It achieves this through exploring how sociologists conceptualised social changes that were held to be challenging medical autonomy, in the form of clinical freedom ‘at the bedside’ and the principle of self-regulation, from the 1980s onwards.
The restratification thesis first emerged in the mid 1980s, in response to the growing recognition within sociology that something was happening to medical autonomy. It was conceptualised as being in decline by what are respectively called the proletarianization and deprofessionalization theses (Freidson 1985). Writing at the beginning of the 1970s, Haug (1973), the originator of the deprofessionalization thesis, argued that medical autonomy was being challenged due to a process of rationalisation and codification of medical knowledge and expertise into standardised rules and procedures. She focused on the role this played in reducing ‘the knowledge gap’ between patient and doctor, as well as in supporting the rejection of professional paternalism, as a more informed and critical general public became less inclined to act deferentially toward experts. Haug (1973:206-7) noted that this process was only just starting: ‘[The] tension between the public demand for accountability and the professionals insistence on final authority has not yet erupted into general warfare .But there have been skirmishes’.
Haug (1973) argued that a ‘tipping point’ had been reached, with medicine starting to lose its prestigious social-political position. She cited five interrelated factors to support her viewpoint. First, while medical knowledge was rapidly expanding it was undergoing a process of codification at a general level. This, Haug argued, was leading to medicine losing its control over its defined body of knowledge due to a rise in automated retrieval systems, such as computer algorithms, for symptom assessment. Second, the public were becoming more educated, better informed about health matters, and more likely to challenge physician authority than ever before. Third, as medical knowledge expanded, medicine as a profession was increasingly fragmenting into specialities and sub-specialties, with individual doctors becoming ever more dependent upon each other for expert advice, as well as ever more dependent upon non-medical expertise. One physician no longer held all the power over a patient. This reduced even further individual and collective autonomy. Fourth, there had been a growth in the patient self-help groups and a rise in alternative medicine as public trust and belief in medical expertise declined. It became ever clearer through high profile media cases, that in reality medicine’s cognitive and altruistic claims did not live up to expectation. Fifth, increases in medical care costs meant the public were demanding doctors be held more accountable for their actions. Indeed, in some cases, they wanted the principle of medical self-regulation to be abolished.
The deprofessionalization thesis tends to focus on topics that indicate that there has been a decline in public trust of medicine and the threat this poses to the principle of professional self-regulation. The growth of media coverage of gross medical malpractice cases like Harold Shipman is a good example. It focuses upon the fact that attitudes to traditional forms of authority are changing and highlights that the public increasingly expects their governing institutions to operate in a transparent and accountable manner. In contrast, the proletarianization thesis highlights the existence of the potential for expert work in general, and medical work in particular, to become subject to rationalisation and routinization. Today’s ‘indeterminacy’ becoming tomorrows ‘technicality’. It focuses upon how this causes medical work to become subject to managerial bureaucratic control in the name of controlling costs and promoting consumer choice.
Writing at the same time as Haug (1973), the originator of the proletarianization thesis, Oppenheimer (1973), held that the work of professionals was becoming subject to a process of rationalisation in the name of economy and efficacy. This had happened in the factory at the beginning of the industrial revolution over a hundred and fifty years earlier. Like Haug (1973), Oppenheimer held that the scientific nature of modern specialist knowledge and expertise meant it was open to communication as a set of rules, procedures and operational imperatives where passed on to others who had not received any formal training. Work tasks could be broken down into parts so that, on one hand, workers performed one or a handful of tasks from a whole process, and on other hand, administrative and bureaucratic authorities could determine overall working conditions and priorities. Furthermore, Oppenheimer focused upon the fact that professionals were operating in large organisational settings (such as modern hospitals) as salaried employees, where he held the growth of bureaucratic rules, procedures and authority was undermining professional autonomy.
‘The bureaucratised workplace..[tends to replace].in the professionals’ workplace factory-like conditions – there are fixed jurisdictions, ordered by rules established by others; there is a hierarchical command system; jobs are entered and mobility exists on the basis of performance in uniform tasks, examinations, or the achievement of certification, or "degrees".The gap between what the worker does and the end product, increases’.
