20 Critiques of functionalism

The professions have historically enjoyed significant social standing and prestige, and to be a professional has always carried a degree of kudos. And although some have recently sought to undermine the value of professional expertise (see, for example, UK politician Michael Gove’s recent announcement that “people in this country have had enough of experts” ^[1]), being a professional, particularly a healthcare professional, remains significant. Functionalism is responsible for a fair amount of this cultural capital because it solidified the professions within the establishment, at a time in the first half of the twentieth century when many people were looking for more order and stability. But since the heyday of functionalism in the first half of the 20th century, there has hardly been a sociologist who has not weighed in to functionalism’s shortcomings.

Functionalism has largely been rejected for a number of important reasons. Firstly, critics argued that it says nothing about the kinds of power that the professions accumulated around themselves during the 20th century. Functionalism has no mechanism to account for the elite professions’ ‘enlightened paternalism’ ^[2][3][4][5]. This has been especially true for the medical profession, whose financial rewards, social privilege, and jurisdictional control over how people experience, think, and practice healthcare ^[6], has caused many critics to doubt Parsons’ early claim that true professionals were altruistic and disinterested in personal or professional gain. Keith Macdonald suggested that the key question we should be asking the professions is how they managed to persuade society to grant them a privileged position in the first place ^[7]. And Jonathan Gabe has even argued that this acquisition of enormous social capital, whilst claiming to be public-spirited and altruistic, represents ‘something of a con trick’ ^[8].

Functionalism says nothing about the ‘self-interested practices of social closure, of professions seeking to maintain their occupational autonomy, their pursuit of high incomes, and the maintenance of their social status’ ^[9]. The whole question of social closure is something I will return to at length later, but it critiques functionalist thinkers for taking the profession’s claims to professionalism at face value. For example, functionalism does not question a profession’s claim to be value free yet, at the same time, ‘good’ ^[10]. Functionalism says nothing about the way that medicine has consistently treated people differently depending on their gender, ethnicity, race, social class, ability, and sexuality, or how it has functioned as ‘a particular, institutionalized form of client control’, with their professional status deriving from ‘the assumed ignorance of the client’ ^[11]. Nor does it account for the ‘greed, hubris, fragmentation, and insensitivity to patients’ that proliferated in medicine in the second half of the last century ^[12]. And it says little about the way medicine routinely makes ‘moral judgements about the role patients play in causing their illnesses’ ^[13], or the way the functionalist position ‘typifies patients as compliant, passive and grateful, while doctors are represented as universally beneficent, competent and altruistic’ ^[14].

Functionalist descriptions of professions suit the professions themselves because they ‘mostly consider traits like expertise, ethicality, autonomy, care, to be self-evident features’ ^[15]. But these fail to explain the broader ‘external’, macroscopic, social structures, that make the professions possible in the first place. They ignore, for instance, the loss of much of the traditional cultural authority possessed by the elite professions, and the fact that many professions — including those allied to medicine — serve important functions in society, but often remain poorly paid and subordinate ^[16]. Also, Abbott and Meerabeau have argued that functionalism provides the justification for professions to serve their own interests as much as those of others, and, because of this, ‘the professions cannot necessarily be relied upon to police themselves effectively, nor to act in the public interest’ ^[17]. Because functionalism makes professions appear self-satisfied, Macdonald has suggested that some studies of the professions, by the professions themselves, have reached ‘a level of uncriticality that is hard to credit’ ^[18].

Building on Macdonald’s criticism, Burns suggests that functionalism actively discourages critical questioning ^[19] because it only provides a description of what a profession is, not what a profession does ^[20]. It has helped the elite ‘true’ professions develop a social brand that others might imitate ^[21], and it has explained why things are the way they are ‘for a particular group or social class at a given point in history’ ^[22], but says little about the external, social forces that shape professions, or the fluidity of social relations that see professions in a constant state of flux. It leads to what Burns calls an ‘abstract universalism’ (ibid), that promotes the idea that there is only one kind of profession, rather than the myriad local, context-specific variations. We see this in the way professions are defined in functionalist terms, implying that they are more stable and resolute than the reality of people’s practice ‘on the ground’. Functionalism tells us little about a profession’s ability to maintain its cultural legitimacy in the face of prevalent social values and concerns ^[23][24]. We know, for instance, that people’s trust in medicine is much more volatile than it once was, but functionalism has no mechanism to explain why this is, or how medicine has changed as a result. Functionalism judges all occupations against an ideal or archetypal model represented in healthcare by medicine. It suggests that professions like medicine and law represent the ideal standard against which we should judge all other professions. Trait theory offers no explanation for how and why an occupation became a profession in the first place, though. It says nothing about the economic and social rewards that flow to elite professions, nor criticises the ways in which these elite social bodies exercise their power, sometimes at the expense of those people they putatively claim to serve.

