23 Wage slavery

Given how debilitating alienation is for workers, one might ask why it is that capitalism has not been overthrown. Part of the reason for this is simply that people feel they have no choice but to work within ‘the system’ in order to live. Capitalism had created the conditions in which almost all of us need to work to survive, rather than working to fulfil our creative potential. And so, we are all, in Marxian terms, wage slaves.

Wage slavery derives from the fact that;

‘most people spend most of their day under somebody else’s supervision and control — namely at work. Every day, they sell not only their labour power but also their autonomy for a certain number of hours. Thus, they lose freedom, which in turn means a loss of self-determination. The power that the capitalists exert over workers doesn’t benefit workers, it benefits the enterprise, which often enough turns against the workers. If you depend on someone else for your survival for the rest of your life, you are constantly forced to ensure that you remain competitive, i.e., cheaper and more productive than others. Your entire social environment is influenced and shaped by this competition, which extends into leisure time too’ ^[1].

And there are some important implications of being a wage slave for health professionals. Firstly, capitalism distinguishes meaningful work (that which maximises the use of people’s time and labour, surplus value, and profit), from ‘indulgent’ work (intellectual development, aesthetic pleasure, fun and games, or what Hannah Arendt called ‘action’). Secondly, it rewards those who help the system to prosper. Physiotherapy’s longstanding focus on treating the body-as-machine, returning people to work, emphasising fitness and purposeful movement, focusing on restoring activities of daily living, and so on, suggest a bias inherent in the profession towards capitalism ^[2][3][4].

The focus on pathogens and germ theory as the basis of all illness, and today’s more recent interest in personal responsibility, self-care, and ‘active’ rather than ‘passive’ therapies, also divert attention away from the social determinants that are known to give rise to disease in the first place. Marxist thinkers in healthcare believe that we are wrong to see illness and disease as residing within the body of individuals. Rather, today’s maladies ‘are located in the economic, political and social arrangements of capitalism, not within individual biology or lifestyle’ ^[5].

Of course, the state’s endorsement of biomedical knowledge through public funding of research and legal protection of medicine’s occupational territory, only reinforces the sense that capitalism is a powerful system into which all orthodox professions, including physiotherapy, are enmeshed. As Alan Petersen suggests;

‘Doctors maintain their high status and incomes insofar as they control public expenditure in the health area; on the other hand, the state maintains its legitimacy as a ‘caring’ state insofar as it is seen to manage ill-health effectively and to deliver medical services which the population has come to regard as an essential component of good health’ (ibid).

Capitalism, therefore, creates a major dilemma for health professionals like physiotherapists. Many would love to spend longer with their client/patients, but they are told the economic constraints of the system will not allow it. They know there are times when they should advocate for their patients, but they know they risk their own security in doing so. And many would love to be able to be more compassionate and caring in their therapy, but the profession places little value on knowledge that cannot be externally verified, objectively measured, or based on quantitative evidence.

A recent Canadian study by Jennifer Bessette, Mélissa Généreux, Aliki Thomas, and Chantal Camden has shown just how conflicted physiotherapy is around its dual role as a patient advocate and as a profession that depends on its special status to provide work for its members. In the study, the authors argue that physiotherapists should play a vital role in helping to ‘address national health concerns, such as the aging population and the opioid crisis’, and that ‘physiotherapists need to be educated to become competent advocates ^[6]. The authors cite evidence that physiotherapy students are taught to ‘speak out on health issues identified by clients’, ‘empower clients to speak on their own behalf’, and to work collaboratively to ‘optimize client care’.

But the authors also found that educators found advocacy difficult to teach and assess ‘in a fair, clinically relevant, and time-effective manner’ (ibid, p.309). The study found that some students were ‘not naturally inclined to defend their patients’ interests’, and that others were ‘often unwilling to engage in advocacy’ (ibid). There were issues finding time in the curriculum to teach advocacy, and limited exposure clinically, unless students were placed in ‘settings with a strong focus on patient-centered care, located in under-resourced areas, or in which students interacted with vulnerable patients offered more opportunities to practise advocacy’ (ibid, p.310).

Crucially, the authors found no evidence that the fundamental ethical contradictions inherent in advocacy had been explored with the students. Often in health curricula, advocacy is seen as a skill or competency to be learned and applied in the way one might undertake a Thomas Test or a Timed Up-and-Go. The therapist here is seen as an objective agent of change, who can apply a set of skills and learned competencies to a situation and ‘treat’ the person’s social situation much as they might treat an unstable shoulder. A Marxist reading of advocacy though would say that advocacy is fundamentally about power, in which an oppressed member of society reaches out for help. The therapist here is not the last link in the chain, but is, themselves, subject to the same system of oppression that envelopes their patient. If they speak out against the injustice affecting their client or their community, they may suffer as a result. They may lose their job, or be rebuked by their peers. The root of the problem of advocacy, then, is that it feels like ‘an abstract concept’ that the students ‘just don’t understand’. It is an ethical principle that should fit in to the schema of all practitioners, but feels, in the end, as if it is ‘just “not physio.” (Supervisor 8)’ (ibid).

No matter how many ethical codes govern what people are supposed to do, if a person has the choice between speaking out and risking their livelihood, and staying quiet, they will most often choose the latter. A recent study by Phillippa Malpas, Warwick Bagg, Jill Yielder, and Alan Merry showed that doctors routinely practiced ‘sensitive examinations (of female breasts and pelvis, female and male rectums and male genitalia)’ on anaesthetised patients without consent ^[7]. And;

‘Students are not alone in acknowledging a conflict in speaking up. When medical oncologist, Ranjana Srivastava asked colleagues to reflect on her experience of not speaking up to a senior colleague about her concerns for a patient’s safety, “each recalls sometimes harbouring misgivings about another doctor’s treatment of a patient but feeling unable or reluctant to comment, even when a patient’s life might be threatened”’ (ibid).

Marxian scholars say that the impulses that lie behind such actions cannot be reduced to individual choice, or understood simply as the actions of an individual corrupting what is otherwise an ethically robust system. These practices are too widespread to be about the individual’s failure to follow an ethical code. In many cases, they are part of a systemic problem that Marxians believe underpins capitalism, and the systemic exploitation that forces people to make choices between advocating for their patients or losing their job. Marxist scholar Antonio Gramsci (1891-1937) argued that we are limited in our ways of thinking about things like advocacy and biomedicine because these ideas are hegemonic, an important concept that also applies directly to physiotherapists.