Oppenheimer (1973: 214)
For Oppenheimer a process began whereby administrative routines, measures and targets controlled professional work. His central thesis was that the work of professionals was increasingly becoming subordinated within bureaucratic structures to the control of administrative elites operating under fixed rules and procedures, which the professions had no control over. McKinlay (1977), McKinlay and Arches (1985) and McKinlay and Stoeckle (1988) noticed this theme from an explicit neo-Marxist perspective, and in the context of medicine. They held that as medicine had advanced and entered large scale corporate and bureaucratic settings, physicians lost several professional prerogatives associated with the principle of self-regulation, such as control over entrance criteria, training context and content, workplace autonomy and the object, tools and means and remuneration of their labour. They discussed how the American federal government and managerial ‘corporate rationalizers’ were affecting the content of medical work and medical school curricula. Medicine was becoming fragmented into sub-specialisms, as medical knowledge expanded. Non-medical staff that operated largely outside of direct medical control were also intervening in the doctor-patient relationship as medical techniques became ever more reliant on new technologies. Patients were increasingly the clients of the organisations doctors worked within, instead of being the direct responsibility of an individual doctor. Under these circumstances, they felt medicine as an occupation could no longer be held to be professionally dominant. Contrasting the position of self-employed physicians at the turn of the twentieth century with their modern day counterparts McKinlay and Stoeckle (1988: 201) concluded that: ‘[Every] single prerogative listed has changed, many changes occurring over the last decade. The net effect of the erosion of these prerogatives is the reduction of the members of a professional group to some common level in the service of the broader interests of capital accumulation’.
They argued that while the proletariat possess a ‘false consciousness’ regarding their true exploited position in capitalist society, doctors similarly possessed a ‘false consciousness’ with regards to their ‘true’ social position: ‘For doctors who are increasingly subject to this process, it is masked by their false consciousness concerning the significance of their everyday activities and by an elitist conception of their role so that even if the process is recognised, doctors are quite reluctant to admit it’ McKinlay and Stoeckle (1988: 201). McKinlay and Stoeckle’s discussion of the proletarianization thesis fails to recognise that doctors are not quite like other workers. It is highly questionable that by the 1980s the entire labour force in the Anglo-American context had been progressively proletarianized under advanced capitalism. Regardless of their salaried status and managerial inroads into controlling medical work, doctors retained the power to direct and supervise the work of others and maintain a range of specialist skills, which enabled them to collectively bargain for positions of high social privilege, status and power.
Neo-Marxists like Navarro (1988) who are critical of Freidson admit he is correct in maintaining that medical autonomy is essentially a collective not individual property. Furthermore, relative to other health care occupations, medicine occupies a prominent position in the health care arena as no other occupation has the capacity to dominate it. This being said, by the mid-1980s Freidson (1994) recognised that medicine was, first, coming under pressure from the state to reform its regulatory and training institutions, second, was being placed under third-party greater surveillance and control by the rise of managerialism, and third, was no longer as dominant over other occupations in the health care arena as it once had been. Nursing, for example, was establishing its independence from traditional medical control as the state started to emphasise multidisciplinary working patterns in its attempts to reduce costs, maximise efficiency and respond to a rise of consumerist calls for increased patient choice.
Medical Autonomy in Decline?
In the 1970s, critical commentators shared a common emphasis on viewing professionalism ideologically as an exclusionary self-regulatory strategy for organising the performance of professional work.Occupational control over members training and discipline forms a logical part of this viewpoint. Yet, by the mid-1980s, the changes posited by the respective deprofessionalization and proletarianization theses were acknowledged as actually starting to occur by sociologists (Saks 1995, Corburn and Willis 2000). It was beginning to look like medical dominance and autonomy was going into long-term decline, just as the deprofessionalization and proletarianization theses had predicted. Rapid advances in medical knowledge made it apparent that medicine was becoming less homogenous and fragmenting into sub-specialities, as new diagnostic and therapeutic technologies developed due to the advent of the computer age and advances in pharmacology, molecular biology, genetics and immunology (Gabe, Kelleher and Williams 1994). This caused medicine to become ever more dependent upon non-medical occupations operating outside of its direct jurisdiction to treat illness and disease (Elston 1997). Concurrent with the rapid growth in medical expertise and the growing internal fragmentation of the profession was a rise in managerial attempts to control medical work. There was the ascendancy of managers or ‘corporate rationalizers’ as the state sought to contain burgeoning health care costs (Coburn and Willis 2000). The invasion of the state via management into ‘medical turf’ was also related to growing public concern with the risks involved in modern medical treatment. High profile media cases engendered doubts in the consciousness of the public concerning the ability of medicine to ensure individual doctors possessed high ethical standards (Stacey 1992). They also contributed further to an already burgeoning consumerist demand for greater patient choice and control over medical encounters as well as health care organisation and delivery (Stevens 1986). This was reflected in the growth of alternative medicine, an increase in the threat of patient complaints and medical litigation, as well as the presence of a high level of dissatisfaction amongst patients with the doctor’s communication and information sharing skills (Fitzpatrick 1984, Stacey 1988, Dingwall 1991).
