionnels comme conséquence de la connaissance pratique, sur l’augmentation des barrières de la connaissance pratique et sur les innovations sociales conçues pour surmonter ces barrières. De nouvelles perspectives voient le jour en ce qui concerne les évolutions de contextes de travail : en particulier la bureaucratie et la recherche d’objectivité et de performance.   

Mots-clés: activités prudentielles, bureaucratie, innovation sociale, incertitude.

 

RESUMEN  

Investigaciones anteriores llamaron la atención para las especificidades de “actividades prudenciales”, cuyas incertidumbres irreductibles requieren atención especial en los casos concretos con que los profesionales acuerdan y la disponibilidad de deliberaciones especiales en casos delicados. Basado en una investigación empírica de arquitectos y médicos, este artículo pretende elucidar lo que son las actividades prudenciales y  presentar tres programas de investigación interrelacionados: sobre compromisos colectivos profesionales como consecuencia de conocimiento práctico, sobre aumentar barreras del conocimiento práctico, y sobre las innovaciones sociales realizadas para superar estas barreras. Están apareciendo nuevas perspectivas en relación a las evoluciones de contextos de trabajo: denominadamente burocracia y la búsqueda a la objetividad y desempeño.

Palabras-clave: actividades prudenciales, burocracia, innovación social, incertidumbre.

 

 

Introduction

How to define a profession? Can any occupation be said to be a profession? Should the status of profession be dedicated to some activities and if so, which activities selected according to which criteria? Sociologists have adopted three successive positions on these issues. According to functionalists, only some activities involving a high level of expertise, enjoying a prestigious status and strong autonomy at work are professions (Parsons, 1951). Interactionists then criticised that definition of professions, which they saw as merely replicating the very discourse of professionals (Becker, 1962). They suggested that all activities be studied in the same manner, leaving aside all questions on the specificities of professions as compared to other occupations (Hughes, 1971). By doing so, they brought forward a new sociological approach to professional activities, but they closed off possible avenues for research programs that would discriminate between types of activities. Thirdly, as professional autonomy was being attacked by new public management, sociologists resumed their investigation of the specificities of a professional model that would justify this autonomy while trying not to refer to the discredited functionalist definition. Here is the third position put forward by Freidson: “I do not think the problem [of defining professions] can be solved by struggling to formulate a single definition which is hoped to win the day. […] It is precisely because of the lack of any solution to the problem that I feel that serious writers on the topic should be obliged to display to readers what they have in mind when the word is used”. (Freidson, 1994: 27). However pragmatic that solution is, it has one disadvantage. Allowing each researcher to propose her/his own definition may hold back the development of shared programs and cumulative studies.

Our own solution is close to Freidson’s, more forward-looking, yet without any ambition to “win the day”. We share the same refusal to return to the functionalist definition as well as to the lack of differentiation between types of activities inherited from the sixty-year old interactionist program. But we differ on one point. We believe that specific types of activities can be exposed and associated to long-lasting specific research programs. This article will more precisely focus on one of these types called prudential activities with reference to the Aristotelian concept of phronesis, namely practical wisdom.[1] This philosophical concept makes it possible to break away from the previous debates held in the sociology of professions. This article mostly ambitions to highlight that the concept is of interest first to develop some original research work in order to study the commitments of professionals, professional segmentation, the role of practical wisdom at work, the obstacles that stand in the way and how some professionals overcome them. It will also allow revisiting these questions dealing with the consequences of new public management on professionals working in organisations, knowing that such questions are at the very core of the current sociology of professions. To illustrate the contribution of practical wisdom, three fields of activities will be studied: architecture, medicine and, based on Lascar’s research, social work (Lascar, 2016).

The article is divided as follows: the concept of practical wisdom and the specific features of prudential activities as illustrated by the fields of architecture and medicine will first be presented. We will then focus on the barriers to practical wisdom in those two activities. The study will be completed by a presentation of the way professionals in medicine and social work attempt to overcome the increasing barriers to actual prudential work.

