Transcript View PDF outline of Dr. Mike Saks` Lecture

John F. Roatch Global Lecture Series
22 February 2013
THE IMPLICATIONS OF
MARGINALITY IN THE MEDICAL
PROFESSION: THE CASE OF
ALTERNATIVE MEDICINE
Professor Mike Saks
Provost and Chief Executive
University Campus Suffolk
RELATED EXPERIENCE
• Dean of Faculty of Health and Community
Studies, De Montfort University, UK
• Chair of the Research Council for
Complementary Medicine
• Adviser to government and professions on
health and social care in the UK
• Recipient of major international funding for
health projects in North America and Europe
• President of the International Sociological
Research Committee on Professional Groups
• Author of thirteen books on professions,
health and social care.
THE IMPLICATIONS OF MARGINALITY IN
THE MEDICAL PROFESSION: THE CASE
OF ALTERNATIVE MEDICINE
1. Marginality in the Professions
2. Marginality and the Medical
Profession
3. The Case of Alternative Medicine
1. MARGINALITY IN THE
PROFESSIONS
THE MYTH OF SIMILARITY IN THE
PROFESSIONS
It is often assumed that professions are
similarly based – when there are
considerable differences in how they are
constituted and their position in society.
The notion of professions as communities
of equals is a myth both in a single
profession and in terms of the relationship
between professions – on which this
presentation focuses.
DEFINING PROFESIONS
Professions are defined in terms of
exclusionary social closure – based on legal
boundaries creating ranks of insiders (vs.
outsiders) with associated privileges.
However, it is recognised that professions
have different forms of social closure. Some
occupations, moreover, have not effected full
social closure and are in the process of
professionalizing – governed by voluntary
rather than statutory regulation.
MARGINALITY AND THE PROFESSIONS
The category of ‘marginalized professions’
and their relationship with dominant
professions highlights the pecking order
within professions. These have a less well
accepted standing, typically reflected in
different levels of income, status and power.
‘Marginal professions’ in contrast are
professionally-aspiring occupations outside
the state-supported orthodox division of
labour.
THE IMPLICATIONS OF MARGINALITY IN
THE PROFESSIONS
The marginal nature of professional groups
can have many implications, not least for
social inequalities – from patterns of
geographical dispersal of practitioners to the
number of practitioners in particular fields.
This issue becomes more politically charged
if the position of marginal professions or
marginalized professions does not relate so
much to their expertise and the significance of
the knowledge base for the wider society, but
rather to interest-based politics.
2. MARGINALITY AND THE
MEDICAL PROFESSION
MARGINALITY IN HEALTH CARE
The differentiation within professional groups
and its impact, especially in terms of social
inequalities, is now illustrated with reference
to health care.
This then builds into the major case study of
the marginalized field of alternative medicine.
CATEGORISING HEALTH PROFESSIONS
Orthodox health professions are divided by
Turner (1995) into the following hierarchical
categories:
• The dominant medical profession which
stands at the pinnacle of orthodox health
care in modern industrial societies.
• Limited health professions (eg dentists and
opticians) which restrict themselves to
particular parts of the body.
• Subordinated health professions (eg nurses
and midwives) in the orthodox division of
labour.
THE IMPLICATIONS OF MARGINALITY
This is a fluid categorisation – given, for
example, the recent dilution of medical
professional power related to the rise of
corporatism and consumerism.
Nonetheless, these differences have
significant implications in areas such as:
• The way knowledge is used in the division
of labour (eg through referral structures)
• The quality of entrants to particular health
professions in the pecking order
• Access to care through the public sector or
insurance support.
THE POLITICS OF HEALTH MARGINALITY
The political debate about the reasons for
marginality in the professions is also reflected
in the health arena (Saks 2003):
• At one end of the spectrum, the medical
profession is seen as being placed on a
lofty pedestal as a result of possessing
complex/esoteric expertise of vital
importance to the public.
• On the other, medicine is seen as selfinterestedly establishing its own exalted
position in society at the expense of other
health professions/occupations.
