The distinctive profile of neo-Weberian studies: A medical illustration

This choice of illustration is based on the notion that the best way of exemplifying the neo-Weberian approach to professions in action is to take a familiar, but coherent, case study to illustrate the difference between this approach and other macro-structural perspectives considered. In Chapter 2 it will be recalled that we descriptively charted in the Anglo-American context the professionalisation of medicine, alongside law, from the early days of industrialisation up to its halcyon period in the 1960s and 1970s - when it attained unprecedented power and autonomy. In light of the macro theories outlined in this chapter, we can now ask how explanatory interpretations of this process differ and assess the relative strength of the distinctive concepts that neo-Weberians have applied in facilitating our understanding of it. We shall begin by looking at the case of medical professionalisation in Britain before moving on to consider the parallel position in the United States. In this respect, both of these cases have been comparatively analysed in depth at the macro level by Saks (2015e) - on whose neo-Weberian contribution we shall now draw.

Medical professionalisation in Britain

In the case of Britain, taxonomic writers see the professionalisation of doctors as arising from the positive intrinsic features of medicine itself, as indeed did Wilensky (1964) in his 'natural history of professionalisation’ that we have already covered. Within the taxonomic approach, functionalist theory goes the furthest at an explanatory level. In this vein, Goode (1960) saw medical professionalisation as being driven by highly valued expertise, which physicians regulate in the common good in return for state-underwritten independence to meet the needs of industrial societies. In Britain specifically, Wallis and Morley (1976:11) hold that medical pluralism was overtaken by the occupational monopoly established by the 1858 Medical Act because of the impact of the Industrial Revolution on “the demand for effective medical treatment and the ability of the profession to provide it”. This was seen as being functionally precipitated by the break-up of communities with growing social and geographical mobility - alongside the development of science and technology with the bacteriological revolution and the discovery of the germ theory of disease, which made medicine more effective.

Such a functionalist approach, however, empirically overstates the extent of social fragmentation linked to the Industrial Revolution (Saunders, 1986). Moreover, as was seen in Chapter 2, it greatly exaggerates the effectiveness of scientific medicine in the nineteenth century as the key pharmacological and other advances in diagnosis and treatment in medicine took place later in the next century (Cook, 2013). In addition, it underplays the serious hazards to health posed by heroic therapies such as bleeding and purging widely employed by doctors, as compared to the safer homeopathic and hydropathic treatment frequently used by their more marginalised rivals (Porter, 2002). In this light, it is hardly surprising that Marxists have taken a more politicised view of the 1858 Medical Act and its aftermath. Thus, Navarro (1978) saw the emergence of the British medical profession as driven by its contribution to capital accumulation in addressing the disease and diswelfare of a class-divided capitalist society, rather than meeting generic societal needs in the bland industrialised world conceived by the functionalists.

However, while Navarro (1976) was clearly more aware than Wallis and Morley (1976) of the counterproductive effects of modern biomedicine, he in turn oversimplifies the relationship between the medical profession and capitalism. In so doing, as noted earlier, he commits the fundamental Marxist heresy of seeing the profession as part of the ruling class, without having ownership of the means of production. Johnson (1977), though, in his Marxist phase, took a more orthodox view in seeing the medical profession in Britain as an agent of capital in the labour process - in which it fulfils the functions of capital, in contrast to those of the collective labourer. He argues that only occupations fulfilling the former role, involving control and surveillance activities in the interests of the capitalist class, can successfully engage in professionalisation under capitalism. Medicine is seen to fit into this theoretical framework by monopolising official definitions of health and legitimising the withdrawal of labour on behalf of the dominant class, which in turn is held to explain its privileges under capitalism.

