Professions and the public interest Medical power, altruism and alternative medicine pot

Professions and the public interest

Do professions subordinate their own self-interests to the public interest?

In Professions and the Public Interest Mike Saks develops a theoretical and

methodological framework for investigating this question, which has yet to be

analysed adequately by sociologists of the professions. The framework outlined

here will be invaluable in future research on the professions.

To demonstrate how this innovative framework can be applied, Mike Saks

focuses on health care and presents a case study of the response of the medical

profession to acupuncture in nineteenth and twentieth century Britain. He

argues that the predominant climate of medical rejection of acupuncture as a

form of alternative medicine has not only run counter to the public interest, but

also been heavily influenced by professional self-interest. He considers the

implications of the case study for the accountability of the medical profession

and makes broad recommendations about the direction of future research into

this academically and politically important issue.

Professions and the Public Interest will be of interest to a wide readership,

including sociologists of the professions and health care, and teachers and

students of social policy, politics, social history and medical sociology. It will

also appeal to orthodox health care professionals and to practitioners of

alternative medicine.

Mike Saks is Professor and Head of the School of Health and Life Sciences at

De Montfort University, Leicester.

Professions and the public

interest

Medical power, altruism and

alternative medicine

Mike Saks

London and New York

First published 1995

by Routledge

11 New Fetter Lane, London EC4P 4EE

This edition published in the Taylor & Francis e-Library, 2005.

“To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection

of thousands of eBooks please go to www.eBookstore.tandf.co.uk.”

Simultaneously published in the USA and Canada

by Routledge

29 West 35th Street, New York, NY 10001

© 1995 Mike Saks

All rights reserved. No part of this book may be reprinted or

reproduced or utilized in any form or by any electronic,

mechanical, or other means, now known or hereafter invented,

including photocopying and recording, or in any information

storage or retrieval system, without permission in writing from

the publishers.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the

British Library.

Library of Congress Cataloging in Publication Data

A catalogue record for this book has been requested

ISBN 0-203-99140-0 Master e-book ISBN

ISBN 0-415-01805-6 (hbk)

ISBN 0-415-11668-6 (pbk)

Contents

Acknowledgements vi

Abbreviations vii

Introduction 1

Part I Sociology, professions and the public interest: a

research framework

1 The sociology of professions and the professional altruism

ideal: a critical review

11

2 The development of a viable conception of the public

interest

35

3 The role of professions: power, interests and causality 71

Part II An empirical application: the response of the medical

profession to acupuncture in Britain

4 Alternative medicine: the case of acupuncture 103

5 Potential explanations for the rejection of acupuncture in

Britain

139

6 Acupuncture and British medicine: the influence of

professional power and interests

185

7 The medical reception of acupuncture in Britain:

professional ideologies and the public interest

229

Conclusion 259

Appendices 267

Bibliography 271

Author index 301

Subject index 311v

Acknowledgements

This book could not have been completed without the assistance of many

individuals and institutions too numerous to single out for thanks here. I would,

however, particularly like to extend my appreciation to Michael Burrage from

the London School of Economics for his support and to the Social Science

Research Council for funding the initial research. I also owe a special debt of

gratitude to my wife, Maj-Lis, and my children, Jonathan and Laura, for their

forbearance throughout the enterprise. Finally, thanks are due to Anita Bishop,

who assisted with the typing of the manuscript.

Abbreviations

AMA American Medical Association

BAA British Acupuncture Association

BMA British Medical Association

BMAS British Medical Acupuncture Society

BMJ British Medical Journal

CCAM Council for Complementary and Alternative Medicine

CFA Council for Acupuncture

DoH Department of Health

GMC General Medical Council

ICM Institute for Complementary Medicine

IROM International Register of Oriental Medicine

MAS Medical Acupuncture Society

MRC Medical Research Council

NHS National Health Service

PMSA Provincial Medical and Surgical Association

PMSJ Provincial Medical and Surgical Journal

RCP Royal College of Physicians

RCS Royal College of Surgeons

RTCM Register of Traditional Chinese Medicine

SA Society of Apothecaries

SMN Scientific and Medical Network

TAS Traditional Acupuncture Society

UKCC United Kingdom Central Council for Nursing, Midwifery

and Health Visiting

WHO World Health Organization

viii

Introduction

In popular usage the term ‘profession’ has a wide variety of connotations,

spanning from a highly skilled and specialized job to any fulltime work from

which income is derived (Freidson 1986). The boundaries of interpretation are

narrower in sociology, but sociologists have also still to reach agreement about

the meaning of the term ‘profession’ and the related question of which

occupations are to count as professions. However, despite the absence of an

unequivocal definition (Abbott 1988), most sociologists have for long

acknowledged the growing importance of professions in Western industrial

societies in the twentieth century. Millerson (1964), for instance, notes that

roughly two dozen new qualifying associations were formed in each decade of

the first half of the century in England, whilst Ehrenreich and Ehrenreich (1979)

