professions, marginality and inequalities · mike saks, 2014, ‘professions, marginality and...

Sociopedia.isa© 2014 The Author(s)

© 2014 ISA (Editorial Arrangement of Sociopedia.isa)Mike Saks, 2014, ‘Professions, marginality and inequalities’, Sociopedia.isa, DOI: 10.1177/205684601411

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Introduction

Professions for many sociologists have become a keypart of the occupational structure in the social strati-fication system of the modern western world(Macdonald, 1995), with a mission typicallyexpressed in their ideologies to serve the public inter-est – including addressing issues of social inequality(Saks, 1995). Accordingly, a substantial amount of theliterature in the Anglo-American sociology of profes-sions has examined the role of professions – from doc-tors and nurses to accountants and lawyers – intackling inequalities amongst client groups and thewider public. This is illustrated by longstanding workin the United States both generally (see, for instance,Krause, 1971) and in specific fields (see, for instance,Navarro, 1986). It is also apparent in more recentwork on professions on enhancing social inclusionand citizenship in Britain and the rest of Europe cov-ering dimensions such as social class, ethnicity andgender (as illustrated by Matthies et al., 2000; Saksand Kuhlmann, 2006). This contribution, though,considers the literature on inequalities within profes-sions themselves from a neo-Weberian perspective,and in particular the hierarchical relationshipsbetween professional groups in the Anglo-Americancontext where professions are characterized by thegreatest degree of self-regulatory autonomy (Collins,

1990). Making reference to the health field and thecase study of complementary and alternative medi-cine, this article outlines such inequalities and notesthat there is a significant gap in the research literatureexploring the implications of inequalities within pro-fessions for inequalities without.It is often assumed in the sociological literature

that professions as single occupational groups arehomogeneous entities, when, as classically pointed outby Bucher and Strauss (1961), there is considerablediversity and conflict of interest within professionalgroups. This conception of in-fighting within specificprofessions, which includes tensions between the pro-fessional elite and the grassroots as well as competingstatus hierarchies of sub-specialisms, is at odds withmany codes of professional ethics and associated ide-ologies which typically foster the idea of professions ascollegial groups forming communities of equals serv-ing the good of the client and/or the wider public (see,for example, Abbott, 1983). However, if the notion ofprofessions as communities of equals serving the pub-lic interest in single professions may be considered amyth (Saks, 1995), this is also true of the relationshipbetween professional groups which is often distinctlyhierarchical, as highlighted by the concept introducedhere of marginal and marginalized professions. Withillustrations drawn from health, it is noted that such

abstract Professional ideologies generally commit to addressing inequalities among clients and/or thepublic. Sociologists of professions in the Anglo-American context have written on the extent to which thiscommitment is honoured. This contribution, however, reviews the literature on inequalities between pro-fessional groups from a neo-Weberian perspective through the concept of marginality, focusing on thehealth context. With particular reference to the case of complementary and alternative medicine, it high-lights that future research needs to focus more on how this affects inequalities outside the professions.

keywords complementary and alternative medicine ◆ health ◆ inequalities ◆ marginality ◆neo-Weberianism ◆ professions

Professions, marginalityand inequalities Mike Saks University Campus Suffolk, UK

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Saks Professions, marginality, inequalities

inequalities between professions may have consider-able implications for clients and the public in liberaldemocratic societies such as Britain and the UnitedStates, especially as regards patterns of inequality.This relatively unexplored dimension of the sociolo-gy of professions is therefore an important topic forfuture research.

