The Sociological Analysis of the Principle of Medical Self-Regulation Part 1

Here the entwined nature of medical governance with the development of the modern state was first noted. As was that a key paradox surrounding recent challenges to the principle of medical self-regulation is that they have occurred at a time when the success of medical knowledge and technology to promote public health is greater than it has been previously. These two themes are explored in this topic and the next. But to do this the topic must start with discussing the perspective which has dominated sociological analysis of professional regulation for the last four decades: the neo-Weberian viewpoint. This in turn requires the topic initially focus upon delineating the development of the sociological study of the professions.

The Sociology of the Professions

‘Regulating doctors is in many ways like regulating other occupations. However, doctors also have their own special features, and one reason they are special is that, almost everywhere, they are thought to belong to a distinctive category called profession. The regulation of the doctor is therefore an example of a particularly important kind of regulatory activity – professional regulation.’

Moran and Wood (1993: 24)

As the quote above notes, the sociological study of medical regulation forms an important part of the field of study in the social sciences concerned with the governance of the special category of occupations defined in the Anglo-American sociological literature as ‘professions’. With particular reference to professions operating in the health and social care arena (i.e. Stacey 1992, Moran and Wood 1993, Johnson, Larkin and Saks 1995, Gladstone 2000, Allsop and Saks 2002, Davies 2004, Slater 2007). Consequently, the sociological study of medical regulation draws its conceptual and theoretical underpinnings from the sociology of the professions literature.

Two interrelated points need to be made. First, it has been said that the occupational type ‘profession’ is a particularly Anglo-American phenomenon. It certainly is true that in the United Kingdom and North America members of occupations traditionally categorised as professions, such as medicine and law, have been able to possess self-employed status and can be said to have enjoyed a closer relationship with the ‘free market’ than their mainly directly state-employed Continental cousins. In European countries, such as Germany and France, state bureaucracies have traditionally controlled arrangements relating to examination, licensing, standard setting and disciplinary procedures. All of which have historically been controlled by independent professional associations in the Anglo-American context. Here it should be noted that traditional Anglo-American professions such as law and medicine have possessed considerable privileges on the Continent despite the direct role played by the state in managing their affairs. Indeed, they have been able to secure high levels of job security and income as well as a large degree of autonomy in their work, similar to their Anglo-American counterparts (Burrage and Torstendahl, 1990). Yet it is not the aim of this topic to undertake a comparative and historical analysis of the arrangements surrounding the organisation of occupational groups regarded as professions across nation-states. Consequently, the reader should be aware that the following discussion of relevant sociological literature is largely limited to the Anglo-American context and they must be careful about generalising its discussion beyond it. This leads onto the second point that needs to be noted at this stage. Namely, although this topic discusses the sociology of the professions literature, its primary focus remains on the medical profession. It draws primarily on relevant literature pertaining to the sociological study of medicine. It takes advantage of the fact that medicine has possessed a particularly significant place in the development of the sociology of the professions literature. Medicine has played an important role in sociological analyse of the professions in the United Kingdom (i.e. Larkin 1983, Dingwall and Lewis 1983, Stacey 1992, Saks 1995, Gabe, Bury and Elston 2004). Its historical dominance in the health care division of labour over other occupations, close association with modern science and technology, as well as its claim to put its client’s interests first, have all ensured it is viewed as an archetype of what a profession is (Turner 1995, Coburn and Willis 2000).

The Functionalist Perspective

‘Our professional institutions are… an important stabilizing factor in our whole society’

Lynn (1963: 653)

A useful starting point from which to begin analysis of the occupational type ‘profession’ is the definition offered by McDonald (1995: 1) who states that a profession is an ‘occupation based on advanced, or complex, or esoteric, or arcane knowledge’. The possession of a specialist body of knowledge, which is socially valued but not possessed by all members of society, is an important element of the occupational title ‘profession’. This is particularly true when new members are required to undergo a prolonged period of University-based education that includes ‘on the job’ training. Indeed, the Oxford dictionary (1979) defines a profession as an occupation, which ‘involves knowledge and training in an advanced branch of learning’ (Hawkins 1979: 644).