point to the rapid expansion in the range of professional occupations in more

recent times on the other side of the Atlantic. This trend, moreover, is widely

held to be paralleled by a major growth in the numbers of professionals in the

work-force (Ben-David 1963; Goldthorpe 1982). Giddens (1981), indeed, has

suggested that the proportion of professional workers in neo-capitalist societies

has trebled since 1950, reaching as high a level as 15 per cent of the labour force

in the United States—a pattern of expansion which is in part associated with the

rise of the welfare, enterprise and information-based professions (Watkins et al.

1992). And, as if to underline the importance of what are assuredly some of the

most privileged and prestigious strata in society (Portwood and Fielding 1981),

Halmos (1970) claims that the political power of professionals has escalated too.

To be sure, professions have sometimes come under political attack from

Western governments in the contemporary era (see, for instance, Burrage

1992), but nonetheless they have increasingly insinuated themselves into

positions of power since the turn of the century by becoming more directly

involved in both national and local government.

The significance of these developments, though, has often been exaggerated,

as is well illustrated by the work of prominent writers on the professions in the

1960s and 1970s. Parsons (1968:545), for example, argues that the ‘massive

emergence of the professional complex…is the crucial structural development

in twentieth century society’, whilst Young (1963) holds that the new

professional technocratic elite will become more secure in its position of

leadership than any other historical dominant group. In a similar vein, Bell

(1974) claims that in the post-industrial economy, services will outstrip

manufacturing and theoretical knowledge will become the central basis for

policy-making. In this new context he believes that the fast

expanding technical-professional intelligentsia of Western Europe and the

United States will supplant the controlling influence of the bourgeoisie; as Bell

says, just as

the struggle between capitalist and worker, in the locus of the factory,

was the hallmark of industrial society, the clash between the professional

and the populace, in the organization and in the community, is the

hallmark of conflict in the post-industrial society.

(1974:129)

One problem with such accounts is that to imply that the occupational structure

of contemporary Western nations is becoming predominantly composed of a

growing number of professional service and technical elites is to engage in a

sociological sleight of hand (Kumar 1978). The image of a society with a

professional majority is soon lost once it is realized that this category consists of

not only groups such as doctors, lawyers and accountants, but also large

numbers of clerical employees, waiters, porters and other workers who would

conventionally be seen as performing routine menial tasks. A further problem is

that even the notion of a narrower band of higher, knowledge-based,

professions emerging as a new ruling class cannot readily be extrapolated from

more recent trends in the development of professions (Shaw 1987). Such a view

also carries the dubious implication that the role similarities of the various

segments comprising the ‘knowledge class’ will transcend the specific interests

of each group based on jurisdictional claims and form the basis for a common

consciousness (Abbott 1988). In addition, the related arguments concerning the

supersession of capitalism and the convergence of the structures of industrial

societies can be questioned (Davis and Scase 1985), even in the wake of the

recent abandonment of socialism in much of Eastern Europe (Deacon 1992).

2 PROFESSIONS AND THE PUBLIC INTEREST

In fact, some sociologists have now begun to argue that professions are not so

much in the ascendance in Western industrial societies as in the process of being

proletarianized or deprofessionalized (see, for instance, Oppenheimer 1973;

Haug 1973; McKinlay and Arches 1985; McKinlay and Stoeckle 1988).