Professions, hierarchies and inequalities

From the interest-based neo-Weberian perspectiveadopted in this article, professions are defined in theAnglo-American context in terms of exclusionarysocial closure in the market based on the establish-ment of legal boundaries creating ranks of insidersand outsiders, with associated privileges accruing toinsiders in terms of income, status and powerthrough credentialism (Saks, 2010). This said, pro-fessions are conceptualized in various ways related toexclusionary closure in the contemporary neo-Weberian literature – from having direct marketcontrol of services (Parry and Parry, 1976) to possess-ing in a more derivative way occupational independ-ence over technical decisions and work organization(Freidson, 2001). Most importantly, though, in thiscontext, the professions are centred in practice ondifferent forms of legally underpinned exclusionarysocial closure linked to their operation in specificsocieties (see, for example, Moran and Wood, 1993).In Britain, for instance, following the passing of thelocally based guilds, there is a national system of pro-fessional regulation, whereas a state by state patternof licensure is more prevalent in countries like theUnited States (Krause, 1996). Similarly, a de factoprofessional monopoly based on protection of titlewhile still allowing wider practice under theCommon Law characterizes professions such as med-icine in Britain, compared to the more prevalent dejure monopolies in the United States, related to dif-ferent sociohistorical circumstances (Berlant, 1975).There is also now increasingly an internationaldimension to the delineation of the boundaries ofexclusionary closure in a single profession in neo-Weberian terms – as exemplified by the opening upof geographical mobility with the mutual recogni-tion of qualifications in the European Union whichcould lead in future to some degree of convergenceof national professional regulatory regimes (Bianicand Svennson, 2010). Moreover, all of these differentpatterns of regulation have potential implications forthe way professions operate in terms of both clientgroups and the broader public because of the differ-ent conjunction of interests that they generate – interms of the balance of benefits and costs to profes-

sional groups and sub-groups in particular decision-making situations (Saks, 1995).More pointedly in relation to this contribution,

though, is the hierarchy of professions which hasemerged in particular countries linked to differentpatterns of professional social closure. In this hierar-chy, professions like law and medicine are classicallyseen to be at the apex in the Anglo-American setting– albeit with their own internal sub-specialist rank-ings which can be illustrated in Britain by the long-standing division between higher status barristersand solicitors in the English legal system (Burrage,2006) and between elite consultants in niche spe-cialisms and general practitioners in the NationalHealth Service (Klein, 2010). Other professions var-iously lie below these groups in a pecking orderresulting from legally embedded patterns of referral,oversight and other arrangements in relation to toptier professional groups – which are also typicallyreflected in differential financial and related rewards.The position of such middle and lower order profes-sions has been conceptualized in neo-Weberian workas ‘dual closure’, where such occupational groups asnurses and teachers take on the characteristics ofboth exclusionary and usurpationary closure, the lat-ter of which is more typical of union action in theworking class (Parkin, 1979). Some other occupa-tions, moreover, have not gained full legallyenshrined social closure and are in the process of pro-fessionalizing – and may be governed by voluntaryrather than statutory regulation which places themstill further down the occupational pecking order(Saks, 2003a). Importantly, it should be stressed insetting out the regulatory inequalities between pro-fessional and proto-professional groups that theinterrelationship between professions is not static,but shifts over time (Abbott, 1988).In terms of social theory it should also be noted

that the neo-Weberian approach to the professionsadopted here has not been beyond criticism. It hasbeen variously criticized for lacking empirical rigour(Saks, 1983), being excessively negative about pro-fessional groups (Saks, 1998) and failing to link itsanalysis to the wider occupational division of labour(Saks, 2003b). These criticisms, however, relate moreto the inappropriate way in which the approach hasbeen implemented than its intrinsic structural weak-nesses (Saks, 2010). It is, however, worth noting thatadvocates of the neo-Weberian perspective – becauseof its focus on the interplay of competitive groupinterests in the market – tend to take a more criticalapproach to professions and the way in which theirmyriad of privileged monopolistic positions haveoriginated and developed. As such, neo-Weberianism stands in a common stream with inter-actionism (see, for example, Becker, 1962), Marxism

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(see, for instance, Carchedi, 1975) andFoucauldianism (as illustrated by Johnson, 1995),which view the hierarchical position gained by pro-fessions as respectively based on their skills in nego-tiating the acquisition of an honorific label, their rolein fulfilling the global functions of capital and thenot always progressive process of governmentality.The main distinction, however, is that the frame-work of the neo-Weberian approach – with its focuson exclusionary closure as the touchstone of profes-sionalism – lends itself more strongly to analysingparticular professions in a more open way, avoidingthe problem of other more critical approaches ofbuilding in an excess of tautological and other theo-retical assumptions that are not in principleamenable to empirical examination (Saks, 2010). As part of the more critical perspectives on pro-

