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This paper examines the organizational processes behind the awarding of the Nobel Prize in Physiology or Medicine. The biomedical field has a complex structure of broad and overlapping disciplines, in which scientists pursue a large number of goals with no clear hierarchy as to which ones are the most important. Nevertheless, the Karolinska Institute in Stockholm selects one or more Nobel laureates in nearly every year, who are then treated as an “ultra-elite” within the life sciences, worthy of influence, prestige, and power. In order to disentangle the social mechanisms at work in each stage of the decision-making process, we collected data on nominees and nominators from 1901 to 1954, the full range of years currently available from the Nobel Archives. We found little disagreement on the worthiest areas of research, but much disagreement concerning individual candidates, especially regarding the relative significance of scientific recognition and social ties. The results carry implications for stability and influence of consecration processes, even in the absence of a strong cultural consensus around notions of excellence.