Medical Dominance Over Health Professionals and Patients

Introduction

The objective of this study is to answer the question of how true the claims are that the medical profession exercises undue dominance over health professionals and patients. Toward this end, this study conducts a review of the relevant literature. According to Willis et al. (2008), the rationale that doctors use for maintaining autonomy and control over their working conditions derives in part from "the importance our society attributes to the relationship between the doctor and their patient," referred to as the patient-practitioner relationship. An important part of the doctor's role is described as "the obligation to provide the best available evidence-based care for patients" (Willis et al., 2008), a concept termed personalized service (Alford, 1975, as cited in Willis et al., 2008). This means that the doctor does not favor one patient over another and maintains confidentiality about the patient's condition. These obligations afford doctors a great deal of control over healthcare, and without autonomy this relationship would greatly suffer.

The power afforded to doctors derives from their history of success in the late nineteenth and early twentieth centuries, which established them firmly as the "dominant controllers of medical care" well before the development of scientific medicine (Willis, 1983, as cited in Willis et al., 2008). This authority is granted by the state and positions the medical profession as what is termed medical dominance (Willis et al., 2008).

Medical dominance is defined as "ideological dominance over developing occupations, power to influence resource allocation decisions, and organizational authority" (Ovretveit, 2008). Autonomy and dominance are closely related concepts. Several types of professional autonomy can be distinguished, which serve to:

Medical Dominance: Definition and Forms of Autonomy

(1) document different forms of independence acquired by an occupational group at different points in history; (2) identify important differences between occupations in terms of the types of independence achieved; (3) explore varying patterns of occupational development, rather than viewing all occupations as following a single inevitable process of professionalization; (4) establish whether aspects of professional autonomy are related to aspects of medical dominance and whether aspects of medical dominance have declined; and (5) examine forms of control over developing health occupations other than those exercised by the medical profession (Ovretveit, 2008).

Professional autonomy exists at multiple levels, including national and international levels. A distinct form of professional autonomy exists "where the state grants members of an occupational group a legal monopoly over a sphere of work" (Ovretveit, 2008). There is, however, a challenge in defining the boundaries of that work. It is reported that such legal monopolies represent "the freedom of an occupational group to exclude others who are not qualified, in the interests of protecting the public" (Ovretveit, 2008). Closely related to this is the right of a profession to regulate its own training schools and educational curriculum (Ovretveit, 2008). In the United Kingdom, this is accomplished through a central council with a majority membership drawn from the profession itself, which accredits training centers, supervises examinations, and issues certificates of competence for practice (Ovretveit, 2008).

At the district level in England — divided into 192 District Health Authorities — professional autonomy takes the form of self-management, defined as "the right of an occupational group to be managed by members of the same occupation" (Ovretveit, 2008). A manager in this context is defined as "one who is accountable for his subordinates' work in all aspects; who is able to assess the quality and effectiveness of his subordinates' work as it is done, and who has the authority to make any further prescriptions or re-assignments of work which he may judge to be necessary" (Ovretveit, 2008). Professional autonomy at the individual level is considered by some to be "incompatible with the nature of the work they do" (Ovretveit, 2008), since the presence of a manager may harm "the formation of a confidential and trusting personalized relationship between the practitioner and patient" (Ovretveit, 2008). This type of autonomy is referred to as practice autonomy, because freedom from managerial interference in clinical decision-making "extends to other areas of the professional's work" (Ovretveit, 2008).

The classic work of Jewson (1976) on the history of the development and production of medical knowledge defines what he termed "medical cosmologies" (Crinson, 2007). These frameworks describe the way in which "historically, developments in science have been intimately linked with the particular social relations and dominant ideas that existed within the society at the time" — in other words, "the production of medical knowledge is rooted within social, rather than the popular notion of a progressive march of science towards ever greater knowledge of the functioning of the human body" (Crinson, 2007).

Jewson's first cosmology is described as "person-oriented," existing before industrialization and the Enlightenment, and requiring the physician to acknowledge the patient as "a holistic entity" (Crinson, 2007). Medical judgments were made "in terms of the personal attributes of the sick person; if they were not, then the physician would lose that person's business" (Crinson, 2007). The development of hospital-based medicine in the late eighteenth and early nineteenth centuries is viewed as being associated with broader social changes, including the growth of capitalist forms of production, industrialization, urbanization, and "the increasing dominance of scientific knowledge and explanation" (Crinson, 2007). Jewson describes this as "an object-oriented cosmology," reflecting a period in which "the doctor-patient balance of power begins to change" (Crinson, 2007). The medical elite were no longer dependent on the patronage of their patients, and "control of medical knowledge passed from the patient to the clinician" (Crinson, 2007). Hospitals became "training centers for the new profession of medicine and sites for scientific research" (Crinson, 2007).

In the late nineteenth century, Jewson's third cosmology — which he labeled laboratory medicine — emerged. At this stage, the patient as the object of medical practice "moves out of the frame and disease becomes a physiochemical process." This development is characterized by what Foucault (1973) termed the new "clinical gaze", reflecting a shifting power relationship between patients and their doctors (Crinson, 2007). Foucault conceptualizes power not as the property of any particular social group or as something exercised through a structural instrument such as the state, but rather as "a relationship which was localized, dispersed, diffused and typically disguised through the social system, operating at a micro, local and covert level through sets of specific discursive practices" (Turner, 1997, as cited in Crinson, 2007). Power is thus conceived as a strategy or "set of discursive practices that characterizes the working of modern social systems" (Crinson, 2007). Foucault captured this in his statement that "power is a machine that no one owns" (Crinson, 2007).

