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SOCIOLOGY THEMES AND PERSPECTIVES
According to the theory, the medical profession is an important occupation in society, and as such must attract some of the most intelligent people. To do this, it needs to be highly rewarded in both financial and status terms, but it must also have a series of safeguards (the traits) to ensure that the highest standards are achieved. The medical profession is further characterised by its provision of a vocation based upon two of the pattern variables of functionalist theory: universalism and affective neutrality. (Pattern variables are the culturally approved ways in which people are encouraged to behave in order that society should run smoothly.) Universalism is the value that ensures that all people are treated similarly, and there is no favouritism based on family/friendship connection, or payment. This is crucial, as doctors must seek to provide the highest standards of health care to all members of society, without favour. Furthermore, as people put their lives in the hands of doctors and do not have the specific knowledge required to question the doctor’s authority, it is crucial that they can completely trust the doctor. Affective neutrality means that the professional will not let personal views or interests affect the way they carry out their professional duties. This is important, as doctors often deal with issues they may find morally distasteful, and they must do so without letting these feelings show. The medical profession’s high status and financial reward, allied to strict adherence to the pattern variables, ensure that there is a specialisation of skill and knowledge by the most able, which benefits the smooth and effective functioning of the social system. Criticism of functionalist approaches Turner (1995) criticised these sorts of trait and functionalist analyses of the professions because, first, they largely reproduce the image that the professions themselves want the public to believe, and second, they ignore the power of the professional bodies, which allows them to manipulate their clients and obtain high levels of reward. Turner points out that these analyses provide an image of the historical development of professions that suggests that they have always striven to attain those particular positive traits. Turner suggests instead that any examination of the history of the professions would show that this is not the case.
Friedson: a ‘Weberian’ view of the professions A third approach to understanding the professions in medicine was provided by Eliot Friedson (1970), who argued that professions operate in order to gain social closure through professional dominance. Friedson was strongly influenced by Weber, who introduced the concept of social closure into sociology. According to Weber, social groups are constantly vying for position in the status hierarchy of any society. One method of maintaining a high position, once it is obtained, is to restrict membership to a limited number of people, usually from similar backgrounds. By doing this, the closed group is able to maintain its privileges. Friedson suggested the best way to understand the position of doctors is to see their dominance as a profession as a form of social closure, whereby they have forced other, competing providers of health care into subordinate positions.
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The various traits which Millerson describes can therefore be looked on as techniques of closure: doctors define a particular form of knowledge and set examinations so that only specially chosen people may enter the profession – usually from the same social class background and with a high percentage of men. Those who would not ‘fit in’ are filtered out in the process of selection by the medical schools. Once in the profession, the only people who can judge the work of the doctor are colleagues, who will prefer to maintain the fiction that all doctors are equally competent than to let the public know that some doctors are incompetent. Finally, the myth that doctors are interested in the general good rather than in financial gain perversely allows doctors to charge a high price for their services, precisely because they are working for the good of the public rather than themselves. Friedson points out that doctors have been so successful that they have not only gained a monopoly over medical practice, but they have also been able to define the roles and tasks of other health care providers. Friedson uses the term paramedical professions for the whole range of other providers, including nurses and midwives.
Bryan S. Turner – Medical Power and Social Knowledge Turner (1995) develops this Weberian approach by arguing that professionalisation by doctors is no more than ‘an occupational strategy to maintain certain monopolistic privileges and rewards’. Turner points to the work of Jamous and Peloille (1970), who provide a useful explanation of how this professional dominance occurred. According to Jamous and Peloille, the basis for the social prestige of a profession is the degree of social distance between the client and the professional. Social distance refers to the degree of access to knowledge or other social resources. Social distance – and therefore prestige – is at its greatest when the professional has access to knowledge that the client is unable to control or check. If the body of knowledge can be codified and simply broken down into clear guidelines for action, then social distance is closed, prestige is lost and skills become routinised. Jamous and Peloille refer to this as the indeterminacy/ technicality ratio, where indeterminacy refers to the ability of the professional to keep the patient mystified as to the exact process by which the doctor has reached a decision. Doctors, particularly surgeons, have been especially successful in maintaining a high degree of indeterminacy, which provides them with high levels of status. Bryan Turner also examined the relationship between the different health care professions, trying to find out how doctors have managed to emerge as the highest-status health care professionals. Turner argues that doctors do not intrinsically perform better or more functionally useful tasks than other health care occupations. What they have successfully achieved is autonomy (they control themselves) and dominance over other health care practitioners who were historically in competition with them. They have done this, Turner argues, partly through the high status achieved via a high degree of indeterminacy, as described above, and partly through a process of occupational domination, which can be achieved in three different ways:
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