Although early students of professionalism at the beginning of the twentieth century recognised the importance of the cogitative elements of the occupational type ‘profession’, they found the concurrent Oxford paperback dictionary definition of ‘profession’ meaning ‘a declaration or promise” (Hawkins 1979: 644) more important Early sociological analysis of the professions was primarily concerned with the fact that certain occupational groups in society claimed to possess high ethical standards and indeed sought to place their clients’ welfare and interests before their own. This explicit moral code governs the behaviour of occupational members towards each other and society as a whole, as the Hippocratic Oath does in the case of medicine. This ‘collectivity orientation’ was seen by sociologists to act as a stabilising force to the excesses of the growing enterprise culture of capitalist industrial society, whose primary concern was taken to be with profit (Turner 1995). Whether or not this viewpoint regarding capitalist society was correct, early sociologies focus on the altruistic connotations associated with the concept of professionalism reflected the concern of functionalist sociology with how social consensus and social order are maintained.

Durkheim, Professionalism and Laissez Faire Capitalism

Indeed, a founding father of functionalist sociology, Emile Durkheim (1957), viewed professional groups as important preconditions to the generation of social stability and consensus in society. Durkheim’s concern with the professions as a stabilising force to the excessive individualism of laissez faire capitalism stems from his view of society as an organism constantly striving for equilibrium. He argued that individuals within pre-industrial societies possessed shared values and beliefs that generated a social consensus called ‘mechanical solidarity’. However, he argued that traditional forms of moral authority, which generated collective norms and values, were being undermined by a growing specialisation within the division of labour. This was due to the increasingly complex nature of industrial society as the eighteenth and nineteenth centuries progressed. This produced a state of affairs, which was causing alienation and anomie (i.e. anti-social individualism) amongst the general populace. This worried Durkheim. He believed that when collective norms and values declined, social restraints similarly decayed. This could lead to a situation where ‘nothing remains but individual appetites, and since they are by nature boundless and insatiable, if there is nothing to control them, they will not be able to control themselves’ (Durkheim 1957: 11). All was not lost. Durkheim argued that a new form of ‘organic solidarity’ was emerging. This was based upon the recognition of the need for cooperation between individuals due to their growing functional interdependence within the social sphere as society became more complex. He held that the professions formed moral communities, which promoted values such as selflessness that engendered social consensus and ‘organic solidarity’.

This viewpoint informed much of the subsequent sociological analysis of the professions until the 1960s. For instance, Tawney (1921) held that the economic individualism of capitalism was inherently destructive to the community interest and that the morality of professionalism could be used to counter its excesses. He stated that ‘the difference between industry as it exists today, and profession is, then, simple and unmistakeable. The essence of the former is that its only criterion is the financial return, which it offers its shareholders. The essence of the later is that though men enter it for the sake of livelihood the measure of their success is the service which they perform, not the gains which they amass’ (Tawney 1921: 94 -95). Similarly, Parsons (1949) emphasised the social altruism of professional groups by arguing they possessed a ‘collectivity-orientation’. While Carr-Saunders and Wilson (1933: 497) held that the professions: ‘inherent, preserve and pass on a tradition .they engender modes of life, habits of thought and standards of judgement which render them centres of resistance to crude forces which threaten steady and peaceful evolution. The family, the church and the universities, certain associations of intellectuals, and above all the great professions, stand like rocks against which the waves raised by these forces beat in vain’.

The early functionalist hegemony regarding the sociological study of the professions also revealed itself in the work of authors who were concerned with identifying characteristics which taken together denote that an occupation is a profession. For example, Etzioni (1969) classified occupations into ‘professions’ and ‘semi-professions’ based upon characteristics such as length of training. Barber (1963: 671) held that professions possessed four essential attributes – a high degree of generalised and systematic knowledge, an orientation towards the interest of the community instead of individual self-interest, a high degree of self-control exercised by practitioners over behaviour through the possession of a code of ethics internalised during a prolonged period of education and training, and finally, a reward system of monetary and status rewards that are symbolic of work achievement not self-interested gain.

To this day occupations such as medicine protest that they possess a ‘service ideal’ when they seek to justify collective privileges. Such as the principle of self-regulation and the individual social and economic rewards which come with the possession of professional status. The previous topic discussed how contemporary changes in the governance of medical expertise have led commentators to re-emphasize the positive social role played by the professions in society (i.e. Freidson, 2001). Yet the core problem with the early functionalist approach to the sociological analysis of the concept of professionalism is that it takes uncritically the altruistic claims of occupations calling themselves professions at face value, while it also views the task of sociology as being to quantify and measure the concept, ‘professionalism’. Furthermore, the functionalist approach to the analysis of professionalism was criticised for being largely ahistorical. It lacked consideration of the process by which occupations utilised their cognitive and altruistic resources to exercise power in order to initially gain and subsequently maintain the social and economic rewards associated with the possession of professional status (Johnson 1972). Sociologists were coming to realise that they were starting their analysis of the professions with the wrong question. As Hughes (1963: 656) wrote ‘in my studies I passed from the false question ‘Is this occupation a profession?’ to the more fundamental one ‘What are the circumstances in which people in an occupation attempt to turn it into a profession and themselves into professional people?’.