 

How research on architecture has led to the discovery of prudential activities

Discoveries are all the more substantial as they have emerged by chance. One cannot run the risk of mobilising a philosophical concept in sociology without some strong and reliable reason. As it happened, I discovered the concept of practical wisdom thanks to a colleague, Philippe Urfalino, who had noticed strong similarities between what I described in one of my articles and some characteristics of prudential practice. That article dealt with the Congrès Internationaux d’Architecture Moderne (CIAM — International Congresses of Modern Architecture), a group of European architects who met regularly from 1928 to 1956 (Champy, 2009). Those architects founded the CIAM as a reaction against the attacks suffered by Le Corbusier and his cousin Jeanneret concerning their project for the League of Nations headquarters in Genova, attacks initiated by Lemaresquier, a Paris Beaux-Arts influential professor and a member of the jury of the architecture competition held in 1927. My article highlighted how modern architecture, particularly concerned about addressing social issues, developed against the overly aesthetic tradition of the Beaux Arts that was then prevailing in public orders.

The CIAM architects first criticised the supremacy of aesthetics and of originality in the projects carried out by the Beaux-Arts. As a reaction, they set new building priorities and put the economy, the uses of living units and the functional integration of buildings into the site at the heart of their architectural engagement. They gradually formalised their architectural principles into an alternative doctrine put forward in the famous Athens Charter (Le Corbusier, 1973 [1943]).[2] The CIAM then attempted to convince commissioners, which they successfully did in France during the post-war Reconstruction period.

Their success sprang from the gap they had identified between the way Beaux-Arts architects prioritised the ends of their practice and what was expected or needed in a world disrupted by urbanisation and industrialisation. That led to significant changes: orders were commissioned to new architects after the Second World War, a number of cities were rebuilt according to an innovative building model drastically differing from the interwar architectural principles. From the 1960s onwards, their work and the modern trend were in turn criticised and a new style entitled post-modernism emerged which, once again, upset the prioritisation of the ends in architectural practice. They particularly revalorised originality and ornament over the modern ideals of functional and economic rationalisation (Venturi, 1966).

This example provided the basis for an original theoretical framework with fruitful consequences for the sociology of professions. In some activities, practice requires deliberating not only about the means to implement but also about the prioritisation of the ends of the activity itself. These ends have remained more stable than one might have expected. A broad study of architectural courses, treaties and competitions has shown that a set of evaluation criteria for architectural projects prevails: elegance of buildings, aesthetic and functional integration into the site, economy, originality, etc. When one of the requirements is overlooked, it leads to a form of degeneration of the activity, quickly followed by critical reactions: “producing a work of architecture always means designing a building, an object which is both functional and aesthetic and which must be considered both as self-sufficient and as part of a broader whole, its site” (Champy, 2011: 85).

Hence, working as an architect means trying to achieve a balance between potentially contradictory aesthetical, functional, urbanistic and economic requirements. Because not all of them can be best met with at the same time, architects have to prioritise the objectives of the activity. Nevertheless, these choices are not to be re-questioned each time. Whether a matter of period, policy or dominant style, a hierarchy tends to prevail as if self-evident. This is what we have called “common practice”. Yet there may be different approaches to the balance to be achieved and reactions emerge each time the common practice, by turning into routine, overlooks some dimensions of the architectural activity, or sets ways of doing things that prove ill-adapted to all operations. That may also happen when expectations towards architecture change. Challenging the previously self-evident prioritisation of ends is then brought forward by committed architects campaigning for an aggiornamento of their activity. Those commitments have significant consequences (Champy, 2011): an “agonistic” segmentation of the profession between conceptions competing against each other; changes in the orders commissioned to the architects; more or less extensive dissemination of those innovations once achieved; changes in the architects’ careers according to their position in the competition between the new and the old normative conception of the activity. These phenomena may apply to other activities (it will be demonstrated in the field of medicine) but not to all of them.