MARGINAL HEALTH PROFESSIONS
Despite the hierarchies, even marginalized
health professions have official recognition
and legitimation and a variety of associated
benefits, such as protection of title, which
has often been linked to enhanced income,
status and power.
This marks out orthodox health professions
from marginal health professions which
largely stand outside formal state-endorsed
frameworks and are based on the
categorisation by Turner (1995) of ‘exclusion’
rather than ‘subordination’ or ‘limitation’ in
the health care division of labour.
FURTHER MARGINALIZATION
Such marginal professions include aspiring
health professions within the orthodox
health care division of labour striving to
professionalize.
The excluded also include occupations such
as those in alternative medicine that are not
yet fully professionalized with statutory
underwriting, but have some form of voluntary
self-regulation.
It is these variations from orthodox medicine
which have the greatest implications for the
health groups concerned and the wider public.
3. THE CASE OF ALTERNATIVE
MEDICINE
(a) THE DEFINITION OF
ALTERNATIVE MEDICINE
DEFINING ALTERNATIVE MEDICINE
Alternative medicine in the West is defined
here in terms of its lack of power relative to
orthodox health care:
Orthodox Health Care
• Health care underwritten by the state
• At present based on biomedical dominance
• Focused heavily on drugs and surgery.
Alternative Medicine
• Not widely supported by the state
• Largely subordinated to biomedicine
• Covers a great diversity of approaches, from
acupuncture to reflexology.
TYPES OF ALTERNATIVE MEDICINE
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Acupuncture
Aromatherapy
Ayurveda
Biofeedback
Chiropractic
Crystal therapy
Healing
Herbalism
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Homeopathy
Iridology
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Yoga
Acupuncture
ALTERNATIVE MEDICINE AND POLITICS
In terms of the approach to professions based
on the concept of social closure, the marginal
position of alternative medicine is viewed as
part of a political process creating insiders and
outsiders.
Importantly, it is not seen simply as those
therapies that lack available scientific
evidence in terms of efficacy and effectiveness
compared to orthodox medicine – which in
itself may be contentious.
.
KEY POINTS ABOUT THE DEFINITION
In terms of this definition, it therefore follows
that:
• Alternative medicine is not based on the
intrinsic characteristics of such therapies,
but their political marginality
•
Depending on the balance of power, the
orthodoxy of one period can become the
unorthodoxy of another, and vice versa.
(b) ALTERNATIVE MEDICINE IN
THE UK
PRE-INDUSTRAL HEALTH CARE IN
THE UK
Pre-industrial health care in the UK was
historically characterized by:
• A comparatively undifferentiated field
• The absence of a national, enforceable
legal monopoly of medicine
• Difficulties in distinguishing practitioners:
- Theories/practice
- Training
- Status/repute.
THE CREATION OF A MEDICAL
PROFESSION IN THE UK
From the early nineteenth century, political
power was used to create the medical
profession through:
• A lobby for a unified profession, led by the
Provincial Medical and Surgical Association
(later the British Medical Association)
• A successful campaign to professionalize
medicine, increasingly sustained by the
state by the ‘medical-Ministry alliance’
• Attacks by the emerging profession on rival
health groups, through the medical media.
THE DEVELOPMENT OF THE MEDICAL
PROFESSION IN THE UK
The rise of biomedicine was underwritten by
the 1858 Medical Registration Act and
subsequent legislation which led to:
• Differentiation from rival practitioners
• Reinforcement of medical dominance with:
- An ever wider state market shelter
- Growing paradigmatic unity
- Advances in medicine
- Subordinated health professions
• A highly privileged professional position in
terms of income, status and power.
PROFESSIONALIZATION AS A POLITICAL
PROCESS IN THE UK
It is claimed that the process of differentiation
that began in the latter part of the nineteenth
century in the UK was political rather than
scientifically functional/justifiable at that time
because, amongst other things:
• Medicine was classificatory (vs. curative)
• Aseptic techniques had not been
introduced
• Anaesthesia was not standard in
operations
• Hospitals were seen as gateways to death.