fessions, neo-Weberianism also differs markedlyfrom the largely deferential earlier trait approachwhich painted a more positive picture of professions(Millerson, 1964). In the trait approach professionalgroups are defined as based on features such as highlevels of expertise and rationality (see, for example,Greenwood, 1957) – and even bulwarks of democra-cy (Lewis and Maud, 1952). This analysis is particu-larly developed in functionalist work where it isusually held that there is a trade-off, in which profes-sions with knowledge that is very important to soci-ety are provided with a privileged position inexchange for committing to use this knowledge tothe public benefit (see, for example, Barber, 1963).The functionalist theoretical approach is also used toexplain inequalities between the professions in theanalysis of Etzioni (1969), who differentiates whathe labels as ‘semi-professions’ like social work andteaching from more fully fledged professions onaccount of their weaker development of professionalcharacteristics like expertise and altruism. This clear-ly departs from the earlier neo-Weberian work ofJohnson (1972), who sees the lofty position attainedby medicine and law in the professional peckingorder in terms of power and interest and is highlysceptical of the claims of such groups to serve thepublic interest, not least in tackling social inequali-ties. Here he queries, for example, the extent towhich lawyers’ interests allow them to representthose who seek radical change to the existing order,but also notes that the services of practising lawyersare very unequally distributed. Little seems to havechanged to judge by recent reports from Britain andthe United States about substantial differences inaccess to legal services by geography, as well as by lowincome, disabled, elderly and ethnic minority groupsdespite legal aid schemes (Robins, 2011; Sandefurand Smyth, 2011). An antidote is therefore providedto the professional ideologies which trait and func-

tionalist writers have been accused of reflexively mir-roring in building such positive features of a profes-sion into the very definition of their operation(Roth, 1974). Johnson (1972) also provides an alternative per-

spective on middle and lower ranking professionalgroups, which suggests that the assumed ‘natural’order of the professional division of labour may notalways be rational. More specifically, after disparag-ing the expertise of general medical practitioners andlawyers as being based more on interpersonal thantechnical skills in terms of their ability to relatewarmly to clients, he notes that:

The emergence of a succession of subordinate ‘profes-sions auxiliary to medicine’ in Britain is the historyof how physicians have been able to define the scopeof new specialised medical roles, and cannot beregarded as … a product of the most rational utilisa-tion of human resources. (Johnson, 1972: 35–6)

This illustration raises many questions about thepotential existence of unjustified inequalitiesbetween professions, as well as their impact on thepublic interest in the Anglo-American context – andin particular in this context their implications forinequalities. Not least of these from a neo-Weberianperspective is how far the limits on both the defini-tion of, and delegation to, allied health practitionershave reduced access to medical care further than itneeds to be in less well-served populations (Saks,2003a). This leads neatly on to a discussion of mar-ginality in the professions, the literature on whichwill now be considered more specifically in thehealth field to highlight further inequalities amongprofessional groups and their potential significancefor exacerbating or otherwise divisions in the strati-fied societies in which they work.

Inequalities and marginality in thehealth professions

Current work on the health professions indicatesthat they, no less than other professions in theAnglo-American setting, contain their own share ofspecific internal inequalities – such as in the dividebetween specialists and generalists in both medicineand nursing as discrete professions and indeedbetween specific specialisms which are more or lesshighly ranked in the pecking order (Klein, 2010). Inmedicine in Britain and the United States there canbe seen to be an elite group driving the professionwhich has meant that there are also internal divisionsin relation to grassroots practitioners, notwithstand-ing formal democratic structures for elections. In

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Britain this includes the leaders of the BritishMedical Association and the Royal Colleges – partic-ularly the Royal College of Physicians and RoyalCollege of Surgeons. In the United States a similarpattern exists primarily through the leaders of theAmerican Medical Association. Amongst otherthings, such groups predominantly define anduphold the mainstream scientific practice of ortho-dox biomedicine through the management of curric-ula, career structures, research funding, journals andother means (Saks, 2003a). However, the focus hereis on the relationship between, rather than within,professions – to which the analysis of the literaturenow turns with the tenet that, despite various chal-lenges, including from the state in Britain and corpo-ratism in the United States, the medical profession asa whole still stands in a dominant position in ortho-dox health care (Ham, 2009; Stanfield et al., 2011). In this respect, in terms of inequalities, there has