What has been observed in the case of architecture has outlined the significance of practical wisdom for some professions, since deliberations about the ends of the activity are a distinct feature of practical wisdom (Aubenque, 1963; Broadie, 1991). This is what will be accounted for now. Practical wisdom is the approach required for acting in specific and complex situations, which produce a high level of uncertainty. It is also the virtue required for protecting others (whether clients of professionals or citizens in the field of politics) from the damage incurred whenever uncertainty is not properly acknowledged. It is the very opposite of a mechanical implementation of rules that are too abstract (that is, devised without any reference to the practical situations to be dealt with), of formalised procedures, of scientific knowledge or of routines. It implies that particular attention is to be paid to the concrete aspects of the situation, to its singularity and complexity. Anything that makes it impossible to grasp the reality in order to take it into account when acting stands in the way of practical wisdom. And yet, even the closest attention to concrete features cannot remove all uncertainties. That is why the prudential actor has sometimes to move on despite irreducible uncertainties, which supposes to make speculations which, although strengthened by experience, may prove mistaken. This conjectural dimension is unavoidable in the situations practical wisdom helps to address. Practical wisdom, though a modest rationality, is both realistic and challenging.

How can one account for the fact that changes in the prioritisation of ends have allowed the identification of a type of professions singled out by the amount of practical wisdom it requires? It is simply that the situations requiring the use of practical wisdom are complex, which means that not every single end can be fully achieved at its best. Practical wisdom then implies that one has to make choices for which the respective importance of the different objectives is to be deliberated. Hence, the diversity of the choices made concerning the priorities to be selected in their work by the members of a prudential activity. By defeating the exclusively technical solution, uncertainty calls for an evaluation based on ethical or political dimensions and may lead to commitments that are specific to prudential activities.

Medicine is the ultimate prudential activity (Aubenque, 1963; Ricœur, 2001). Because it is bound to deal with the individuality of patients and the complexity of the human body and psyche, it is the perfect illustration of all the features of prudential activities.

Treatments must sometimes be attempted even if the exact nature of the disease is not ascertained. In addition, even though diagnoses may be reliable, reactions to the treatment may differ from one patient to another. Therefore, doctors have to carry on working while taking into account those uncertainties. Besides, due to the complexity of medical work, a number of principles of action may be competing: quick recovery, preventing relapses and complications, limiting undesirable effects of the treatment, cost effectiveness, consequences on public health. Thus, doctors have to analyse the way they will balance those principles according to each patient. Excessive and pointless therapy is an example of the failure of collective judgement, which has raised protests. Michel Castra’s research work on palliative treatment has outlined how doctors confronted to often unreasonable routine treatments have fought for a wiser palliative approach and have finally been listened to by public authorities (Castra, 2003). The history of the struggle that led to the implementation of palliative treatment illustrates the same type of phenomena as those exemplified by the CIAM. It shows that, even if scientific knowledge is crucial in the field of medicine, it is not enough. Because of the twofold conjectural and political dimension of medicine, scientific knowledge alone cannot provide answers to all the difficulties doctors meet in their practice. Neither can professional routines, set protocols or rules. Proper judgement is required, which evidences the prudential dimension of medical practice.

This does not mean that the concept of practical wisdom is well known in the medical world. Quite the opposite, impressive technical progress has contributed to a lack of visibility of the prudential dimension (Champy, 2015). Concerning diagnoses, the progress in biomedical research and medical imaging, which have provided doctors with remarkable investigative tools, has pushed the more uncertain clinical work into the background. Concerning medical decisions, the development of epidemiological techniques has introduced statistics and probabilities (hence mathematics) into the practice, with Evidence-Based Medicine. The latter enables doctors to determine which treatment will be the most successful taking into account the characteristics of the patient and of his/her pathology, particularly in cancerology. Hence, the conjectural dimension of the medical decision recedes. Formerly seen as an “art”, medicine is now so close to a highly scientifically delineated practice, that it sometimes arouses the hope that science might finally overcome the remaining part of uncertainty and challenge left in the decision. Observing these changes has led some to herald the disappearance of medicine as currently practiced by doctors, i.e. by prudential professionals (Vallancien, 2015).

Other activities, such as education and law, provide examples of controversies fuelled by the debate over the prioritisation of the ends of the activity, but not all activities do (Champy, 2011). The concept of practical wisdom can thus be used to identify a specific type of professions. Above all, by bringing to light the part played by practical wisdom, it highlights two key issues in the field of work. The first one is the necessity to adapt to individual persons, cases or situations addressed: do working contexts still allow for such adaptation? For example, are treatments well adapted to each patient, taking into account their specific pathology, general condition, social situation, etc.? Similarly, are court rulings individualised, even though scales have been set in order to reduce unfair treatment of the offenders depending which court they are tried at? The second issue concerns the type of commitments already mentioned: is the critical assessment of common practices and proposals for alternative practices still possible, as exemplified by the discussions around modern architecture and palliative treatment? On the contrary, aren’t professionals more and more trapped in technical practices far from this type of considerations? The issues at stake in prudential activities definitely make it all the more necessary to study them as original sociological objects since the changes taking place in working contexts tend to increase the barriers to prudential practices.

