Medical professionalisation in the United States

In exploring the drivers of medical professionalisation in the United States, the functionalist variant of the taxonomic approach has run into similar difficulties to those in Britain. Notwithstanding the comments already made about Wallis and Morley (1976), their functionalist perspective seems to stand up better in the United States than in Britain in relation to the scientific drivers for professionalisation in meeting system needs. This is because professionalisation based on state-by-state licensing took place half a century later, at a time when there was less medical deployment of heroic medicine, aseptic techniques and anaesthesia were more widely applied, and there had been greater technological advance (Ramsden, 2013). While Stevens (1998) supports this view about medical professionalisation meeting the public interest at this stage, it is important to exercise caution as the application of the scientific method was still at an early stage in the early twentieth century and most significant developments in surgery and other medical fields came several decades later (Le Fanu, 2011). In explaining the professionalisation of medicine in the United States, therefore, it is understandable - just as in Britain - that more overtly politicised accounts have come to the fore.

Here the Marxist account of Navarro (1976) again overstates the historical contribution of medicine to capital accumulation. Aside from not sufficiently problematising the role of medicine in the class divide between capital and labour, Starr (1982) notes that Navarro more generally overrides the complexity of the relationship between medicine and capitalism in the United States. However, some Marxist theorists have a more subtle interpretation. Thus, McKinlay (1977), for example, recognised that American physicians had some autonomous control over their domain, although it was restricted by the interests of industrial and financial capital. Nonetheless, even his account does not give enough credence to the more open political structure of Anglo-American liberal democracies. This is also true of the Foucauldian analysis of Johnson (1995), who precludes the connection between the state and the medical profession from being operationally examined because of their inextricable entanglement in the institutionalisation of expertise (Saks, 2003b). What, then, of neo-Weberian explanations of medical professionalisation in the United States? What shape do they take and are they more persuasive?

The neo-Weberian analysis of Johnson (2016) seems as good a fit in the United States as it is in Britain. His conception of medical professionalisation as a type of institutional control in a pluralistic social order is endorsed by Starr (1982). Notwithstanding the greater degree of specialisation of American physicians compared to British doctors under the biomedical umbrella, Starr noted the increase in both the fragmentation of medical clientele and upper-class medical recruitment in the United States. His neo-Weberian analysis can in fact be aligned with the seminal account by Freidson (1970), who claimed that medical professionalisation occurred in the United States as a result of broad public support in the market - as well as sponsorship by strategic elites which led to growing state sanction. The work of Berlant (1975) again well illustrates the neo-Weberian approach. He stressed the de jure nature of the exclusionary closure surrounding medicine in the United States based on the legal control of practice, as opposed to the de facto monopoly in Britain. From his comparative examination of these two societies, he also argued in classic neo-Weberian style that in the more devolved American system, the medical profession won and extended its monopolistic standing by using the political rift between national and local economic interests to its benefit. In a strong antitrust climate, state medical licensure therefore was a measure to protect local economic interests against large-scale corporations.

As in Britain, there is also a lively neo-Weberian literature on the pursuit of professional self-interests by American physicians in attacking unlicensed practitioners of alternative therapies through bodies such as the American Medical Association and the Food and Drug Administration (see, for instance, Boyle, 2013; Kelner et al, 2003). In the course of these neo-Weberian analyses, as we shall see on both sides of the Atlantic, not all the battles to exclude rivals were successful - such as in relation to osteopaths and chiropractors (Saks, 2006). However, there are some difficulties surrounding such neo-Weberian explanations of American medical professionalisation. Freidson (1970), for instance, errs in not explicitly identifying the strategic elites to which he refers in promoting the autonomous professional control of medicine (McKinlay, 1977). Proponents of neo-Weberianism in the United States, like those in Britain, may need also to give greater attention to gender and other aspects of social closure related to inequalities in explaining the form of professionalisation (Tang and Smith, 1996). This leads on to further brief consideration of neo-Weberian work outside of the medical arena to illustrate its broader application.