THE INCREASING MARGINALITY OF
ALTERNATIVE MEDICINE IN THE UK
Nonetheless, with the rise of orthodox
medicine came the growing marginality of
alternative medicine, as indicated by:
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Common Law rights, but no state legitimacy
Restrictions on claims to treat conditions
Medical ethics restricting collaboration
Intensified attacks in the medical journals
Informal medical colleague controls
Stifling the professionalization of alternative
medicine.
This led to a fall in use of alternative medicine
and the numbers of alternative practitioners
by the mid-twentieth century in the UK.
THE EMERGENCE OF A COUNTER
CULTURE
However, there was growing public demand
for alternative medicine from the late
1960s/early 1970s. This was linked in the UK
to the development of a medical counter
culture based on:
• Increasing awareness of the limits to
medicine and the availability of alternatives
• A response to medical depersonalization
and disempowerment
• A desire by consumers to exercise greater
control over their own health care.
THE PROFESSIONALIZATION OF
ALTERNATIVE MEDICINE IN THE UK
These trends are an important context to the
professionalization of alternative medicine in
the UK. This has been accentuated by the
following political pressures:
• Growing medical incorporation of
alternative medicine
• Disaffection with orthodox medicine
• Greater receptivity of government to the
professionalization of alternative medicine
• House of Lords Select Committee support
• Lobbying for alternative medicine (eg
Prince Charles).
THE RECENT RESURGENCE OF INTEREST
IN ALTERNATIVE MEDICINE IN THE UK
The development of this counter culture was
the spur to the resurgence of interest in
alternative medicine in the UK by the
beginning of the new millennium with:
• More than 1/7 of the population using
alternative medicine
• 60k+ alternative medicine practitioners in
existence
• Increasing employment of alternative
medicine in the National Health Service by
medical and non-medical practitioners.
THE GROWING PROFESSIONALIZATION
OF ALTERNATIVE MEDICINE IN THE UK
In consequence, there has been an increased
move to professionalize alternative medicine:
• Alternative medicine has increasingly been
based on education/training
• Ever more alternative medical practitioners
like acupuncturists have voluntary regulation
• The General Osteopathic Council and the
General Chiropractic Council were
established in the 1990s with statutory
regulation
• Increasing numbers of alternative therapists
are qualified health professionals.
THE FUTURE OF PROFESSIONALIZATION
OF ALTERNATIVE MEDICINE IN THE UK
Although there have been obstacles to
professionalization in the past, this is now
becoming more of a direction in the UK.
This was addressed by the 2007 White Paper
on Trust, Assurance and Safety – The
Regulation of Health Professionals in the 21st
Century. This proposed, amongst other things:
• Ensuring regulation for alternative medicine
proportionate to the risks and benefits
• Statutory regulation for certain groups (eg
psychotherapists and counsellors).
THE STEERING GROUP FOR ALTERNATIVE
MEDICINE
The 2007 White Paper led to a Steering Group
exploring the regulation of acupuncture, herbal
medicine and Traditional Chinese Medicine.
This reported to Ministers in 2008 on the
statutory regulation of these groups – and
prompted a consultation with key parties in
2009, the results of which were fed back in
February 2011.
The consultation showed, amongst other things,
that most respondents preferred statutory to
voluntary regulation to protect the public in
these fields and to enhance practice quality.
THE FUTURE PROSPECTS FOR
ALTERNATIVE MEDICINE AS A
MARGINAL FIELD IN THE UK
The future prospects for professionalization
in the UK, though, are not that rosy:
• The Government is planning to statutorily
regulate herbal and traditional medicine
practitioners because of EU licensing issues
• Acupuncture, which has long lobbied for
statutory regulation, does not look like it will
be allowed to move in this direction at
present
• The position is limited by current attacks on
alternative medicine as non-scientific.