 

Barriers to practical wisdom in bureaucratic contexts

Difficulties met in architectural design

The prudential dimension of the activities is largely ignored in western societies fascinated by technical and scientific progress, and that goes beyond the case of medicine.[3] This lack of visibility of practical wisdom makes it vulnerable to the influence of other developments, such as the idea of professionalism expected from professionals by users or clients, or at least by managers who claim to represent the latter (Fournier, 1999; Evetts, 2003). “Occupational professionalism”, which used to highly value the know-how and an autonomous implementation, is being gradually replaced by some “organisational professionalism” valorising different qualities: performance, responsibility, capacity for supposedly objective decision-making (Fournier, 1999; Evetts, 2003). The concept of practical wisdom enables to grasp more precisely the difficulties arising from these new expectations since in the very situations loaded with strong and abiding uncertainties that would require resorting to practical wisdom, those expectations cannot be met. How could a professional be objective when he is confronted with such uncertainties that his action can only be based on speculations? How can he be increasingly efficient and pay attention to the complexity of the cases he is to address? Professionals are sometimes faced with those difficult questions at the very core of their practice. Besides, the evolution of the prevailing model of professionalism is reinforced by very concrete organisational changes that leave little room for practical wisdom but whose negative effects are difficult to criticise systematically. Studies in the fields of architecture and medicine have underlined to what extent bureaucratic regulations often stand in the way of prudential approaches.

Architectural work consists in gradually incorporating a number of decisions into a project to rule out initial indecision while trying, as shown previously, to strike a balance between the various dimensions of the project (Champy, 2011). However, balance was more easily achieved when the architect was in the position of a conductor enjoying a global overview that enabled him to base his decisions on an overall analysis of the project. The overall vision has been maintained, but, in the case of major public works, architects no longer enjoy any relevant authority over the other professionals (in particular engineers) involved, so that they are no longer in a position to mediate all the major decisions contributing to move the project forward. While architects used to be centre stage as the ordering party, the other stakeholders have, since the 1970s, been directly dealing with the client on equal footing. Two more recent changes have also added to the fragmentation of decisions, the first one being the increasing division of labour. More and more stakeholders are called in to ensure that all the quality criteria are being taken into account in the design: beyond the engineering consultants and the technical and economic building consulting offices who have been there since the 1960s, we now have urban planners or landscape designers to make sure the building fits into the site, together with acousticians or colourists to look after the sensitive qualities of the interior or ergonomists to ensure spaces are functional. This increasing division of labour may help to ensure that none of the dimensions of the initial design is left aside by an unscrupulous or incompetent architect, but balancing the ends of the activity is made more difficult.

Secondly, the process of architectural design is getting increasingly rigid. Projects used to be conducted in a rather flexible manner, which meant that some decisions could partly be questioned as a consequence of later considerations. For instance, the interior organisation of a building might have led to slightly reconsidering the whole volume of the work. But decisions now tend to become much more compelling, they are less and less easily likely to be questioned at later stages as work develops and as the architect’s overall view improves, thus reducing the constraint-related uncertainties. The greater number of stakeholders and the loss of the architect’s authority add to the rigid organisation since any reconsideration of a decision first requires all the stakeholders’ agreement. As a result, stakeholders tend to feel bound by former decisions they see as project-related contracts. These three changes altogether make it difficult to try and achieve the prudential balance which has long characterised the work of architects (Champy, 2011).

The evolution in programming is a particularly good illustration of these trends. The bill of specifications is now drafted by professionals other than architects who are bound by it. Direct relation to reality (such as analysing the expected uses of the building in order to design adequate spaces), is being replaced by a simplified written presentation of those uses and of the characteristics of the use-related spaces. Constraints are listed prior to any overall reflection on the project. These constraints may well have some effects on the building which architects could have tried to avoid, but which they now have to comply with as inescapable consequences of the division of labour. More and more sequential decisions are being made without any global overview, without any overall reflection on the project, that is, without much practical wisdom. Because of the predominance of the bill of specifications, what is being lost here is the architect’s direct reflection on the relation between the function expected to be accommodated by the building and the spaces.