Hughes was highlighting that classifying an occupation as a profession was what society did and it was not the task of sociology to do it in more scientific terms. Rather, its focus should be on investigating the socio-economic and political circumstances out of which the concept of professionalism arose. This signalled the beginning of a more critical turn in the sociological study of the professions. In contrast to the Functionalist viewpoint, this focused upon the material and symbolic benefits gained from the possession of an occupational monopoly over license to practice (McDonald 1995). According to this more critical viewpoint ‘professionalism is not a set of traits which jobs have in common, nor a distinct ethic, but a mode of occupational control’ (Moran and Wood 1993: 25)

Critiquing the Altruistic Foundations of Medical Privilege

‘The professional rhetoric relating to community service and altruism may be in many cases a significant factor in moulding the practices of individual professionals, but it also clearly functions as a legitimation ofprofessional privilege’.

Johnson (1972: 25)

As the above quote illustrates, by the start of the 1970s sociologists were turning away from the viewpoint that the professions transcended the unbridled self-interest they held to be symptomatic of modern society (McDonald 1995). Functionalist sociologists mostly accepted the altruistic claims to public service espoused by professions such as medicine. Indeed, they often endorsed the fact that this separated them from other occupational groups. However, the 1970s saw social scientists question increasingly the legitimacy of the self-espoused altruistic tendencies and ‘value-neutral’ knowledge claims of occupational groups, which possessed professional status. In the context of the medical profession, they began to focus upon how medical professionalism has operated ideologically as an exclusive form of occupational control. This was seen to operate both at the micro-level of everyday interaction through the concept of clinical freedom at the bedside and the macro-institutional level through the principle of state-licensed self-regulation. They highlighted how poorly performing doctors, and in some cases even criminals, were being shielded from public accountability by the ‘club rule’ of mutual protectionism inherent within medicine’s self-regulatory system.

A focus upon professional self-interest as opposed to professional altruism lay at the heart of the growing Symbolic Interactionist critique of the early Functionalist view of the professions in American sociology. The Interactionist viewpoint assumes reality is socially constructed in and through everyday social interaction. Consequently, it viewed professionalism as ‘an ascribed symbolic, socially negotiated status based on day-to-day interaction’ (Allsop and Saks 2002: 5). Studies of the medical profession inspired by this viewpoint, such as Becker’s Boys in White (1961) highlighted that ‘[the] professional principles of altruism, service and high ethical standards were. less than perfect human social constructs rather than.abstract standards which characterized a formal collectivity’ (McDonald 1995: 4). Yet, instead of focusing on the micro-individual level of the individual professional interacting within his or her work-sphere, the growing critique of the professions in the Anglo-American literature primarily focused on the macro-organisational and societal level. This was largely informed by neo-Weberian sociology, as the next section of the topic will now demonstrate.

The Neo-Weberian Perspective

‘[No] summer’s bloom lies ahead of us, but rather a polar night of icy darkness and hardness’.

Weber (1946: 128)

The 1970s saw the growth of the neo-Weberian critique of the professions in general and medical dominance and power in particular. Weber focused upon trying to understand emerging new social patterns in the nineteenth century caused by the rise of industrial technology, the growth of scientific knowledge and the greater potential than ever before for participation by the general populace within the political sphere. Weber was a polymath interested in law, economics, politics, science, religion as well as sociology. A key unifying theme in his writing is the idea that the progressive rationalisation of life was the main directional trend in western civilisation (Whimster and Lask 1989). By rationalization, Weber meant a process by which explicit, abstract, calculable rules and procedures (what he called ‘formal rationality’) increasingly replaced more traditional and personal, social values and ways of life (what he called ‘substantive rationality’) at the organisational and institutional levels which govern social life (Gerth and Wright Mills 1946). Rationalisation leads to the displacement of religion by specialised rationalistic knowledge and scientific expertise. It also leads to the replacement of the skilled worker and artisan with the factory production line and machine technology. It demystifies and instrumentalities life, and ‘means that.there are no mysterious incalculable forces that come into play, but rather that one can, in principle, master all things by calculation’ (Weber 1946: 139).