(c) ALTERNATIVE MEDICINE IN
THE USA
PRE-INDUSTRIAL HEALTH CARE
IN THE USA
Pre-industrial health care in the USA was
similarly characterized as in the UK by:
• Great eclecticism, especially given the
anti-corporatist resistance to monopolies
• The co-existence of a spectrum of
practitioners from herbalists to
homeopaths
• Difficulties in distinguishing ‘regular’ and
‘irregular’ practitioners in terms of
remedies, education and other factors.
THE CREATION OF A MEDICAL
PROFESSION IN THE USA
In the less unified system in the USA, state
medical licensing systematically emerged in
the early twentieth century – some five
decades after medical professionalization in
the UK. The formation of the medical
profession largely resulted from:
• Lobbying from the increasingly influential
American Medical Association
• Careful political positioning to ride the
waves of the anti-monopolistic culture
• Attacks by the emerging profession on
alternative health groups as ‘quackery’.
THE DEVELOPMENT OF THE MEDICAL
PROFESSION IN THE USA
In the USA the rise of biomedicine was
underwritten by a de jure monopoly (legally
bounded) rather than a de facto monopoly as
in the UK (with protection of title but where
anyone can practice under the Common Law).
This led to differentiation from rivals and
market privileges in the USA – and the
reinforcement of medical dominance with:
• Growing biomedical unity
• Ever greater specialism in medicine
• Creation of subordinate health professions.
PROFESSIONALIZATION AS A POLITICAL
PROCESS
The claim that the process of differentiation
in the early twentieth century in the USA
was political rather than scientifically
justifiable is less convincing than in the UK
as the move to professionalization came fifty
years later.
At this time the scientific underpinnings of
biomedicine in the USA were stronger. Even
so, medicine could still not be considered to
be rigorously founded at this time – with
controlled studies only just starting and doubts
over the general competence of medical
practitioners.
THE INCREASING MARGINALITY OF
ALTERNATIVE MEDICINE IN THE USA
Despite this, as in the UK, with the rise of
orthodox medicine came the increasing
marginality of alternative medicine in the
distinctive USA context in particular as:
• It became illegal for the unlicensed to
practice without their own licensing board
• There were tough legal powers against
those practising without a license
• There were attacks on alternative therapists
and other medical controls existed.
This also led to a decline in alternative medicine
by the mid-twentieth century – even if by the
1950s osteopaths were licensed in most states.
THE RISE OF A COUNTER CULTURE
Nonetheless, there was similarly growing
public demand for alternative medicine from
the late 1960s/early 1970s in the USA linked to
the development of a medical counter culture.
This was exemplified in the USA by, amongst
other things, the Boston Women’s Health
Collective and the ping-pong diplomacy that
excited interest in acupuncture.
This gave alternative medicine impetus in the
USA in the back half of the twentieth century,
with a medically incorporationist culture
contrasting with the UK – linked to the more
laissez-faire climate and more limited risk of
legitimation of outsiders.
THE PROFESSIONALIZATION OF
ALTERNATIVE MEDICINE IN THE USA
As in the UK, these trends are a key context
to the professionalization of alternative
medicine in the USA. This has been
accentuated in the USA by the following
political pressures, amongst others:
• Growing medical incorporation of alternative
medicine (eg with the establishment of the
American Holistic Medical Association)
• On-going public disaffection with orthodox
medicine
• Greater receptivity of local/federal
government to alternative medicine
• Lobbying for specific alternative therapies.
THE RESURGENCE OF INTEREST IN
ALTERNATIVE MEDICINE IN THE USA
In the USA the resurgence of interest in
alternative medicine seems to have gone
further and faster than in the UK. This
is indicated by the fact that by the beginning
of the twenty-first century in the USA:
• An increasing percentage (42%) of
Americans reported using alternative
medicine
• Out of pocket expenditure on alternative
medicine had reached $27 billion
• More than 35% of physicians practiced at
least one alternative therapy.
THE GROWING PROFESSIONALIZATION
OF ALTERNATIVE MEDICINE IN THE USA
In consequence, as in the UK, there has been
a further move to professionalize alternative
medicine, as exemplified by the following:
• There are a myriad of associations
representing the alternative therapists, with
licensing typically based on graduation from
accredited schools (eg in naturotherapy)
• Chiropractic, for long the bane of the
American Medical Association, has gained
widespread state licensure, as well as the
right to reimbursement under Medicare and
Medicaid.