Medical practice at the hospital

Hospital medicine is also affected by two organisational evolutions, whose effects increase the lack of visibility of practical wisdom and reinforce the cultural influence of the new “organisational professionalism”, thus making prudential practice more difficult. The first one is an increasing division of labour, among specialists for example, which results into organ-focused specialisation which, in turn, may affect the understanding of patients as individuals with their own identity and willpower. In urban areas, there have been attempts to counterbalance the division of labour by setting up interprofessional health care centres and clusters. More generally, interprofessional organisation has become one of the major themes of discussion for contemporary medicine. But the hospital being the place of extreme functional and hierarchical distinctions between specialities on the one hand and between professional groups on the other, has stayed well away from the evolution. Besides, the 2009 HPST bill (Hospital Patients Health Territories) changed the mode of payment of medical treatment so as to promote technical procedures which hospitals would have previously limited in their global budget. A “price per activity” (tarification à l’activité — T2A) was established for most procedures. Unfortunately, encouraging more technical procedures came at a price, that is, lower recognition of less technical treatments. As a result, hospital missions such as prevention, exchanges with patients and medical education have been discouraged. And yet they bear a close relation to practical wisdom, as they favour direct contact with patients, which enables doctors to take into account the various concrete aspects of their situation (lifestyle, disposable income to face treatment expenses, personal choices), all those aspects which are often overlooked by organ and biomedical specialists for whom decisions may only consist in implementing technical procedures based on medical records. These evolutions are more disturbing for specialised fields, such as diabetology where assisting patients is of utmost importance, than for more strictly technical specialities. A concrete example will be later used to demonstrate how the technical and bureaucratic hospital organisation has hindered appropriate care.

So, as can be seen, the recent evolutions in working contexts are often barriers to practical wisdom. Even though professionals are becoming aware of increasing difficulties, they find it difficult to devise adequate solutions, mainly for three types of reasons. First of all, the lack of clear understanding of the concept of practical wisdom prevents systematic explanations of the harmful consequences of those evolutions. Inconveniences and adverse consequences are quite easily identified. But without the concept of practical wisdom, criticism is incomplete, since what is at stake in these evolutions and their harmful consequences cannot be clearly named. Moreover, when critical professionals call for the right to depart from damaging regulations or to ignore orders that cannot be satisfied, they may be suspected of defending corporatist postures favouring a professional autonomy that would be detrimental to those users’ interests new public management claims to support. Finally, for a number of reasons, some professionals opt for these evolutions. First, the idea of professionalism is rather rewarding. Given the lack of systematic criticism of the barriers to practical wisdom, it might be difficult to justify one’s refusal of (organisational) professionalism, of efficiency and of objectivity. Besides, senior professionals socialised through the older prevailing model of “occupational professionalism” are being replaced by younger colleagues who have been trained in a management-focused context characterised by a greater valorisation of the norms of “organisational professionalism”. Last of all, some professionals get some advantages, particularly economic benefits, out of the current evolutions as the new norms of predictability, objectivity and performance, concerning everyone working in an organisation, remove some sources of unpredictability that may complicate matters at work. And yet, supporting the values of organisational professionalism does not make things simpler. On the contrary, it may add to professionals’ discomfort, even to their suffering, when faced to injunctions that they tend to see as legitimate, but cannot always satisfy since they have to deal with situations characterised by irreducible uncertainty.

 

Professionals start mobilising

Health Care Access Programs

These changes in professional contexts not only affect the daily conduct of work, but also the critical movements characterising prudential professions. As has been previously shown, mobilisations to promote specific approaches to activities (modern architecture; palliative care) used to characterise prudential activities. But those examples are rather dated. There are but very few more recent examples. Studies show that the prevailing professional figure is more that of a technician rather than that of an activist committed to defending a particular approach to her/his activity. It looks as if critical reflexivity is receding under the efforts made to meet the new public management’s expectations and their prevailing value of objectivity. Focusing their attention on the constraints they are imposed, professionals might no longer be in a position to collectively imagine news ways of doing things away from common practices, as they used to. The discourse of new professionalism is perfectly in line with the conception of professional work as mainly technical, as fostered by these new constraints (Fournier, 1999; Evetts, 2003).