Not Decline, But Restratisfication
Despite these broad changes the proletarianization and deprofessionalization theses and their applicability outside the United States of America was questioned (Gabe 1991). By the end of the 1980s, many commentators agreed that although clear differences between the American and UK health care systems remained ‘[both] countries are moving towards greater third-party control of both global health care budgets and clinical decisions’ (Harrison and Shutz 1989). Yet as Elston (1991) pointed out, although there had been a rise in managerialism on both side of the Atlantic, after the establishment of the NHS in 1948 the majority for UK doctors had become salaried state employees. This meant greater potential existed for direct state interference with regards to medical autonomy in the NHS, as well as medical school admission numbers and curricula content to meet NHS workforce planning needs (Larkin 1983). Elston (1991: 66) highlighted that, under the conditions assumed by McKinlay and Arches (1985), ‘the proletarianization of the British medical profession was virtually completed forty years ago’. Rather than showing that UK medicine had been proletarianized earlier than American medicine, Elston (1991: 66) argued that this demonstrated the importance of ‘disaggregating components of autonomy in analysis’. Following Starr (1982), Elston (1991: 61) defined ‘Medical Dominance’ as medicines authority over others and subdivided it into 1) ‘Social Authority’, which related to medical control over the actions of others, and 2) ‘Cultural Authority’, which related to the acceptance of medical definitions of reality and therefore medical judgments being accepted as valid and true. She divided ‘Medical Autonomy’ into three main categories: 1) ‘Economic Autonomy’ (the right of doctors to determine their remuneration), 2) ‘Political Autonomy’ (the right of doctors to make policy decisions as the legitimate experts on health matters) and 3) ‘Clinical or Technical Autonomy’ (the right of the profession to set its own standards and control clinical performance, as exercised through clinical freedom at the bedside and collegial control over recruitment, training and discipline) (Elston 1991:61).
Elston argued that it was possible for the different components of medical autonomy to operate independently from each other. She held that her historical and comparative analysis of UK and American medicine showed that for much of the twentieth century American doctors enjoyed a considerably higher level of ‘Economic Autonomy’ compared to their UK counterparts. The reduction of UK doctors ‘Economic Autonomy’ because of their employment in the NHS after its inception in 1948 had not affected their other professional privileges. The profession’s prominent position within the NHS meant it possessed considerable ‘Social Authority’ over other occupations operating in the NHS. Likewise, its ‘Clinical Autonomy’ and ‘Political Autonomy’ were enhanced, as it exerted a powerful influence over the shaping of health care policy and practice. Approximately 80% of all health expenditure was determined by decisions made by doctors with the government leaving medicine effectively in charge of the NHS during this ‘golden age’ of medical power (Klein 1983).
Elston (1991) was equally critical of the deprofessionalization thesis. Focusing on doctor’s right to self-regulate their activities, she acknowledged that there had been challenges to the principle of medical self-regulation, as embodied by the GMC. Nevertheless, she argued, ‘the modifications of professional self-regulation appear as a series of incremental adjustments to contain criticism rather than substantial diminution of collegiate control’ (Elston 1991: 81). Furthermore, she recognised that patients demanded to be given greater informed choice and this was tied up with the dominance of neo-liberal economic ideology within the health care arena, and specifically NHS reforms emphasising ‘the discipline of the market and consumer power’ (Elston 1991: 78). However, she found little hard evidence to support the viewpoint that the public was rejecting the validity of medical science’s ‘Cultural Authority’. She acknowledged that the potential power of medical knowledge and expertise to cure all ills was increasingly questioned. But she argued that ‘[the] growth of the women’s self-help movement and holistic well-women centres and the apparently increasing use of alternative practitioners suggests some of the disillusioned are exiting the system, but only partially and on a small scale. [furthermore there]. is little baseline data against which changes in the level of public confidence in and valuation of medicine can be tested’ (Elston 1991: 82)
Additionally, sociologists could not agree if the proletarianization and deprofessionalization theses were applicable within the American context, where they were first generated. Freidson was a key critic (i.e. Freidson 1985 1994). He agreed that changes were occurring in medicine’s relationship with the public, and acknowledged that this was due to medical knowledge and expertise expanding, as well as becoming formalised into rules and procedures with the advent of computer technology and the information and communication revolutions. However, he argued that: ‘The professions.continue to possess a monopoly over at least some important segment of formal knowledge that does not shrink over time, even though both competitors and rising levels of lay knowledge may nibble away at the edges. New knowledge is constantly acquired that takes the place of what has been lost and thereby maintains the knowledge gap. Similarly, while the power of computer technology in storing codified knowledge cannot be ignored, it is the members of each profession who determine what is to be stored and how it is to be done, and who are equipped to interpret and employ what is retrieved effectively. With a continual knowledge gap, potentially universal access to stored data is meaningless. In sum, while the events highlighted by proponents of the deprofessionalization thesis are important, the argument that members of the professions are losing their relative prestige and respect, their special expertise, or their monopoly over the exercise of that expertise over time are not persuasive’.