THE FUTURE OF PROFESSIONALIZATION
OF ALTERNATIVE MEDICINE IN THE USA
The professionalization of alternative
medicine is now therefore becoming even
more common in the USA, as in the UK.
This is accentuated by the establishment of
the National Center for Complementary and
Alternative Medicine in 1998 as part of the
National Institutes of Health by the federal
government to fund alternative medical
research – with a $128m pa budget in 2012
that adds greater legitimacy to alternative
medicine.
THE FUTURE PROSPECTS FOR
ALTERNATIVE MEDICINE AS A
MARGINALIZED FIELD IN THE USA
The future prospects for alternative medicine
professionalization in the USA, as in the UK,
though, do have limits which highlight its
on-going marginality:
• The degree of licensing varies for specific
therapies from state to state – with medical
control in some states
• Just as in the UK, the largest use of such
therapies continues to be through self-help
• The position is restricted by on-going attacks
on alternative medicine as ‘cultism’.
(d) A WIDER PERSPECTIVE ON
ALTERNATIVE MEDICINE
IN THE UK AND THE USA
THE RELUCTANCE OF ALTERNATIVE
PRACTITIONERS TO PROFESSIONALIZE
FURTHER
For all the developments in alternative medical
professionalization in the UK and USA, such
therapists have often been reluctant
professionalizers:
• There was a considerable delay in forming
voluntary/statutory organizations
• There are many outlying alternative
therapists, even in professionalizing areas
• Some alternative practitioners continue to
resist professionalization.
THE INDEPENDENCE OF ALTERNATIVE
THERAPISTS
This is partly explained by the independence
of alternative practitioners who often:
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Work in private practice
Operate outside state structures
Dislike bureaucracy and hierarchy
Regard individualism as sacrosanct
See a free spirit as essential to practice
Hold egalitarian philosophies
Do not collaborate within/across disciplines.
The term ‘herding cats’ has been applied to
alternative therapists as this has undermined
their unity in the politics of professionalization.
BROADER SYSTEMS OF POWER
However, the main reason for the limits to
professionalizing alternative medicine seems
to relate to the impact of broader systems of
power, for example:
• The mainly negative response to the
resurgence of alternative medicine by
orthodox medicine
• The interlinked rejection by local/national
government of certain individual therapy
interest in gaining professional standing
• The pressures bought by other interest
groups (eg the pharmaceutical industry
and the private health insurers).
THE IMPACT IN A MARGINAL AREA
As with the marginalized health professions
discussed earlier, this situation has impacted
on alternative medicine through, for instance:
• The way knowledge is used in the division
of labour – including through referral
structures
• The quality of entrants to particular fields of
alternative medicine
• Access to alternative medicine care through
the public sector or insurance support.
ALTERNATIVE MEDICINE AS
SELF-HELP
It has also impacted in the UK and the USA
on the use of alternative medicine as selfhelp by:
• Limiting the range of consciousness
about alternative medicine
• Increasing the use of alternative medicine
as self-help where there is an absence of
professionalized practitioners.
(e) THE IMPLICATIONS OF ONGOING
MARGINALITY FOR ALTERNATIVE
MEDICINE IN THE UK AND THE USA
BENEFITS OF THE
PROFESSIONALIZATION OF
ALTERNATIVE MEDICINE
The potential benefits to the public and
practitioners of decreasing marginalization
of alternative medicine through increased
professionalization include:
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Stronger educational base
Certified knowledge/expertise
Evidence-based practice
Codes of ethics
Protection of the public
Increased public access
Security of practitioners
Enhanced income, status and power.