Some representative professional institutions have been dealing with those difficulties. For instance, as early as the end of the 1990s, the Conseil National de l’Ordre des Architectes (the National Council of Architects) has criticised the rigid procedures imposed by the separation between programming and design. Similarly, public authorities have repeatedly called for more interprofessionality and global approaches to patients. But, alongside those initiatives resulting from top-down logics, some more definite answers are emerging from those Eliot Freidson named “professional practitioners”, who use the very difficulties they meet in their practice as a starting point. The idea presented here, relying on ongoing research work, is that the difficulties arising from increasingly rigid work contexts give birth to new types of professional mobilisations. Professionals are no longer advocating, as they used to, a particular approach to their activity, but calling for less rigid work organisation, which would allow new opportunities for a more prudential practice. In reference to the concept of “moral entrepreneurs” (Becker, 1963), these professionals can be named “prudential entrepreneurs”.

The first example is provided by the field of medicine. It comes from Health Care Access Services (Permanences d’accès aux soins de santé — PASS), which receive patients who are denied access to other medical facilities, often because they are uninsured. Many of them are foreigners without any residence permit or have just arrived in France. Extremely precarious conditions and exclusion may include lack of permanent accommodation, poor and insufficient food and breaking away from any reliable social relationships. These extremely difficult living conditions are likely to disrupt their health care pathway and treatments prescribed by specialised doctors are not always adequate to satisfactorily improve their health condition. Better hygiene, accommodation and diet as well as struggling against the violence of social relationships endured, particularly by foreigners, are often as necessary as strictly medical care. That is why a holistic approach appears as the most appropriate to these tragic situations. But hospital practitioners are rarely comfortable with that type of approach which does not really fit in with their highly specialised technical identity. That is why the PASS medical staff, more used to dealing with those difficulties, plays a decisive role in treatments. However, hospital organisation sometimes makes things more complicated.

Let us take the example of a rather straightforward medical case made more difficult by the hospital financing regulations. The medical decision concerned a thirty-one-year-old mother of several children who was sleeping under a tent in Paris and begging for a living. Her children lived back in her country of origin. She was taken to the emergency service in a Paris hospital and diagnosed breast cancer two weeks later. The case was a straightforward radiotherapy treatment followed up by regular medical supervision. Under good conditions, the treatment allows a very favourable prognosis, with a probability of sustainable remission or recovery close to 1. Because she had been in France for less than three months, she was not entitled to any comprehensive health cover. But her cancer treatment, whose cost was lower than 5000 Euros, could have been paid for by specific funding dedicated to urgent and vital care. The case was medically and financially quite straightforward.

In order to implement the treatment, the hospital where the patient was looked after contacted the radiotherapy service of another hospital. But the oncologists wanted the patient to have decent accommodation and a proper diet as a prerequisite. None of the solutions considered could be achieved. The best would have been accommodation in a care institution or a hotel. But hospitals are forbidden to finance outside accommodation, even if it would be far less costly. The hospital in charge of the treatment refused to receive the patient, arguing that it would amount to a nightly 1600 Euros loss over several weeks. Thus, the only available solution was also the most costly: keeping the patient in the hospital where she had been admitted, with, not only the same hospitalisation costs, but also some extra costly transport and strain for the patient who was also suffering from a slight mobility handicap.

In order to try and solve this type of problems, the doctor in charge of the local PASS set up multidisciplinary meetings gathering the PASS doctors, the specialists in charge of the patient, nurses, social workers and a representative of the hospital finance department. Their main objective was to contribute to a global reflection on both medical and social care, purely medical problems being dealt with in exclusively medical meetings. The observation of seven of these multidisciplinary meetings and the analysis of five extra meeting reports have permitted to form a better idea of the PASS doctors’ objectives: beyond trying to solve the economic or social problems obstructing treatment, they mean to expose the therapeutic aporia resulting from therapeutic routines and from bureaucratic rules. These aporia are very easy to understand in such difficult cases as PASS patients, yet it is to be remembered that they may be met with elsewhere in the hospital. Analysing the cases before representatives of the financial services and before specialists rarely confronted with treating highly precarious patients has thus become an end in itself, regardless of the decisions achieved. Their next goal is to propose amendments to those routines and rules and to highlight the know-how of the PASS medical staff to solve situations which leave colleagues in other services unable to cope, even though some obstacles on the way do not always permit the PASS stakeholders to fulfil these objectives.