Though Weber did not specifically address the issue of the growth of the professions his concept of rationalisation is clearly tied to the development of modern scientific forms of expertise, of which modern medicine is a part. As Murphy (1988: 246) notes ‘[the]process of formal rationalization has generated a new type of knowledge, the systematic, codified, generalized (which implies abstract) knowledge of the means of control (of nature and of humans)’. This is a point the topic will return to in a moment. However, it is important to note here that sociologists with a historical bent, such as Parry and Parry (1976), Berlant (1975) and Larkin (1983), primarily drew upon Weber’s economic theory of monopolisation when analysing the initial growth and subsequent development of professions such as medicine (Weber 1978). In doing so, they highlighted collective preoccupations with pecuniary interests, securing economic and technical domains, as well as consolidating positions of high social status and power within the socio-political arena. This was to be expected as Weber views professionals as a privileged commercial class, alongside bankers and merchants. He holds that they seek to exclude competitors and reap economic and social rewards through pursuing strategies that enable them to monopolise the marketplace for their services by controlling market entry and supply. By engaging in collective social mobility (i.e. the formation of group organisations and political pressure groups) occupational groups such as medicine seek to obtain privileges from the political community, to become what Weber (1978: 342) calls a legally privileged group, and ensure ‘the closure of social and economic opportunities to outsiders’.

Freidson and Medical Power

Two key early proponents of the neo-Weberian ‘social closure’ model of the professions were Freidson (1970) and Larson (1977). As his work came chronologically first, the topic will discuss Freidson before moving on to Larson. In 1970, Freidson published his landmark study of the American medical profession, Profession of Medicine. In line with Weber’s ‘social closure’ perspective, Freidson held that medicine was a particularly powerful example of how professionalism operated ideologically as a form of occupational control to ensure control of the market for services. Freidson (1970: 137) highlighted that the professions possessed three powerful interlocking arguments on which they justified their privileged status: ‘Professional people have the special privilege of freedom from the control of outsiders. Their privilege is justified by three claims. First, the claim is that there is such an unusual degree of skill and knowledge involved in professional work that non-professionals are not equipped to evaluate or regulate it. Second, it is claimed that professionals are responsible – that they may be trusted to work conscientiously without supervision. Third, the claim is that the profession itself may be trusted to undertake the proper regulatory action on those rare occasions when an individual does not perform his work competently or ethically’.

Freidson recognised that medical autonomy must be viewed as having limits as the state was involved in the organisation and delivery of health care. Occupations must submit to its ‘protective custody’ to reap the social and economic rewards associated with being a profession. Nevertheless, the state largely left doctors alone to control the technical aspects of their work. This made it for him such a good example of what a profession is. He argued that ‘so long as a profession is free of the technical evaluation and control of other occupations in the division of labour, its lack of ultimate freedom from the state, and even the lack of control over the socio-economic terms of work, do not significantly change its essential character as profession’ (Freidson 1970: 20).

Freidson discussed how medical professionalism operated ideologically as a form of occupational control at the micro-level of everyday interaction through the concept of clinical freedom at the bedside, as well as at the macro-institutional level through the principle of state-licensed, self-regulation. The common link between the micro and macro aspects of medical autonomy for Freidson was the need for a doctor to exercise personal judgment and discretion in her work due to it’s inherently specialist nature (Freidson 1970 1994 and 2001). This state of affairs was legitimised by the scientific basis of modern medical expertise and public acceptance of medicine’s altruistic claim that it put patient need first. Furthermore, Freidson argued that medicine’s freedom to control the technical evaluation of its own work had led to it possessing a high level of dominance and control not only over patients but also over the work of other health care occupations, such as nursing for example. Freidson (1970: 137) stated that medicine ‘has the authority to direct and evaluate the work of others without in turn being subject for formal direction and evaluation by them. Paradoxically its autonomy is sustained by the dominance of its expertise in the division of labour’.

In Profession of Medicine and his other major study, Professional Dominance (1970), Freidson was concerned with mapping out the negative consequences of medical autonomy in the Anglo-American context. He concluded that the dominance of medicine in the health care arena had a negative effect on the quality of health care patients received. For Freidson medicine was failing to self-manage satisfactorily its affairs and ensure that adequate quality control mechanisms to govern doctor’s day-to-day activities were in place. Freidson (1970: 370) believed that the development of unaccountable, self-governing institutions surrounding medical training and work had led to the profession of medicine to possess ‘a self-deceiving vision of the objectivity and reliability of its knowledge and the virtues of its members..[Medicine's] very autonomy had led to insularity and a mistaken arrogance about its mission in the world’.