Critics argue that functionalism promotes the belief that society is innately stabilising and progressive, and that the professions serve as stabilising agents. But such ‘consensus’ theories were largely advanced during periods of the 20th century when there was more faith in authority figures, and people were more accepting of grand narratives like science and religion ^[25]. Since the 1960s, conflict theories have been used much more to explain how professional projects have shifted and changed over time, and consensus theories have largely been jettisoned.

In the functionalist tradition, ‘people disappear into social structures, become passive reactors to those structures and lack any ability to engage with the external world as their actions are deterministically structured by them’ ^[26]. This is true of individuals who make up the collective face of a profession, but it is also true of the clients, patients, consumers, and service users, as well as the myriad ’others’ that the professionals work with (Different terms for patients, clients, consumers, and service-users are used throughout the book. I have attempted to use them in their particular context rather than offer one standardised term. Thus the idea of the consumer and service-user, in contrast to the ‘passive’ patient, become highly relevant when I discuss the neoliberal market economies now driving Western healthcare.) Functionalism says nothing about the relational nature of health care practice, or the existential and subjective experience of being a professional. It assumes that all of the professionals of a particular stripe conform to the same traits and characteristics, and everyone is subject to the same social rules, which operate uniformly throughout the profession.

Finally, and perhaps most significantly for this book, functionalist ways of thinking may hamper a profession’s own abilities to grow and change because they tend to see social institutions like the professions as ‘simply and naturally, how things are’ ^[27]. But this assumed ‘naturalness’ is not supported by history. It also discourages critical interrogation of the profession’s role and social context because its existence and purpose are seemingly explained by the profession’s affinity with the traits of other elites. Burns goes as far as to say that functionalism is ‘increasingly getting in the way of the important job of linking professions with the kinds of societal questions that they should be answering’ (ibid).

Suffice to say, much of the literature in the sociology of the professions has, in recent years, ‘taken a critical stance, challenging the motivation of professionals and suggesting that they control clients and are concerned primarily with their own status and economic rewards’ ^[28]. Worst of all, particularly for any project that tries to explain how a profession like physiotherapy becomes even thinkable and practicable, is that functionalism fails to answer some of the most pressing questions facing the professions: ‘is the present configuration of this particular professional service best? Best for whom? Who pays? Who pays most? Who should pay most? Who benefits most? What implicit costs are there in this situation? How best to improve, remake a professional group or deliver a professional function?’, and ‘how might things be otherwise?’ ^[29].

The lack of social theory in physiotherapy explains, in part, why functionalist thinking persists in the profession, long after it has been discredited. We see functionalism every day in the traits promoted by our professional bodies. But we also see functionalist motifs repeatedly used by profession leaders who claim that physiotherapists are well-meaning, altruistic, public-spirited, objective, rational, and dispassionate. But, of course, physiotherapy isn’t alone in over-relying on functionalist ideas to explain what it is;

’Even today functionalism, though discredited in social theorising, remains the default mode of thinking about professions and professionalism for the majority of professionals, if they think about their professions in a broader way at all. It reaffirms for themselves, and reasserts to others, the previously hegemonic conception of conjoined professional goodness and expertise” ^[30].

Burns suggests that functionalism persists in at least four areas:

1. Within the professions themselves, in ‘accounting for their social positioning’;
2. Amongst politicians and policymakers;
3. With the lay public, ‘which holds a conflicted mixture of ‘doctor knows best’, and the ‘sense of being excluded from many decisions in many spheres’;
4. And within the media, whose ‘stereotypic positioning of professionals… mixes adulation, fascination and demand in frequently unsatisfactory ways, but which also at times breaks open covert, bad professional situations needing public examination’ (ibid).

Clearly it is necessary to move beyond simply analysing how professions function in society, or the rudimentary categorising of what a profession is or does. And this is especially true in times of rapid and profound social change. And while there is no need to reject functionalism outright, we have definitely arrived at the point where we can move past it, and consider some other ways to think about how professions function within the complex matrix of possibilities and contingencies that is contemporary healthcare. To do this, we need to understand some of the ideas that have supplanted functionalism and open up to some other ways of thinking about physiotherapy. So, this is where we go next.