However, such theories are difficult to examine because of their loose

formulation (Elston 1991). And whilst there is evidence for some of the

associated claims about changes in the position of professional groups, their

proponents also tend to err by overstating the currently depressed state of the

professions (Murphy 1990). Although sociologists have at times inflated the

contemporary significance of the professions, therefore, this author at least still

believes that recent trends continue to endorse the view of Freidson (1973:19)

that these occupational groups are of ‘very special theoretical and practical

importance’—and thereby raise crucial questions about the nature and role of

professions in modern Western societies. None of these questions is more

pressing than that on which this book focuses, the issue of whether professional

groups subordinate their own interests to the wider public interest in carrying

out their work. Certainly, this broad altruism claim is made by most professions

in the current Anglo-American context, alongside other central elements of

their ideologies like the prescription that the occupation will encourage and

maintain high standards of practice and give impartial service. As such, it can be

seen as a core aspect of the majority of codes of professional associations today,

to which even responsibility to the individual client tends to be subordinated.

The commitment of both established and aspiring professions to the public

good can readily be illustrated. Town planners in Britain, for example,

frequently claim that they take altruistic decisions in the allocation of land uses

as a result of their political neutrality and technical expertise (Simmie 1974).

The notion of a duty to serve the interests of the public is, similarly, a traditional

component of veterinary codes in this country (Carr-Saunders and Wilson

1933), as well as of the codes of practice of groups such as pharmacists, social

workers and nurses (Harris 1989; UKCC 1992). These trends are also clearly

exemplified in the British context by the classic case of law where the Council

of the Law Society has for long endorsed the general view that the legal

profession is for the protection and advantage of the wider public (Council of

the Law Society 1974). The altruism claim, moreover, figures no less heavily in

the ideology of professions in the United States. Here the standards of conduct

adopted by the legal profession, from the early Canons of Professional Ethics to the

more recent Code of Professional Responsibility, have given increasing recognition

to the limits imposed on lawyers’ actions by the interests of the

public (Marks et al. 1972). It is interesting to note too that, as in Britain, such

INTRODUCTION 3

formal expressions of a public-interest orientation are by no means restricted to

the highest ranking professional groups; a wide range of professional bodies in

America, including the Institute of Chemical Engineers and the Society of

Mechanical Engineers as well as the Institute of Professional Architects, have

adopted the principle of serving human welfare as a central, codified

professional objective (American Association of Engineering Societies 1987).

These tendencies, though, are nowhere more strongly in evidence than in the

case of medicine. As early as the nineteenth century in Britain, the Royal

College of Physicians (RCP) was defending corporate monopolism in medicine

on the basis that the art ‘should, as far as possible, be rendered both safe and useful

to society’ (Navarro 1978: 6). Such claims about the public duties of the profession

have been reiterated very often in modern times. Sir Kaye Le Fleming, for

instance, reminded doctors at the annual meeting of the British Medical

Association (BMA) in 1938 about their responsibilities to ‘the public as a whole’

(Marshall 1963b:165) and, as Jones (1981) points out, the BMA today will still

argue—like any other professional association that the ends it pursues promote

the common good. On the other side of the Atlantic, meanwhile, the Principles of

Medical Ethics which the American Medical Association (AMA) adopted in 1912

asserted that the profession ‘has as its prime object the service it can render to

humanity; reward or financial gain should be a subordinate consideration’

(Duman 1979:127). This theme has been reiterated in its modern code which

states that the honoured ideals of the medical profession imply a duty to

improve not only the well-being of the client, but also that of the wider

community (Berlant 1975). The medical profession in both Britain and the

United States, therefore, seems for a long time to have drawn strongly on the

spirit of the Geneva Code of Medical Ethics, adopted by the World Medical

Association in 1949, which involves doctors in a pledge to consecrate their lives

to ‘the service of humanity’ (Campbell 1975).

The public service aspect of professional ideologies, however, has not always

been so firmly emphasized. Gilb (1966) claims that nineteenth-century

professional ethics in North America were more concerned with the

relationship between individual professionals and their clientele. This view is

reinforced in relation to such fields as law, where the early organized efforts of

the private Bar placed greater explicit stress on the acquisition and

improvement of the skill base for dealing with paying clients than ensuring

responsibility to the public per se (Marks et al. 1972). The broader altruism

ethos, though, appears to have been particularly slow to develop amongst

professions in England—in large part because this country has historically been

far more bound by traditional social distinctions than the United States

4 PROFESSIONS AND THE PUBLIC INTEREST

(Stevens 1971). As a result, Elliott (1972) argues that in the later years of the

pre-industrial period in English society, groups like the physicians, clergy and

members of the Bar did not need to justify their position on the grounds that

their learning was vocationally relevant or that they were oriented to the public