Larson and the Indeterminate and Determinate Cognitive Dimensions of Professional Privilege

There can be no doubt that Freidson argued forcefully that medicine was a powerful example of how professionalism operated ideologically as a form of occupational control. For him it was a publicly mandated state supported supplier of a valued service, exercising autonomy in the workplace. This included dominance over other occupations in the health care division of labour as well as collegiate control over recruitment, training and the regulation of members conduct. Regardless of Freidson’s critical insights, his work lacked a thorough historical dimension. Aware of this, Larson undertook an historical analysis of the rise of professionalism as a legitimate form of occupational control in her work ‘Rise of Professionalism’ (McDonald 1995). She discusses how by engaging in a ‘professional project’ occupations such as medicine sought to become professions by obtaining a monopoly over the market for their services and enhancing the standing of group members within the social and political spheres: ‘My intention. .is to examine how the occupations we call professions organized themselves to attain market power. Professionalization is thus an attempt to translate one order of scare resources – special knowledge and skills – into another – social and economic rewards. To maintain scarcity implies a tendency to monopoly: monopoly of expertise in the market, monopoly of status in the system of stratification’ (Larson 1977: xii and xvii).

As topic two noted, the rise of the clinical gaze of modern medicine in the eighteenth century changed the nature of the doctor-patient power relationship in favour of the medical profession (Jewson 1974 1976). Bound up with this was a growing focus upon gaining direct personal experience of clinical phenomena on which to build ‘craft expertise’ and justify clinical decisions. This is not to say that the increasingly formal and scientific aspects of medical expertise did not play a vitally important role in medicines successful claim to professional status. Clearly they did. But as Larson (1977) notes, in addition to the possession of a formal knowledge base, it requires the presence of a high level of ‘indetermination’ in the exercise of expert judgment and technique for the monopolistic claims of the ‘professional project’ to succeed. Larson (1977: 31) specifies that an occupation’s knowledge base must be ‘formalized or codified enough to allow standardization .and yet …must not be so clearly codified that it does not allow a principle of exclusion [or discretion] to operate" Furthermore, Larson (1977: 41) observes that "the leaders of the professional project will define the areas that are not amenable to standardisation; they will define the place of unique individual genius and the criteria of talent that cannot be taught’.

Larson is indebted to the work of Jamous and Peloille (1973). Following Weber’s insights into the nature of modernity these authors recognised that the abstract, scientific, nature of modern expert knowledge meant it was open to a process of rationalisation and codification into standardised rules and procedures. They argued that this was offset by the fact that uncertainty is ever present in the application of such knowledge, and they put forward the notion that occupations possess an ‘indetermination’ and ‘technicality’ ratio (an I/T ratio). Those occupations classified as professions, possess a high level of indetermination at the basis of their expertise. Similar to Larson they held that the outcomes of the application of expert knowledge are more dependent on the ‘potentialities and talent of the practitioner than techniques and transmissible rules’ (Jamous and Peloille 1973: 140). This leads to an emphasis in professional education and training on ‘individual and social potentialities, experience, talent, intuition etc’ (Jamous and Peloille 1973: 139).

In examining the process by which occupations originally claim and subsequently maintain professional status, Larson (1977: 6) acknowledges that ‘the goals and strategies pursued by a given group are not entirely clear or deliberate for all the members’. This is an important point. Larson’s reliance on historical documentary evidence means the concept of ‘professional project’ does not refer to the day-to-day actions of individual ‘rank and file’ members. Rather it refers to a generalised course of collective action initiated by organisational and institutional professional elites over a particular historical period. The value of Larson’s analysis is that it highlights the key role in obtaining and sustaining a market monopoly played by the establishment of occupational control over the educational credentials associated with entry into a profession. This includes the important role the ‘indeterminate’ aspects of a profession’s expertise play in establishing this control as legitimate.Particularly for understanding how professionalism operates ideologically as a methodology of occupational control. The possession of exclusive control over the dissemination of its knowledge base to new members means a profession’s elite organisations possess substantial bargaining power from which to negotiate a ‘regulative bargain’ with the state. As Allsop and Saks (2002: 6) state: ‘access to formally accredited education and training is. a crucial portal on which exclusory closure is based that generates definitions of insiders and outsiders’ For example, in his analysis of the legal profession Burrage (1988: 228) states that: ‘In my judgement four goals have been constant and pre-eminent in the history of the legal profession…First, lawyers have sought to control admission to, and training for, legal practice. Second, they have tried to demarcate and protect jurisdiction within which they alone are entitled to practice. Third, they have tried to impose their own rules of etiquette, ethics or practice on one another. Finally, they have tried to defend and if possible enhance their status’.

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