been a recent resurgence of interest in the sociologyof professions in marginal professions in the divisionof labour, particularly in the health field (see, forinstance, Saks, 2008) building on strong historicroots from the early analysis of the role strains of chi-ropractic as a marginal profession in the UnitedStates (see Wardwell, 1952). In this context, the cat-egories of ‘marginalized professions’ and ‘marginalprofessions’ have recently been defined in the litera-ture (Saks, 2014 forthcoming) which helps to con-ceptualize the relationship with dominantprofessions and underline the position of other pro-fessions in the pecking order. As such, ‘marginalizedprofessions’ have a less well accepted standing with-in orthodox ranks, which is typically reflected in dif-ferent levels of income, status and power, but stillhave some form of legally enshrined exclusionarysocial closure. ‘Marginal professions’ in contrast areprofessionally aspiring occupations largely operatingoutside the state-supported orthodox division oflabour. The resulting inequalities between profes-sions are at their greatest in relation to dominantgroups with respect to these two categories and pro-vide the strongest potential for generating, or at leastexacerbating, inequalities without – from patterns ofgeographical dispersal to the nature, sufficiency andaffordability of practitioners operating in particularhealth fields. The category of marginalized professions maps

well on to the classification of health professions out-side of the dominant medical profession as set out byTurner (1995). He distinguishes two relevant cate-gories. The first is ‘limited’ health professions such aspharmacists, dentists and opticians whose practice islegally restricted to particular parts of the body. Thesecond category is that of subordinated health pro-fessions like nurses and midwives, physiotherapists

and radiographers who take on delegated tasks fromdoctors in the orthodox division of labour. Despitetheir lower positions in the pecking order comparedto physicians, marginalized health professions havenonetheless gained through professionalization offi-cial legal recognition and legitimation as well as asso-ciated benefits, including protection of title linked toenhanced income, status and power (see, forinstance, Allsop and Saks, 2002). This separates allshades of orthodox health professions from marginalhealth professions which lie mainly outside state-endorsed frameworks and are viewed by Turner(1995) as being based on ‘exclusion’ rather than ‘lim-itation’ or ‘subordination’ within the health care divi-sion of labour. Examples of marginal healthprofessions include elements of aspiring groups likehealth support workers who are striving to profes-sionalize – such as, most recently, operating theatrepractitioners in Britain (Saks, 2008).This categorization and the hierarchal ordering of

professions becomes more politically charged if theposition of marginal or marginalized health profes-sions are not seen to be based on their level of expert-ise and contribution to the wider society, but ratheron dominant medical professional interests in theneo-Weberian frame of reference. This is preciselywhat was being suggested by Johnson (1972) inpointing to his view of the ‘irrational’ utilization ofresources in analysing the comparative position ofallied health professions in the division of labour.This view, however, contrasts with the lofty pedestalon which the medical profession is placed relative togroups like nurses by functionalist theorists whoargue equally fiercely that their privileged positionhas been gained, amongst other things, by its posses-sion of knowledge of vital importance to the public(Etzioni, 1969). The question of whether the med-ical profession is to be condemned or applauded forits exalted position in the division of labour ulti-mately must, of course, be resolved through empiri-cal investigation rather than simply by fiat. Whatshould be said, though, is that the division intoeither dominant, marginalized or marginal profes-sions in terms of the unequal hierarchy of health pro-fessions is inevitably fluid – it was after all little morethan a century and a half since doctors themselveswere professionalized, in the mid-nineteenth centuryin Britain and the early twentieth century in theUnited States, and even later when nursing, mid-wifery and other allied health professions emerged asmarginalized professions (Saks, 2003a). Before thistime in the nineteenth century in both societies therewas a relatively open field in which practitioners ofall types – including some of those who are nowdefined as complementary and alternative medicine(CAM) therapists – competed in the market on a