Freidson (1994: 134-5)
Although he recognised that medical paternalism had been rejected and the public were more active health care consumers, Freidson dismissed the idea of deprofessionalization as he held that medicine was not losing control of its monopoly over its expertise. He believed that the development of new techniques to monitor the efficiency of performance and the allocation of resources did not in itself reduce medical autonomy. What matters is whose criteria for evaluation are used and who controls any ensuing action This is an important point, for as the topic has repeatedly highlighted, to function ideologically as a method of occupational control, professionalism requires that occupational members control the technical evaluation of work activities. In the context of the proletarianization thesis, the growing threat of bureaucratic-managerial control over medical work does challenge medical professionalism as it can, for example, introduce non-medical criteria from which to judge work performance. Freidson recognised this. Furthermore, he held that many of the changes that neo-Marxist authors such as McKinlay and Stoeckle (1988) identified have indeed occurred. It was true for instance that in America a large number of doctors had moved from possessing self-employed to employed status. Concurrent with this shift were moves towards subjecting the work of individual doctors to performance evaluation and management control (Coburn and Willis 2000). This was because the spread of ‘managed care’ across America to control costs and improve efficiency had created strong pressures to reduce medical autonomy in clinical decision-making. However, Freidson retorted that while the individual autonomy of doctors was affected by this state of affairs the collective institutional autonomy of the profession as a whole remained intact (Freidson 1994). This was because concurrent with these changes to the health care system in America had been the growth in co-opted medically qualified managers controlling the surveillance and evaluation of medical work. Freidson argued that the rise of medically qualified mangers illustrated that medicine was not undergoing a process of proletarianization, but rather was dividing into more pronounced ‘elite’ and ‘rank and file’ segments. For him, it became internally fragmented due to advances in medical knowledge as well as the threat played by the rise of managerialism on one hand and the consumerist ‘patient choice’ movement on the other: ‘Professionalism is being reborn in a hierarchical form in which everyday practitioners become subject to the control of professional elites who continue to exercise the considerable technical, administrative, and cultural authority that the professions have had in the past’ (Freidson 1994: 9).
Freidson believed that the loyalties of these co-opted doctors ultimately lay with their clinical colleagues not their ‘corporate masters’. He held that the purpose of ‘elite’ placing the ‘rank and file’ under ever more formal surveillance and control was to maintain collective privileges and sustain medical professionalism as a methodology of occupational control: ‘[These] changes do not affect the position of the profession as a corporate body…so much as they affect the internal organisation of the profession in the relation amongst physicians. In essence, I suggest, they are creating more distinct and formal patterns of stratification within the profession than have existed in the past, with the position of the rank and file practitioner changing most markedly’ (Freidson 1985: 6).
For Freidson the rise of peer review mechanisms brought about by the increased use of surveillance tools such as medical audit were not a sign of the proletarianization of medicine. Rather they were an essential part of the process of restratification, which he held was occurring within medicine. Audit and peer review were well-established surveillance mechanisms in America by the late 1970s, unlike in the UK (Harrison and Schulz, 1989). Furthermore, Freidson (1994: 145) went on to argue that ‘there is little evidence that the special status of rank and file professionals will deteriorate so much that they will find themselves in the same position as other workers. Even though they will be subject to more formal controls than in the past. [in] all likelihood, they will also exercise considerably more discretion than other workers in performing their work, and will be able to participate in formulating standards and evaluating their own performance through some type of peer review. Finally they will still enjoy at least occupational kinship with their superiors\
Freidson’s arguments for the existence of restratification within medicine feel like good common sense. This because any attempt to raise standards and cut costs clearly requires the cooperation of the medical profession (Gray and Harrison, 2004). Also, it is somewhat ironic that at the same time sociologists were arguing about a possible decline in the status and power of the medical profession, modern medical technology and expertise were making significant improvements to people’s lives. As Kelly and Field (1994: 36) note: ‘To deny the effectiveness of modern medical procedures such as coronary artery bypass, renal dialysis, hip replacement, cataract surgery, blood transfusion, the pharmacology ofpain relief and the routine control of physical symptoms in restoring or improving the quality of life for those suffering from chronic illness is to deny the validity of the everyday experiences of the lay public in modern Britain. In stressing the limitations and costs of medical interventions, the physical and social contributions of modern medicine are all too frequently ignored’.