Moreover, to support their critical in situ analysis, relying on concrete cases, of an exclusively technical care model, the medical staff of several PASS launched a more clearly political action and in 2011 set up the Collectif National des PASS (PASS national movement) as a national advocate for their reflection. Team work on research, ethics and communication, seminars and symposiums as well as publications is gradually promoting the idea of an alternative model to the hypertechnicised and bureaucratic hospital. The main characteristics of the model are a better connection between medical and social aspects; interprofessional exchanges providing better opportunities for the staff other than doctors, civil service representatives, lawyers, philosophers… to express themselves; more amenable protocols, whenever adapting to a particular case may be required and justifies departing from the set protocol. The 2015 PASS symposium proceedings were entitled “Caring for People” as an illustration of their commitment to holistic medicine (Georges-Tarragano Astre and Pierru, 2015). In 2016, the symposium, which was entitled “The PASS, a laboratory for tomorrow’s hospital”, outlined the ambition to use PASS experience to support innovations that could be transferable elsewhere in the hospital.

Caring for “those juvenile offenders nobody knows what to do with”

The situations prudential professionals are faced with do not necessarily trigger collective mobilizations. However hard we tried, we were not able to find any convincing example in the field of architecture. That is why the second instance presented here concerns social work and relies on the study developed by the director of a social centre for juvenile offenders (Lascar, 2016).

Eric Lascar’s study reveals strong similarities with the PASS cases. Innovation has come from the professionals responsible for those “unmanageable” juvenile offenders with a history of repeated failures through a succession of institutional care centres. It must be underlined that looking after these youngsters is particularly difficult as they fall under the responsibility of a number of heterogeneous logics of intervention (disciplinary, educational, economic, psychiatric), which no single institution is altogether familiar with. Hence, moving from one to another institution results in disruptive paths that prevent any sustainable improvement. Some social workers confronted with those difficulties are considering other modalities, largely relying on interprofessionality, which implies working together towards a common cultural approach. These social workers, just like the PASS professionals, keep insisting on the necessity of being allowed to ignore some of the current rules they are imposed on. For instance, in the case of an adolescent under care running away, formal procedures are mostly disciplinary, so the runaway is automatically notified to the police, which leads to punishment, often to dismissal. The very rules both adolescents and social workers have to abide by lead to disruptive paths, which is precisely what should be avoided, as it contributes to their construction as “unmanageable” adolescents.

As a consequence, these social workers propose to reverse the perspective and prioritise mutual trust between adolescents and their social workers at the very top of their objectives. When dealing with a runaway, a more sympathetic approach should be privileged over more systematic reactions, with, if necessary, throwing off disciplinary rules in order to follow the adolescent, to accompany him during his runaway and, once the critical phase over, to bring him back. The question is no longer to apply rules that cannot be complied with and which generate a high risk of breakup, the aim is to come forward with realistic objectives that would preserve the educational follow-up and avoid escalating rejection and failures. But, for social workers to be able to implement such logic would mean leaving their workplace and taking up an adventurous path with no idea where or how far that would lead them. Any social worker choosing that approach would risk heavy disciplinary sanctions for serious professional misconduct. It is therefore to address these challenges that social workers, among whom Eric Lascar, have come forward with the idea of institutions operating on completely different principles. Unfortunately, the centre Eric Lascar had managed to set up had to close down eighteen months later for lack of support from the Ministry in charge of juvenile protection.

Everywhere, innovation is being obstructed by routines and set rules. As outlined by Norbert Alter (2005), the logics of innovation and the logics of organisation are mostly contradictory as innovating also means modifying stakeholders’ territories, hence their responsibility. In the two previously studied cases, the logics of innovation go beyond an occasional adaptation of the rules. It aims to transform them so as to promote more comprehensive care models, allowing more opportunities to adapt to each patient (to her/his medical and social distinctive characteristics) or to the adolescent (taking into account her/his difficulties to abide by some rules). These innovations not only come up against organisational rigid approaches, but their explicit objective is also to make them more flexible. It is the very determination of these medical staff or social workers to set adaptation to concrete cases as a matter of priority (even though it means criticising applicable rules) that truly makes them prudential entrepreneurs.