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relatively level playing field where they were very dif-ficult to distinguish in terms of theories, practice orrepute (Porter, 1995). This leads on to the consideration of the position

of CAM, which has been one of the most controver-sial areas in the sociology of professions from theviewpoint of inequalities within the health profes-sions in the Anglo-American context. Certainly byfar the greatest numbers of those engaged in margin-al health professions are CAM practitioners who arenot yet fully professionalized (Saks, 2008). In termsof the inequalities between professions, it should benoted that CAM is defined here not in relation to itsintrinsic characteristics, but rather its position ofbeing largely excluded from the orthodox health caredivision of labour underwritten by the state andbased on an increasingly unified biomedical para-digm centred on drugs and surgery. CAM is definedin this way because it encompasses such a great diver-sity of practices in the Anglo-American context,from aromatherapy and herbalism to homoeopathyand naturopathy. As such, it is impossible to capturethe CAM field through overly simplified conceptssuch as holistic and/or traditional medicine whichonly relate to a part of its conceptual universe (Saks,2003a). It is also equally important to note in termsof inequalities between the health professions thatthe orthodoxy of one era can become the CAM ofthe next, and vice versa. With these definitionalbridges traversed, the article will now turn to consid-er the literature surrounding the CAM case study inthe Anglo-American context.

Case study: complementary and alternative medicine

As Saks (2003a) has documented, the marginal pro-fession of CAM in the contemporary context hastaken shape following a long history of attacks bymedical orthodoxy on both sides of the Atlantic. Inboth Britain and the United States, over manydecades, medical elites have striven to reduce thecredibility of CAM through, amongst other things,enforcing orthodox curricula control in medicalschools, debunking the practices and practitioners ofCAM in the medical journals, limiting access tomedical research funding, and orchestrating careerblockages for collaborators. In Britain, as in theUnited States, marginalization meant that the CAMtherapies concerned lacked legitimation. However,while CAM practitioners in Britain could normallypractise under the Common Law without obtainingexclusionary closure backed by the state, licensingwas required in the United States (Freidson, 1994).Nonetheless, the odds were still stacked against

CAM therapists in the pecking order for health pro-fessions, especially with restrictive codes of medicalethics inhibiting collaboration between physiciansand CAM practitioners. In Britain, moreover, lawswere passed creating state shelters for medicine in thefirst half of the twentieth century initially throughthe National Health Insurance scheme and then theNational Health Service. This barrier was augment-ed by legislation in the same period prohibitingCAM therapists from claiming to treat a range ofdiseases such as diabetes, epilepsy and glaucoma(Larkin, 1995). The consequence of this and similar-ly restrictive practices in relation to such areas ashealth insurance schemes and hospital attendance inthe United States (Saks, 2003a) was that CAM wasincreasingly heavily depleted in face of the rise of themedical profession by the mid-twentieth century –not least with the mushrooming growth of a range oflimited and subordinated practitioners in orthodoxhealth care on both sides of the Atlantic which rein-forced the dominance of medicine (Saks, 1999).Having said this, there was a resurgence of public

interest in CAM both during and after the counter-culture of the 1960s and 1970s (Roszak, 1970). Thisled to an upsurge of demand such that most mem-bers of the public in the Anglo-American contextwanted selected CAM therapies more freely availableby the 1980s and by the start of the new millenniumin Britain one in seven members of the populationwere regularly visiting CAM practitioners and in theUnited States over four out of 10 Americans report-ed using CAM (Saks, 2003a). This was related tosuch factors as an increasing awareness of the limitsof orthodox medicine, a desire to go beyond a tech-nocratic approach to medicine centred on deperson-alization and disempowerment, and a search byconsumers for greater control over their own health(Saks, 2000). The upshot is that there are growingpressures from users for access to CAM therapies –including through the incorporation of CAM by themedical profession and allied health professions.This led to some moderation of the stance of ortho-dox medicine towards CAM, particular in its lesschallenging complementary, rather than alternative,forms (see, for instance, British Medical Association,1993). It also further promoted the practice of CAMby health professions in the public and private sector– the usage of which was backed by political lobbiesin both Britain and the United States, as well as byhealth professional bodies and government (see, forexample, Cohen, 1998).The current position outside medical orthodoxy

is that, while some CAM therapists prefer solo prac-tice to becoming part of a profession, most CAMtherapies have sought professionalization of somekind. In Britain this has typically been as marginal