COSTS OF THE FURTHER
PROFESSIONALIZATION OF
ALTERNATIVE MEDICINE
There are also potential downsides too that
need to be acknowledged from the viewpoint
of alternative medicine:
• Distancing from the client
• Constraints on the scope of practice
• More limited client accountability and
responsiveness
• Potential economic costs
• Dangers of professional tribalism
• Barriers to integrated working
• Lack of a sufficient evidence base in terms
of safety, efficacy and effectiveness.
A GLOBAL PERSPECTIVE
These costs and benefits should be seen in a
global perspective in so far as other world
systems (eg in Asia) have reversed the
pecking order in the West – including in
Canada and Western Europe as a whole.
This means that the relatively recently
established orthodoxy of biomedicine is seen
as more of a marginal practice as compared
with other therapies that are considered
alternative medicine in the West.
This is well exemplified in the East by the
cases of China (where Traditional Chinese
Medicine prevails) and India (where Ayurvedic
Medicine is more of a force).
SOCIETAL VARIATIONS
This is not to say that there are not societal
variations in alternative medicine as a
marginalized therapy in the West, for example:
• In the USA practices like prayer, herbalism
and meditation dominate
• In Canada chiropractic is the most popular
type of alternative medicine
• In the UK therapies such as acupuncture
and herbalism prevail
• In France homeopathy is the most broadly
employed therapy
• In the Netherlands spiritual healing is the
most widely used alternative therapy.
KEY QUESTIONS
However, these comparisons should make us
think in the West very carefully in our own
society in a recessionary world about:
• The alternative therapies that have the
strongest evidence base
• Their cost-effectiveness relative to orthodoxy
• The methods that we use to form the
evidence base (quantitative vs. qualitative)
• The extent to which voluntary vs. statutory
regulation is desirable in particular cases
• How far the practice is restricted to medicine
• To what extent the self-help use of alternative
therapy should be limited.
The quality and cost of health in the UK, USA
and elsewhere hinges on these questions.
POLITICAL ISSUES
To concretise this in the USA – not least with
the implementation of the 2010 Affordable
Care Act – there are some key political issues
about the alternatives in an increasingly harsh
financial climate in terms of individual rights:
• Which alternative therapies should be paid
for through Medicare/Medicaid or private
health insurers or customers at the point of
access?
• What should be the threshold criteria of
eligibility for federal/state/private health
insurer funding of the alternatives?
• What are the implications of marginalization
of alternative medicine for health care
delivery in this context?
SELECTED REFERENCES
Kuhlmann, E. and Saks, M. (eds) (2008)
Rethinking Professional Governance, Policy
Press
Saks, M. and Allsop, J. (eds) (2013)
Researching Health, Sage, 2nd edition
Allsop, J & Saks, M. (eds) (2002) Regulating
the Health Professions, Sage
Saks, M. (2003) Orthodox and Alternative
Medicine: Politics, Professionalization and
Health Care, Sage
SEE ALSO...
Kellner, M., Wellman, B., Pescosolido, B. and
Saks, M. (eds) (2003) Complementary and
Alternative Medicine: Challenge and Change,
Routledge.
Saks, M. (1995) Professions and the Public
Interest, Routledge.
Saks, M. (2000) “Medicine and the Counter
Culture”, in Cooter, R. and Pickstone, J. (eds)
Medicine in the Twentieth Century, Harwood
Academic Publishers.
Saks, M. (2006) “The Alternatives to Medicine”,
in Gabe, J., Kelleher, D. and Williams, G. (eds)
Challenging Medicine, Routledge.
AND…
Saks, M. (2010) “Analyzing the Professions:
The Case for the Neo-Weberian Approach.”
Comparative Sociology, 9: 887-915.
Saks, M. (2013 forthcoming) “Marginalized
Health Professions”, in Stevens, F. (ed)
Encyclopaedia of Health, Illness Behavior and
Society, Wiley-Blackwell.
Saks, M. and Kuhlmann, E. (2006) ‘Introduction:
Professions, Social Inclusion and Citizenship’,
Knowledge, Work and Society, 4 (1): 9-20.
Turner, B. S. (1995) Medical Power and Social
Knowledge, 2nd edition, Sage.
Thank you
for listening.
Any
questions?