67 Professions under fire

Although it may be tempting to lay all of the responsibility for the plight of health professionals today at the door of late capitalism, this would be misleading because at the beginning of the chapter I commented that there were two forces shaping post-professionalism, with the second being the critique now being levelled at the professions themselves. And despite the protests from within the professions that their autonomy, prestige, and everyday work is being increasingly disrupted, there remains much to criticise about the professionalisation of social life in the 21st century.

Central here are what are known as the professogenic effects of healthcare, or what Julian Tudor Hart called inverse care failures ^[1]. These are often thought to stem from shoddy work and clinical errors, or institutional and individual malpractice ^{[2][3][4][5][6]}. But they also derive from the prestige and privilege health professionals claim for themselves by virtue of their perceived ‘goodness’ and expertise. These attitudinal mythologies surround elite, orthodox healthcare professions, and are performatively burnished by the professionals themselves, as a way to bolster their cultural, economic, and social capital. They are part of their habitus, and convey the sense that there is something natural and obvious about their command of Western healthcare.

Part of this mythology derives directly from the work of earlier functionalists, who codified a set of traits that the professions themselves were only too willing to embrace. These included altruism, public spiritedness, disinterest in personal gain, affective neutrality, ethical scrupulousness, balanced judgement, and social order ^[7][8], all of which have subsequently been disputed.

But the innate desire of all professions to secure and protect their hard-won boundaries, has often resulted in a resistance to any external critique that might weaken the profession’s position ^[9]. The result of which led Heather Simpson to complain that although criticisms of health professional conduct had been ‘expressed, and supposedly agreed with, for decades… system changes have been only marginal at best’ ^[10].

20 years ago, the UK’s Chief Medical Officer, Liam Donaldson, stated that future healthcare must ‘address the deep-seated problems of the past’, and health services must ‘give priority to developing health professionals equipped to practice in a new way’ ^[11]. ’The current system of health professions is too rigid’, Claire Warnes argues, and professional silos are ‘everywhere’ ^[12]. Professional boundaries could be much more porous, and healthcare professionals could embody a much ‘greater breadth of skills’ ^[13]. Perhaps it is not surprising, then, that many people agree that healthcare professionalism remains ‘an inherently conservative discourse’, demanding of its members ‘’unquestioning obedience’ to a set of impersonal rules and procedures laid down by the authorities within the profession’ ^[14]. It is for this reason that Max Weber argued that the content of the professional’s conscience should be of ‘immediate concern to us all’ ^[15], or as Alan Petersen puts it;

’If it is accepted that professional struggle is as much, if not more, to do with occupational groups self-interest and their attempts to gain power as with client advocacy and social justice, then any serious change strategy should as a starting point include critique of the nature of professional practice and of professional training’ ^[16].

At the heart of this critique would be the professogenic effects that are ‘systematically produced as part of the social organisation’ of the professions ^[17].

Edgar Burns argues that we need post-professionalism to act as a direct challenge to the kinds of protectionism and insularity so often seen in professional conduct, and to the ‘disproportionate advantage’ achieved by those professions that have increasingly claimed power and prestige for themselves to enable them to become ‘apex social actors’ ^[18]. All too often, Burns suggests, the ‘latent consequences’ of the well-intentioned professionalising projects of doctors, nurses, physiotherapist, and others, are simply ‘written out of the script’ when the professions define themselves and their work (ibid).

We have perhaps seen echoes of this in the way physiotherapists adopted evidence-based practice in the 1990s, without giving adequate thought to its links to the marketisation and accounting logic creeping into healthcare ^[19]. So whereas evidence-based practice could have ‘challenged physiotherapists to discuss more overtly the ontological basis of professional knowledge, its professional ethic, practice and ongoing, career-span development’ (ibid) — and thereby turning more away from professional protectionism and towards its clients — it, instead, encouraged physiotherapists to see the patient as ‘something additional rather than integral to ‘evidence’’ ^[20], and drove aggressively towards medicine and the pursuit of greater objectivity, reductionism, and positivism. It did this, perhaps, in an attempt to ‘shore up its jurisdictional claims’ ^[21], and keep ‘decision-making practitioner-led rather than person-centered or shared’ ^[22].

Western health professions often cite the advent of managerialism and an audit culture for their declining fortunes (as in the rhetoric of de-professionalisation above), but health professions are equally complicit when they, perhaps unknowingly, put their own security and prestige above public service. When they do this, their oft-repeated claims to be altruistic, trustworthy, and caring can sound like ‘a litany of intention or aspiration at best and special pleading for more average performance’ (ibid). As Edgar Burns reminds us; ‘all professional interventions across every profession have the potential for adverse consequences’ ^[23], and there is nothing inherently good about being a professional. But Burns also suggests that, ‘letting go of such automatic claims’ (ibid) to goodness, as implicit explanations for the privilege professions give to some people, practices, and ideas, may allow us to focus more on people’s needs and the knowledge and skills needed to meet them.