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professions without the statutory backing requiredfor full exclusionary social closure (Saks, 2014 forth-coming). Thus, a number of CAM therapies current-ly operate with voluntary forms of self-regulation,including setting out minimum educational stan-dards and codes of ethics. In Britain acupuncture hastaken this step through the British AcupunctureCouncil and British Acupuncture AccreditationBoard and homoeopathy has done so too throughthe Society of Homoeopaths (Saks, 2006). In theUnited States sporadic state licensing for CAM prac-tice as in the case of naturopathy is more of thenorm, except in self-help contexts. Some types ofCAM, moreover, have now gained systematic statu-tory underwriting on both sides of the Atlantic –most notably, that for osteopaths and chiropractors(Saks, 2003a). In this regard, there was earlier licens-ing for these CAM practices in the United States fol-lowed by the Osteopathy Act and the ChiropracticAct in Britain setting up a professional register andgiving protection of title in the 1990s – bringingthem more into the realm of marginalized, not mar-ginal, professions. Moreover, the British governmentis currently considering setting up similar registersfor herbalists and traditional Chinese medicine prac-titioners in light of licensing requirements in theEuropean Union which may otherwise mean the endof such practice in Britain (Hansard, 2011). In terms of the implications of the inequalities

between groups of professionalizing and profession-alized CAM practitioners and more orthodox healthprofessions, the impact of CAM simply being a mar-ginal profession without statutory regulation is verysignificant as there is less legitimacy, less private andpublic funding support and certainly no legal protec-tion of title – despite attempts by relevant CAMpractitioners to put in place voluntary regulation(Saks, 2006). However, even for those CAM practi-tioners who have gained statutory licensing and havetherefore become marginalized rather than marginalprofessions, there are still major disadvantages in thehierarchy of more orthodox health professions.Although they do have protection of title, they sharea highly restricted presence in the orthodox medicalcurriculum and mainstream medical journals and arerarely in receipt of official research grants – even ifmore research funding opportunities have opened uprecently, through the National Center forComplementary and Alternative Medicine in theUnited States (Adams et al., 2012). Moreover, thereremain legally enforced limits on the claims that canbe made for treatment in both societies and inBritain the ability of CAM therapists to practise inthe National Health Service is restricted – even if theethical restrictions on medical collaboration haveslackened. In the United States meanwhile only

some CAM therapies qualify for reimbursementunder Medicare, Medicaid and private health insur-ance schemes and there are often strong restrictionson such matters as referrals in state licensing forCAM – which can in itself be quite patchy from stateto state (Saks, 2003a). In sum, even the few CAMoccupations that have gained statutory regulation arestill very much marginalized in the health care divi-sion of labour on both sides of the Atlantic – withgenerally negative consequences for practitionerincome, status and power.What, then, of the impact of inequalities between

marginal and marginalized CAM professions andmore orthodox health professions on inequalitieswithout – namely, for clients and the wider public?There certainly seems to be a major impact on geo-graphical access – particularly as CAM has largelybeen driven into the private sector with little centralplanning in Britain and there is sporadic state licens-ing in the case of some CAM therapies in the UnitedStates (Saks, 2003a). Moreover, there are associatedfinancial barriers to access in terms of support forvisits to many types of CAM therapy in a predomi-nantly private market, in which there may in bothsocieties be particularly significant negative effectsfor lower class groups in light of their ability to pay(see, for instance, Fitzpatrick, 2008). In addition,there are issues for minority groups in relation toethnicity and gender which should not be ignoredgiven the concentration of white males in higherpositions in the dominant health professions (see, forexample, Kuhlmann and Annandale, 2012) – a pat-tern which is interestingly also replicated in thepecking order for CAM professionalization in whichthe predominantly white male professions ofosteopathy and chiropractic are in receipt of thegreatest state support for their practice in Britain andthe United States. Such inequalities in access andavailability have been systematically examined bySaks (1995) in relation to the predominant rejectionby the medical profession in Britain of acupunctureand the subsequent hierarchical position of medicaland CAM practitioners of this therapy over manydecades – which he concludes after careful scrutinyhas not been in the public interest. In this respect,there are other dimensions to the public interest inliberal democracies than egalitarianism, includingliberty and the general welfare – which in the case ofCAM may not be best served by the often limitedknowledge of CAM by orthodox health professionsin referral networks and the untoward effects of posi-tioning in the health professional pecking order onthe quality of recruits to CAM practice.Notwithstanding rising public demand for CAM,

such implications become more defensible if thereare major health hazards with CAM or evidence that

