32 Critiques of Marxian approaches to the professions

Assuming that most of the readers of this book are physiotherapists or other health professionals, the first critique one might level at Marxian approaches is that they seem to have little good to say about the professions. Unlike functionalism, which gave us the idea of the professions as altruistic, public-spirited experts, deserving of our respect, Marxian ideas appear to portray the professions as a cadre of elite, power-hungry, and mean-spirited, petit bourgeoisie. And while this is a very reasonable reflection, we should remember that Marxian analysis arrived at a very particular time in our recent history, and that its application to the sociology of the professions was only one dimension of its broader analysis of capitalism. Marxist sociologists see a clear distinction between those who have power and those who don’t. So in western healthcare it is perhaps understandable that they would take aim at the elite professions, particularly medicine, and advocate for those who are often disenfranchised and powerless. This often means that Marxian thinkers view the professions’ attempts to bolster their professional power, protect their boundaries, and promote their truths, in a rather dim light.

A second critique from physiotherapy readers might be about the uptake of Marxian ideas in the literature. With only one or two exceptions, very little of the material presented in this chapter appears in the physiotherapy literature. But I suspect this is not because physiotherapists have thoroughly appraised Marx’s ideas and found them wanting. In my experience, physiotherapists have almost no exposure to these ideas, and if they do, it is not because of their training or practice. And so, I believe that the limited uptake of these ideas, relates more to our ignorance of their value than any judgement of their utility.

Some sociologists have criticised Marxian ideas for being too heavily ‘structural’, and thereby resembling functionalism. Both Marxian sociologies and functionalism are concerned with the way social systems can be designed to manage and maintain social order. And so, even though Marxist sociologists regard capitalism as ‘an unjust and ultimately unstable’ system ^[1], they both still take the central role that medicine plays ‘in safeguarding the health of the labour force, present and future, and in controlling workers access to the privileges of the sick role’ (ibid), as the basis for their analysis.

Others have suggested that the claim, particularly in Larson’s work, that the professions are always working to secure a hegemonic monopoly over their territory, belies the fact that, empirically, professionals actually spend very little time in the pursuit of monopoly. Indeed, Halliday ^[2] has suggested that the professions are far from self-serving, and;

‘while there is no need to revert to the functionalist view, which takes professions entirely at their own evaluation, these occupations are providing the services that they claim to provide in relation to the life, health, property and other matters of crucial importance to their clientele. It is, after all, essential that they do so, because they cannot keep afloat on ideology alone. Some of their actions may be mere self-enhancement, economic or social, but by far the greater part of the actions of members of professions are providing a service for their patients or clients’ ^[3].

Notwithstanding the work of more recent advocates of Marxism like Theador Adorno, Louis Althusser, Etienne Balibar, Terry Eagleton, Max Horkheimer, Henri Lefebvre, and Georg Lukács, it is also important to note that there have been few strongly Marxian studies that have focused explicitly on medicine and healthcare. With the exception of Vincenzo Navarro ^[4][5], Howard Waitzkin ^[6][7], Terry Johnson ^[8][9][10], and Magali Larson ^[11], there have been few Marxism studies of health professional practice, and none, to date, explicitly considering physiotherapy or rehabilitation.

Some of the reason for this lies in the broad social rejection of Marxian scholarship in mainstream academic circles, particularly in the United States after the neoliberal economic reforms of the 1980s. As William Cockerham pointed out;

’Political events sank Marxist theory in the universities. First, French scholars turned their backs on Marxism as a “theory of domination” in response to Soviet labour camps, the Cold War, Soviet military interventions against revolt in the former Czechoslovakia in 1968, and the Polish government’s suppression of the Labour union Solidarity in 1981, that was followed by similar reactions elsewhere in Europe and Latin America, such that by ‘the beginning of the 1990s, under the impact of post-modernism and the collapse of ‘existing socialism’ in Eastern Europe and the Soviet Union, Marx was a dead dog for most intellectuals there as well’ ^[12].

Cockerham’s epitaph to Marx may well be a little premature, though, if Yoram Hazony’s recent suggestion of a resurgence of interest in Marxism reflects current social and political realities: ‘Marxism is back’, suggests Hazony, ‘and making an astonishingly successful bid to seize control of the most important American media companies, universities and schools, major corporations and philanthropic organizations, and even the courts, the government bureaucracy, and some churches’ ^[13].

Perhaps the two most important criticisms of Marxism are substantive, however, and need to be given careful consideration. The first is that Marx’s theories see power in quite a hierarchical, binary, and linear way. Society, for Marx, is made up of oppressors and the oppressed, and assumes that all societies are fundamentally exploitative. Because of this, Marx believes that all societies are in some ways revolutionary, and that the education of the oppressed will, in time, lead to the overthrow of the dominant class. In healthcare, this might mean that the patients take back the healthcare system from the health professionals and the managers. It assumes that less powerful members of society are frustrated by their position and are agitating for change. But this is often not the case. Many professions, including physiotherapists, appear quite content with their subordination by medicine, and many patients are often quite happy to defer to experts in the wake of illness or injury. So Marxian theory often fails to address whether system-wide revolution is always necessary or productive.

The second major critique is that Marxian social theory always defaults to what is known as ‘economic determinism’, or the belief that ‘all social, political and intellectual development is caused by economic changes and even that all human action is economically motivated’ ^[14]. While this makes Marx’s analysis distinctive, it fails to address a number of other ways to critique health and healthcare. It fails, for instance, to address the critically important relational dimension of healthcare. It has little to say about the gendered and racial nature of medicine, or the discursive way knowledge and power operate in society. It sees the biological basis of western healthcare as a tool in the class struggle, rather than a biological reality in its own right, and it offers little when it comes to understanding the lived experience of illness and injury.

So to understand health professionals and professionalisation projects more thoroughly, we need to move beyond Marx. But perhaps not too far to begin with, because Marxian methods and ideas form the backbone of some of the most fertile and penetrating analyses of the professions ever to emerge. As the distinct threads of class, race, gender and disability scholarship slowly came together during the second half of the twentieth century, a new field of critical theory emerged around healthcare and the health professions, sweeping away much of what had gone before, and laying the foundations for much of our thinking today. And so, it is to these people and the ideas of critical theory that we now turn.