 

Conclusion

The identification of prudential activities has led to some progress in research. It has first closed down the old sterile debate over the definition of professions by avoiding both the no longer reliable functionalist definition and the interactionist approach ill-adapted to build research programs exploring the consequences of new public management, and this new solution is more forward-regarding than Freidson’s. The activities investigated have demonstrated that the perimeter of prudential activities is not the same as for the old functionalist professions.[4] Social work is a prudential activity which functionalism did not consider as a profession. Examples have also demonstrated that care activities are iconic of practical wisdom, but the case of architecture clearly shows that they are not the only ones.

Some researchers may want to debate the exact perimeter of prudential activities. This is however of less significance than the process through which this ideal type has developed, by focusing on the very contents of the activity, more precisely on how crucial practical wisdom is to them, as opposed to functionalism based on status differences. The shift in perspective opens up original avenues for research, such as studying the propensity displayed by members of prudential activities to promote their own conceptions of their activity, together with resulting agonistic segmentation. This change highlights new challenges emerging from work contexts, among which the development of new public management and growing bureaucracy: the professionals’ daily capacity to adapt their work to individual cases; their ability when necessary to reflect critically upon their own routines; more recently, their mobilisations so as to provide new spaces for practical wisdom.

These challenges are not limited to the sole professionals but concern the users they work for. This is a significant breakthrough for the sociology of professions which most often used to focus on professional power and autonomy. Since Freidson demonstrated that autonomy rarely benefitted the users, these traditional objects of study are a key issue only to the professionals. The practical wisdom-related issues offer an opportunity to broaden the perspective to issues that are significant to the users of professional services (Champy, 2018). The criticism of excessive bureaucratic rules could certainly lead to valorising professional identity again. But the ambivalence of rules should not be ignored, as they often aim at protecting users from professional discretionary power and sometimes contribute to do so. Indeed, some rules compel professionals to consider users’ interests. The main barriers to practical wisdom are definitely excessive ruling and binding ill-adapted rules.

Rather than hastily drawing conclusions on professional autonomy, rules or other aspects of work contexts, the concept of practical wisdom does encourage one to turn to philosophers and use their reflection on practical wisdom to construct accurate questions adapted to each sociological object and to each field. This new theoretical frame allows innovative investigations focusing on professional training, rules, devices used in work, hierarchical relationships and organisations (Champy, 2018). For instance, could a rule not be complied with when it is obviously ill-adapted to the case concerned? And if rules may be deviated, which provisions, such as an a posteriori control of the justifications, should be made to prevent unjustified deviation? The concept of practical wisdom may also contribute to questioning work organisation. For example, in case of difficulties, could an overview of the cases and ample time for deliberations be provided? Do relationships between professionals allow for diverging opinions helping to avoid mistakes due to taken-for-granted assumptions? Because the concept of practical wisdom provides space for that type of questions, it opens up new avenues for sociological research.

 

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Received: 05/01/2018 Approved: 18/01/2018

 

Notes

[1]Prudence is another translation for phronesis: practical wisdom and prudence can be used either. Yet prudence is not as satisfying as practical wisdom, as it brings an idea of pusillanimity ,while phronesis sometimes supposes audacity to act despite irreducible uncertainty. The latin root prudencia is useful mainly because it gave the adjective prudential. I am thus using the name “practical wisdom” and the adjective “prudential”.

[2]However, taken as a whole, both the Beaux-Arts and the modern architects have similar ends: only their prioritization is revised (Champy, 2011). This crucial point will be discussed further

[3]It is as much the case else where as in the sociology of professions. For example, particularly in scientific contexts, risks are often dealt with as if uncertainties didn’t make the cost-benefit aprroach most inappropriate (Champy and Lepiller, 2016).

[4]Research conducted so far to study practical wisdom particularly focused on architecture, medicine, social work, industrial project managers, research, police, judicial authorities, education and diplomacy. But the list is not restrictive.