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CAM therapies are ineffective in particular cases. Inthis respect, Wallis and Morley (1976) argue from afunctionalist perspective that CAM has been mar-ginalized in the health care pecking order because itstherapies lack scientific evidence in comparison toorthodox medicine. However, this is not entirelycredible when the conditions under which medicinefirst gained statutory standing as a profession areconsidered. When the Medical Registration Act waspassed in the mid-nineteenth century in Britain,there was little to differentiate doctors from theircompetitors; medicine was primarily classificatoryrather than curative; neither anaesthesia nor asepticand antiseptic techniques were in use; and hospitalswere associated with death (Saks, 2003a). Of course,the licensing of physicians in the United States tookplace some five decades later when a little more med-ical progress had been made and there have sincebeen further medical advances in a range of fields,from the use of antibiotics against bacterial infec-tions to cataract and hip surgery (Le Fanu, 2011).Nonetheless, while more systematic research mayneed to be conducted into CAM (Ernst et al., 2008),orthodox medicine has arguably become rather tooheavily fixated on randomized controlled trialswhich do not fit many CAM therapies as evaluativetools and have not been applied pervasively to ortho-dox health care – accentuating the need for moreflexibility in the use of qualitative and quantitativehealth research methods (Richardson and Saks,2013). In this light, given the threat that CAM has posed

to elite and other medical interests particularly inrelation to CAM therapies presented as panaceaswith counter-posed philosophies to biomedicine –such as traditional forms of acupuncture based onneedling underpinned by yin-yang theories andmeridians (Saks, 1992) – it is difficult to believefrom a neo-Weberian perspective that such interestsare not a central explanation of the general orthodoxmedical resistance to CAM. There is in suchinstances a real challenge to professional income, sta-tus and power – except of course when incorporationis an attractive option for orthodox health profes-sions in the marketplace where non-threateningCAM opportunities exist. These circumstances applywhen, for instance, CAM is adopted within medicalorthodoxy in limited form to enhance private prac-tice for generalists or provide innovative career pro-files for more established medical specialists – as inthe case of consultants adopting formula acupunc-ture to treat specific conditions based on neurophys-iological explanations of its modus operandi (Saks,1995). It should be stressed, though, that the incor-poration of CAM by orthodox health practitionersdoes not significantly mitigate the exacerbation of

inequalities through the marginalization of CAM inhealth professional hierarchies because such practiceis typically more restricted and usually based onmuch shorter training as compared to that undertak-en by non-orthodox CAM practitioners themselves(Saks, 2003a).

Conclusion

In conclusion, the review of the literature undertak-en here suggests that inequalities between the profes-sions as illustrated in the case study of CAM – andfacilitated by the concepts of marginalized and mar-ginal professions outlined – seem to have had a sub-stantial impact in exacerbating such externalinequalities as those based on geography, class, gen-der and ethnicity in both Britain and the UnitedStates, especially in relation to access to services forindividual clients and the wider population. At atime when governments are more sensitive than everto the principles of equality and diversity, it is there-fore very important that they are alive to the policyimplications of the hierarchical professional designa-tions of the workforce, including the impact of sanc-tioning different relational forms of social closure inthe health field and elsewhere. Following on fromthis review, additional research from a neo-Weberianperspective would be very helpful in health and otherprofessional domains to understand more fully theimplications of inequalities and marginality betweenprofessional groups – in a complementary way to thefurther study of inequalities within particular profes-sions. This would be most apposite at a time whenmuch of the sociological literature to date hasfocused more on ‘top dog’ rather than middle andlower order professions and has not always sufficient-ly considered their roles in the context of the wideroccupational division of labour. This is critical notonly in terms of the responsiveness of professions toclients, but also in relation to the broader publicinterest. As this contribution indicates in highlight-ing the need for further research in this area, current-ly the ideologies of professional groups may not beappropriately representing their activities to govern-ment and the wider community in terms of theimpact of their hierarchical interrelationship on soci-etal inequalities.

