30 Are individual physiotherapists responsible?

So, to what extent are individual physiotherapists complicit in perpetuating capitalism in healthcare, and in society at large? Because Marxian theory is heavily structural, meaning that it looks at the social conditions that make it possible for people to act, rather than individual agency, it does not apportion much responsibility to individual social actors. As Keith Macdonald suggests, ‘what happens to the profession’, is an ‘outcome of the workings of a society based on capitalist relations of production’ ^[1].

And it would be hard to believe that when physiotherapists apply reductive, biomechanical approaches to their assessments and treatments, they are deliberately attempting to diminish their clients’ subjectivity because they are driven by malign, capitalistic intent. It would be more reasonable to argue that they operate in this way because an objectivist biomedical hegemony dominates the profession. And Marxian theory would be much more likely to focus attention on the physiotherapy profession as a whole. In their 2008 article, Physiotherapy as a profession: Where are we now? ^[3], for example, Clair Kell and Gwyn Owen used Magali Larson’s work to suggest focus on the physiotherapy profession, not its individual practitioners. In the paper, Kell and Owen argued that a profession needs to be able to draw on three related assets in order to gain recognition:

• Economic: Building and capital assets and resources
• Organisational: A credentialing body that controls access to the profession and serves its members interests directly
• Cultural: Shared values, understanding and beliefs (ibid).

These three ‘assets’ (note the language), are necessary, Kell and Owen argue, to build trust. Keith Macdonald made a similar point when he suggested that professional projects are always pursued within the social and economic sphere. In other words, a profession cannot survive or gain the trust of funders, governments, and the public, unless it responds to both social and economic imperatives. The economic sphere is important because it is where the profession establishes ‘legal monopolies of knowledge-based services’ ^[4], or commodity control, in Magali Larson’s terms. Crucially, it is only when both projects are successfully pursued — especially in the case of medicine — an effective monopoly on knowledge combines with public trust and the profession can effectively assert ‘social closure’ (ibid). So, how much of this can realistically be achieved by individual practitioners? Clearly very little. It is perhaps ironic, then, that physiotherapists place so much emphasis on personal responsibility in their therapy. If they had real faith in the power of individual action, they might fight against the injustices that cause so much illness and injury in the first place. The fact that they do not do this to any great degree, suggests that physiotherapists do not have real faith in individual agency, or they are happy to support the capitalistic hegemony that has seen their individual and collective professional projects prosper.

The fact that physiotherapists colonised certain forms of knowledge and skills, and used these to establish allies and status within mainstream Western society, is a pattern that has been replicated throughout the professional sphere. Marxian scholars might argue that the prestige acquired from doing valuable work, and being an ally to biomedicine, coupled with the state sponsorship and protective legislation that flowed from being recognised as a legitimate, orthodox profession, may well have been more than enough compensation for the need to perpetuate capitalistic attitudes to health and illness. And so, physiotherapy, like medicine, became a ‘class instrument’, focused on ‘curative, individualistic and technical solutions rather than social and political ones involving a fundamental restructuring of capitalist economic and social arrangements’ ^[5]. It was what Daniel and Richard Susskind called the profession’s grand bargain ^[6].