Nonetheless, the interpretation by Johnson (1977) also falls foul of a number of common weaknesses in Marxist accounts. Not only does it lack detail, but it is not wholly sustained by evidence in the process of critically exploring available data. For example, by linking the professionalisation of medicine solely to its role in the class structure, he does not fully explain the continuing existence of professions like the

Competing theories of professions 67 clergy, whose standing is based on a legacy from the pre-capitalist era (Portwood and Fielding, 1981). Similar criticisms can be made of Johnson (1995) in his later Foucauldian mode, where he sweepingly sees the medical profession in modern Britain in terms of govern-mentality, where medicine is an institutionalised form of expertise in state formation. Both these interpretations can be seen as tautologous in Marxist and Foucauldian accounts since the profession is viewed as inevitably following structural imperatives for the state - without any apparent need for supporting or contradictory evidence. What, then, of the distinctive neo-Weberian approach to conceptualising and explaining medical professionalisation in Britain?

The starting point for neo-Weberians here is that medicine in Britain is based on a national system of exclusionary social closure in the market, beginning with the 1858 Medical Act. In this vein, Parry and Parry (2019) view the coming together of physicians, surgeons and apothecaries to obtain legally sanctioned registration arrangements as an act of ‘collective social mobility’. In his neo-Weberian phase, Johnson (2016) endeavours to account for such medical professionalisation as a form of institutional control won through interest-group politics. He argues that this goal is most likely to be achieved when consumers form a heterogenous group, which enables producers to assume greater power over them. He observes that this condition was present by the mid-nineteenth century in Britain with the emergence of an urban middle-class market for medical services with industrialisation. This broke the hold of upper-class patronage that had characterised medicine in pre-industrial Britain (Saks, 2002a). The growing homogeneity of the medical profession itself also added to its bargaining power, along with the increasing high-class recruitment to medicine and its network of aristocratic and other elites. Although more evidence needs to be explicitly adduced for such claims in Johnson’s neo-Weberian analysis, other contributors have provided this (see, for instance, Waddington. 1984). Johnson’s analysis therefore clearly provides insight into the main contours of the neo-Weberian approach in practice.

Importantly, Berlant (1975) further exemplifies the distinctive nature of neo-Weberianism. He contended that the furthering of medical interests through professionalisation in the Anglo-American context stemmed from both its tactics of competition and the prevailing socio-economic conditions in the market. Organised medicine in Britain was thus able to progress its position by shifting its ideology to ride liberal attacks on corporate monopolies in the nineteenth century. This step, which resonates with discourse analysis, is accentuated by its ideological emphasis on the General Medical Council controlling the performance of doctors and protecting itsmedical title in a de facto monopoly. This emphasis recognised that excluding unregistered practitioners, whose practice was underwritten by the Common Law, was strategically best avoided. However, in examining medical professionalisation on both sides of the Atlantic, Berlant is open to the accusation of being gender blind, although this has subsequently been addressed from a neo-Weberian perspective by the work of contributors like Witz (1992) - who highlighted the influence of patriarchy on the development of the largely male medical profession in Britain. But if Berlant needed to give more attention to this aspect of the British socio-political context, Saks and Adams (2019) underline this by calling for greater use to be made of Weber’s original concepts to enable us to examine the much-neglected ‘black box’ of the internal workings of the state in understanding the dynamics of medical professionalisation in Britain.

The discussion to date - while critical - helps further to highlight the distinctive texture of neo-Weberianism. This includes its analysis of the competition between the medical profession and outsiders, which plays a key part in explaining how the medical profession managed to gain, maintain and extend its position of exclusionary social closure in the period up to the 1960s and 1970s. Within a neo-Weberian perspective this has tended to be seen as based primarily on the pursuit of professional group interests, although there are sometimes tensions with the common good. Given the need for more empirical evidence on these potential tensions in some neo-Weberian accounts, Saks (1995) has developed a methodology for examining the extent to which professional groups subordinate their self-interests in enhancing their own income, status and power to the public interest. In operationalising the theoretical concepts involved, he was able to demonstrate that, in the response of the British medical profession to acupuncture in the nineteenth and twentieth centuries, the public interest had been compromised by professional self-interests in a predominant climate of rejection. Much neo-Weberian work has since been conducted on the more general historical interplay of medical interests, professionalisation and different forms of complementary and alternative medicine in Britain (see, for instance. Saks 1996; 2003a; 2008). We shall now exemplify how neo-Weberians have deployed their approach to explain the rather different route to medical professionalisation in the United States, as against other macro interpretations.