Annotated further reading

Kuhlmann E and Annandale E (eds) (2012) The PalgraveHandbook of Gender and Healthcare, 2nd edn.Basingstoke: Palgrave Macmillan.This edited volume is significant because it illustrates

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well one dimension of inequality in relation to thehealth professions, their clients and the wider public– bringing together contributions from authors ongender and health care in a range of internationalcontexts.

Macdonald K (1995) The Sociology of the Professions.London: Sage.This book provides a useful overview of varioustheoretical perspectives on professions and theoperation of a wide range of professional groups inthe stratification system, drawing on studies ofprofessions in Britain, the United States and WesternEurope.

Saks M (2003) Orthodox and Alternative Medicine:Politics, Professionalization and Health Care. London:Sage.This book is important because it covers theintegrated history of orthodox and alternativemedicine in Britain and the United States over thepast 500 years – examining dynamically some of thekey issues of marginality and inequality amongst thehealth professions.

Saks M (2010) Analyzing the professions: The case forthe Neo-Weberian approach. Comparative Sociology9(6): 887–915. This article is helpful as it comprehensively exploresthe nature, strengths and weaknesses of the neo-Weberian approach to the Anglo-American sociologyof the professions adopted here – as well as itscomparison to other theoretical perspectives on theprofessions.

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Adams J, Andrews GJ, Barnes J, Broom A and Magin P(eds) (2012) Traditional, Complementary andIntegrative Medicine: An International Reader.Basingstoke: Palgrave Macmillan.

Allsop J and Saks M (eds) (2002) Regulating the HealthProfessions. London: Sage.

Barber B (1963) Some problems in the sociology ofprofessions. Daedalus 92: 669–88.

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Mike Saks is International Research Professor at University Campus Suffolk (UCS) in Ipswich,UK – having previously been Provost and Chief Executive at UCS, Deputy Vice Chancellor atthe University of Lincoln and Dean of the Faculty of Health and Community Studies at DeMontfort University, UK. He holds Visiting Chairs at the University of Essex and the Universityof Lincoln and is the former President (and now Vice-President) of the InternationalSociological Research Committee (RC52) on Professional Groups. He has published over adozen books on health care and the professions and has been a policy adviser in these areas togovernment and professional bodies. [email: [email protected]]

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résumé Les idéologies professionnelles, lorsqu’elles relèvent des missions de service public, prônentgénéralement le combat des inégalités parmi les usagers à titre individuel et/ou sein de la population. Lessociologues des professions dans le contexte anglo-américain se sont penchés sur la question de savoirdans quelle mesure cet engagement est honoré. Cette contribution offre toutefois une revue de lalittérature sur les inégalités entre les groupes professionnels dans une perspective néo-Wébérienne, enayant recours au concept de marginalité et se focalisant sur le secteur de la santé. En faisantspécifiquement référence au cas de la médecine complémentaire et alternative, on souligne que larecherche future doit se centrer davantage sur la façon dont cela se répercute sur les inégalités en dehorsdes catégories socioprofessionnelles.

mots-clés inégalités ◆ marginalité ◆ médecine complémentaire et alternative ◆ néo-Wébérianisme ◆professions ◆ santé

resumen Las ideologías profesionales vinculadas con el ejercicio de funciones de servicio públicoabogan por el combate de las desigualdades entre los usuarios a título individual y/o el público en general.Los sociólogos de las profesiones en el contexto anglo-americano han analizado hasta qué punto se verificaeste compromiso. Esta contribución brinda no obstante una revisión de la literatura sobre lasdesigualdades entre los grupos profesionales desde una perspectiva neo-weberiana, apelando al conceptode marginalidad y centrándose en el sector de la salud. Haciendo particular referencia al caso de lamedicina complementaria y alternativa, se destaca que la investigación futura deberá focalizarse sobretodo en la manera que esto influye sobre las desigualdades al margen de las categorías socio-ocupacionales.

palabras clave desigualdades ◆ marginalidad ◆ medicina complementaria y alternativa ◆ neo-weberianismo ◆ profesiones ◆ salud

professions, marginality and inequalities · mike saks, 2014, ‘professions, marginality and...

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