Horowitz, R.In the Public Interest: Medical Licensing and the Disciplinary Process. New Brunswick: Rutgers University Press. 2013. 268pp $29.95 ISBN: 978–0‐813505426–6 (pbk) £60.95 ISBN: 978–0‐8135–5427–3 (hbk)

This book explores the role, function and processes of medical boards in the USA, whose special place in society is reflected in their unique ability to ‘give and revoke permission to practice medicine’ (p.1), that is, in their ability to stop doctors from working. The book emerged from a concern that the general public is unfamiliar with what medical boards do, despite widespread interest in doctors’ mistakes and conduct. This book is an exploration of how issues of public interest and trust are balanced and maintained in the context of private, professional and regulatory activity in medical practice. Horowitz provides a historical account of the licensing of doctors in the USA and of the mechanisms that have been developed more generally to certify doctors. Appeals are made in the book about the importance of deliberative democratic processes, seeking to widen public participation and transparency in this process. This petition is founded on historical evidence that suggests that medical boards and those controlling them have shifted away from a focus on the professional licensing and rehabilitation of doctors towards disciplining them and protecting the public. The detail of the book is confined to the USA, although its more general attention to questions of public interest and the conditions under which deliberative democracy might successfully offer guidelines for balancing legitimacy, transparency and public deliberation widens the scope of its potential readership. For medical sociologists this book is primarily an ethnographic account of the author's extended experience as a public member of two medical boards over 15 years, and her observations of two other boards. She does not include in this book many of the methodological details on which this study is based. These may be found in Horowitz's (2009) contribution to an edited text on public sociology in which she explores what it means to be of service as a professional sociologist and a researcher engaging in an ethnographic study of her own situation as a member of the public. The ethnographic account in the book under review does not always make for comfortable reading. Her account is frequently reflective and sometimes personal. She does not avoid expressing the emotions that she tells us can come from the experiences of co-option, collusion or independence. Horowitz exposes and at times disagrees with decisions that the medical boards have taken. She is able to tackle this challenging ground by fostering a wholesale account of the positive good of having the public as members and regulators of medical boards. In the opening chapter, Horowitz explains the general role of medical boards. She summarises the debates about expertise, the challenges and complexity of public policy for informed and lay citizens, and the notion of public good. These concepts inform the rest of the book. In the next two chapters she sets out a historical account of licensing; focusing on training, practices, standards and social closure which limits competition and imposing standards. She explores how medical boards belong to a set of organisations that promote social closure and that frame concerns about doctors in terms of the economic and moral issues that affect them, rather than as public concerns. She argues that since the 1970s and through the contribution of sociologists, the issue of public participation and the shift towards realising the public was the intended audience of medical boards became a matter of interest. From this time, public membership on the boards began to increase. Chapters Four and Five address the way in which the media and legal, medical and public interest discourses began to shape the work and oversight of medical boards. For example, media attention meant that board ineffectiveness and the lack of disciplinary action over doctors after complaints against them often became a matter of public attention and later, legislative change. These ideas are developed in Chapter Six, where she discusses how the move towards public protection and legal discourse shifted the focus of board deliberations towards the doctors’ acts rather than their character and status. The broadening of the discourse further opened up opportunities for public members to contribute as it required new forms of expertise and skill. The last two chapters focus on the conceptual issues that link transparency, public interest and democratic deliberation, making the claim that these actions of the boards, their commitment to selection and training, to being evaluated, to make these processes robust in terms of legal and external scrutiny. She ends the book with a set of recommendations that are consistent with these findings for overhauling the medical board system. In conceptual terms, Horowitz notes there are many practical problems in putting models of democratic governance into practice; the difficulty of getting the public involved, the fragmentation and localism of governing bodies, the challenges of efficiency and tensions with individual privacy, communitarianism and scientism (p. 194). Her concluding list of recommendations suggests that these matters can be pragmatically overcome. Her most substantial critique is addressed to Elliot Freidson's claim that the medical profession requires a strong medical community. She claims that Freidson's promotion of social closure narrows professionals’ perspectives on the public good and works against deliberative democratic processes, such that doctors will refuse to testify against other doctors in the name of collegiality or that the number of medical school places will be restricted. For sociologists, this book contributes to the ongoing debate about the regulatory activities of the medical profession and offers an insight into the principles that inform public and patients’ engagement.

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