Historical Development of Medical Dominance

From this perspective, government "depends on systems of knowledge and truths that constitute the object of its activity, and here the roles of experts and their expertise are central" (Crinson, 2007). In medicine, "power is embodied in and comes with the day-to-day rational-scientific practices associated with the work of doctors in the hospital or clinic, which Foucault (1973) termed the 'clinical gaze.' Such everyday practices contribute to the social construction and reproduction of what has been termed the 'biomedical discourse'" (Crinson, 2007). For Foucault, the relationship between knowledge and power is "an inevitable and inextricable one: any extension of power involves an increase in knowledge." Institutions such as medicine "exercise power not through overt coercion but through the moral authority over patients associated with being able to explain individual problems (such as illness) and then provide solutions (i.e., treatment) for them" (Crinson, 2007).

Miller and Rose argue that medical experts serve as mediators between individuals and authorities, shaping conduct "not through compulsion but through the power of truth, the potency of rationality, and the alluring promises of effectivity" (Miller and Rose, 1993, as cited in Crinson, 2007). From this view, "power is essentially relational rather than something that is possessed by individual doctors in the medical profession as a social group" (Crinson, 2007). Power is exercised most effectively when the subject of the discourse internalizes the gaze "to the point that he is his own overseer, each individual thus exercising this surveillance over, and against, himself" (Foucault, 1980, as cited in Crinson, 2007). Armstrong's (1993) work on the "New Public Health" argues that public health strategies are "purely a contemporary example of medical power exercised through the surveillance of a population's health behavior" (Crinson, 2007).

Irvine, Kerridge, McPhee, and Freeman (2002) report that "interprofessional relationships continue to be characterized by conflict rather than co-operation and are frequently distorted by mutual suspicion, hostility, and disparities between the way that a particular profession views itself and how it is viewed by other occupations." Ethical critiques of healthcare generally adopt "one of a number of normative ethical approaches, including principle-based, consequentialist, deontological, or virtue-based approaches" (Irvine et al., 2002). There is considerable division among healthcare occupations. In addition, the intense scrutiny under which the medical profession has come due to scandals in hospital medicine and general practice has prompted inquiries and reports, with both government and the profession responding through changes to the regulation process.

Bahnisch (2012) states that professional education has not been able to keep pace with the challenges of contemporary healthcare, and that systemic problems have been met with "laudable efforts to address these deficiencies" that have "mostly floundered, partly because of the so-called tribalism of the professions — the tendency of the various professions to act in isolation from, or even in competition with, each other." Bahnisch further notes that "institutional and cultural embeddedness may not have been given adequate weight in shifting educational, organizational, and policy agendas towards interprofessional practice" (2012). Questions that must be addressed include: (1) How are the dynamic boundaries of medical authority reproduced in educational, institutional, and organizational cultures? (2) What are the implications of the cultural reproduction of medical authority for education and public policy? (3) What are the implications of this cultural reproduction for modes of governance and the pace of organizational change? (Bahnisch, 2012).

There has been a "general erosion of professional autonomy vis-à-vis control or monopoly over knowledge" (Bahnisch, 2012). Ovretveit (2008) questions whether medical dominance has declined due to the increasing autonomy of developing health professions, and raises the theoretical question of whether such changes in autonomy are associated with, or a result of, a decline in medical dominance. Some propose that "the increased independence of developing health occupations is a major challenge to medical dominance and is either associated with, or a result of, a decline in medical dominance" (Ovretveit, 2008). Others contend that medical dominance has not significantly declined and that "the increased independence of these occupations is of a particular kind which is consistent with the continued dominance of medicine in the health division of labor" (Ovretveit, 2008). These two views can be distinguished by their "different conceptions of autonomy and different views about the extent of the autonomy possible in developing health professions" (Ovretveit, 2008). More recent scholarship on developing health occupations describes the "increasing independence of such occupations from medicine in a number of areas," using the concept of autonomy in a way that "links the increase in autonomy of developing occupations to a decrease in medical dominance" (Ovretveit, 2008).

This study set out to answer the question of how true the claims are that the medical profession exercises undue dominance over health professionals and patients. This brief examination has traced the historical development of medical dominance and demonstrated how it has remained well positioned over the last three centuries. However, with the advent of many new occupations in the medical field, the findings indicate that medical dominance, while still strong in many respects, is experiencing a decline due to the increasing number of occupational fields in medicine that now practice with full autonomy. The sociological literature reviewed here — from Jewson's medical cosmologies to Foucault's analysis of the clinical gaze and contemporary interprofessional research — collectively suggests that medical dominance is real, historically deep-rooted, and structurally embedded, but is not immune to the pressures of professional diversification and policy reform.

Bahnisch, M. (2012). Medical dominance and the continuing robustness of professional cultures in healthcare. CMEDRS/DME Research Rap, 7 Aug 2012.

Crinson, I. (2007). Concepts of health and illness, Section 2: Sociological conceptualization of medical knowledge and power. Health Knowledge.