good—for this was the period of ‘status professionalism’, in which such

occupations were able to maintain a foothold in the ranks of gentlemen on

account of their leisured and honourable life-style. However, such social

superiority based on a status associated with the patronage of a small and

wealthy group of landed aristocrats could no longer be sustained in the wake of

industrialization. Accordingly, Elliott claims that it was only really at this stage,

in the face of the decline of the landed gentry and the diversification of demand

for services amongst the ascendant commercial and industrial classes, that the

professions were forced to develop systematically professional training schools

and, most importantly, to cultivate an ideology stressing the need for certified

competence and public responsibility. In this shift towards what Elliott

categorizes as ‘occupational professionalism’ in the nineteenth century, Duman

(1979:117) views the service ideal as the crucial aspect of the unique ideology

which was being fashioned, for it ‘provided professional men with a moral

justification for their claim to high social status’.

This adoption of a chivalric code, contrasting with the business ethic which was

seen to exhibit greed and selfishness (Perkin 1989), undoubtedly helped to

provide an alternative platform for the defence of the established professions in

England. From the outset, the new ideology contained references to the duty of

professions to serve the wider, public interest; Percival’s standard work on

medical ethics published as early as 1803, for instance, informed doctors that

they should only promote their occupational interests ‘so far as they are

consistent with morality and the general good of mankind’ (Duman 1979:118).

Initially, however, the question of whether the duty of the profession to the

client was more important than that to a wider public was much in dispute. But,

with the drift away from a predominantly laissez-faire system dominated by

private professional practice and the emergence of an age in which greater

emphasis was placed on the fulfilment of broader public obligations, it was

increasingly recognized that service to clients was insufficient in itself. As Marshall

(1963b: 163) wrote in 1939: ‘the professions are being socialized and the social

and public services are being professionalized. The professions are learning…to

recognize their obligations to society as a whole as well as those to individual

clients’. This trend has, if anything, been accentuated over the last thirty years

as the number of professional organizations with formal codes of conduct has

mushroomed (Harris 1989).

INTRODUCTION 5

Yet if professions in the Anglo-American context do now more resolutely

and frequently claim to serve the public interest, notwithstanding the greater

emphasis that has recently been placed on market forces by governments in

Britain and the United States in areas previously regarded as the prerogative of

the state (King 1987), do these elite occupational groups in fact embody a

special moral standard based on the ideal of service? Or should such claims,

which are often used in defence of professional privilege, be viewed with rather

more cynicism? One of the main aims of the book is to develop an analytical

framework for assessing the extent to which the altruistic ideologies of

professions in modern Britain and the United States are translated into practice

at the macro-level. This task is undertaken in Part I of the text, which highlights

the fact that, despite the growing appreciation of the importance of professional

groups in Western industrial societies, a rigorous examination of the degree to

which professional self-interests are actually subordinated to the public interest

is still awaited in the sociological literature on this subject. The reason for this

unfortunate and important omission is located in the disturbing tendency of

contributors in the field to substitute assertion for argument and to engage in

research which is both inadequately formulated and insufficiently substantiated.

Accordingly, an attempt is made to tackle the theoretical and methodological

difficulties involved and develop a satisfactory research framework for

investigating claims about the organized altruism of professions. The empirical

applicability of this framework is then illustrated in its entirety in Part II, with

reference to a novel case study of the response of the British medical profession

to acupuncture in the nineteenth and twentieth centuries. This extensive case

study of alternative medicine is centred on the analysis of the explanation for,

and the implications of, the predominant climate of professional rejection of

acupuncture established over the past two hundred years in Britain and raises

important questions about professional accountability. These questions are taken

up in the Conclusion, in which recommendations are also made about the future

direction of research into the relationship between professions and the public

interest.

It merely remains to say that, in discussing the issue of whether professions

are ‘simple monopolies whose anticompetitive effects distort the social and

economic organization of a society or are…institutions which have developed

for public interest reasons and should be preserved’ (Dingwall and Fenn 1987:

51), attention will be mainly restricted to Western industrial societies in

general and the Anglo-American context in particular. Although the analysis of

the structure and role of the professions in other parts of the world is no less

crucial or interesting (see, for example, Bennell 1983; Heitlinger 1992), this

6 PROFESSIONS AND THE PUBLIC INTEREST