28 The conquest of official privilege

Magali Larson was particularly interested in this ‘conquest of official privilege’ ^[1], that had been used by the orthodox professions in the 19th century and after, as a way of establishing their ‘monopoly of credibility’ (ibid). Ian Kessler, Paul Heron, and Sue Dopson suggest that Larson viewed ‘professional projects as the competitive and power-driven pursuit of labour market status and reward by self-interested occupations’ ^[2].

Larson showed that part of the reason for medicine’s success in establishing its social position in the 19th century was due to its ability to use ‘educational credentials to affect social closure, to restrict entry to the occupation to those able to obtain formal training’ ^[3], and to deliberately enhance it’s ‘claims to offer valued services, through espousing a scientific basis to medical knowledge’ (ibid). Social closure allows the profession to establish the rules and principles upon which any future contest over ideology takes place. Having control over what is reasonable and unreasonable makes it much more difficult for others to compete because to do so may require the profession to abandon the principles it was built upon, weakening its claims in the face of a hegemonic, controlling competitor. This is why Marxist scholars argue that one of the major concerns with the capitalist system in healthcare lies in the way it reinforces occupational control as a strategy of medical power.

Gabe suggests that another critical factor in the growth of medicine’s social capital came from ‘the expansion of a middle-class able to purchase medical services in 19th-century Britain or the United States’ (ibid). The ability of the increasingly professionalised middle class to influence state policy and bolster its own interests resulted in the ‘involvement of the state in supporting, at least partially, medicine’s bid for monopoly control of healthcare provision’ (ibid).

Larson’s work here built on earlier Marxian scholarship that had argued that capitalism had enabled the creation of a new class of petit bourgeois professionals; a ‘nouveau riche’ class of middle-class workers that had managed to attract enormous wealth, power, and privilege to itself. In a recent study of the highest paying jobs in America, based on Bureau of Labor Statistics data, for instance, health professionals made up 11 of the 13 highest annual wage earners, and nine of the top 10 ^[4].

Larson suggests that state intervention to support the professions has historically favoured the bourgeoisie, ‘Indeed, reliance upon the state was not merely a pattern borrowed by the 19th-century professions from the medieval guilds, but also the means by which the ascending bourgeoisie had advanced towards a self-regulating market’ ^[5].

Neo-Marxian scholars like Larson, then, see the question of professional autonomy very differently to functionalists. Where functionalists argue that the ability to self-regulate is one of the rewards for a profession’s help in resolving social problems, Larson and others ^[6][7][8], argue that autonomy had little to do with the profession’s social contract, or its technical expertise, but was, part and parcel of ‘the processes of class and state formation’ ^[9]. As Edgar Burns has suggested, professionalisation is ‘a substantially intentional and effortful occupational activity, not a historically autonomous or reified process’ ^[10].

Far from a profession seeking to act autonomously, Neo-Marxian scholars showed how vital it was that professionals were intimately connected to the processes of class and state formation;

‘The medical profession is, for Marxists, part of the ideological state apparatus. As Waitzkin ^[11] puts it, ‘medicine fosters an ideology that helps maintain and reproduce class structure and social domination.’ The profession, along with educators, lawyers and other elements of the middle-class, plays a key role in legitimating the capitalist state and the search for profit and capital accumulation upon which the economic and social system relies. By presenting illness and disease as an individual, rather than a social issue, physicians contribute to legitimating the social conditions which create illness as well as profit. However, on the other hand, Marxists are not suggesting that capitalism thrives on a sick population — only that when there is an excess of labourers over employment (as there has been at most times since the nineteenth century), sickness like unemployment can be not only tolerated but approved, since its costs are predominantly borne by either individuals or the state’ ^[12].

The professions are key to the process of class and state formation because it is, perversely, in their competitive interest to see the illnesses and suffering caused by alienation and social inequality persist, especially if those illnesses further their claims to commodity control and special expertise. For instance, many of the diseases, injuries, and illnesses that have given the Western medical professions their power and prestige were directly created by living and working conditions engineered under capitalism. As John Swain, physiotherapist Sally French, and Colin Cameron suggest, the professions are ‘parasites’ in this regard ^[13].

Capitalism has also rewarded those who fuelled the engine of productivity and profit with protective legislation, subsidised training, and privileged access to the ill and injured. And established a system of social reward and validation that encouraged elite and privileged health providers to perpetuate the system and entrench it as a hegemonic way of thinking in society.

Western medicine’s focus on seeing health and illness in individualistic terms has also detracted attention from the deeper social determinants of health that might encourage people to critique the system that perpetuates them. A focus on personal prevention emphasises the importance of people taking individual responsibility for their own health and wellbeing, and rewards people who remain productive, independent, autonomous members of society. This perpetuates the Marxian view that healthcare practitioners have historically blamed the victim ‘rather than recognising that the major causes of social problems were outside the control of the individual’, and they have ’acted as agents of social control on behalf of a capitalist state by individualizing social problems’ ^[14].