Academic journal article Health Sociology Review

Medical Dominance Then and Now: Critical Reflections

Academic journal article Health Sociology Review

Medical Dominance Then and Now: Critical Reflections

Article excerpt

Introduction

In 1983 Evan Willis wrote a book on medical dominance, ranked as one of the most influential books in Australian sociology. At about the same time writers in other countries were also analyzing the role of medicine. Paul Starr published The Social Transformation of American Medicine (1982), Gerald Larkin wrote Occupational Monopoly and Modern Medicine (1983) on British Medicine, and two colleagues and I published a much shorter historical description of 'the rise and fall' of Canadian medicine (Coburn et al, 1983; Coburn 1999). We are now faced, 20 years later, with various retrospectives on medical power. For example, the Journal of Health Politics, Policy, and Law in 2004 published a special edition of 20 comments on Stair's book. Now Health Sociology Review is publishing a re-visitation of the concerns that Willis had in 1983.

Why the coincidental publication of various analyses of medicine in the 1980s?

Perhaps the most important stimulant to sociological analyses of the role of medicine actually preceded the spate of works published in the 1980s. Eliot Freidson's books, Profession of Medicine, and Professional Dominance (both 1970), used the medical profession as an archetype in analyzing what was happening to the professions in general. Professions were different from other occupations, Freidson asserted, because they controlled their own work and the conditions under which this work was carried out. As did Durkheim, Freidson saw professional work as having the potential to avert the alienation of bureaucratic work and the subordination to profit of the market professions. Freidson concluded that medicine was the dominant source of power regarding health and illness. By dominance Freidson implies control by medicine over the content of work, other health occupations, clients, and the terms and conditions of work, although perhaps the most analyzed aspect of medicine has been its control over other health occupations.

How did medicine rise to dominance and how does it maintain its power? According to Freidson, medicine had to persuade the public of its efficacy, to gain a legal monopoly and to have the sponsorship of a societal elite and the state. Important in attaining and maintaining dominance was the organized power of the American Medical Association as well as the ability of medicine to appropriate new 'medical' knowledge through its control of medical schools and the basic sciences and scientists contained within it.

Later, a number of writers either used Freidson's notion of medical dominance and/or criticized it as being underlain by an inadequate explanatory schema and as being insufficiently socially contextualized (Coburn 1993; Larkin 1983; McKinlay 1977; Saks 1983,1995; Willis 1983). Particularly problematic was the relationship between medicine and unspecified 'elites' (Navarro 1976).

Nevertheless, Freidson set the stage for the study of the power of medicine in the latter half of the 20th century and many of his critics were captured by the concept of professional power and medical dominance.

If medicine was indeed dominant, however, two questions immediately arise: has medicine always been dominant; and, is medicine dominant the same way everywhere? The challenge was to place the notion of dominance in historical and comparative perspective. After Freidson (1970), came numerous historical or national studies of medicine and related health care occupations and professions. Many of the health care occupations analyzed were those, in Willis's terms, excluded, limited or subordinated by medicine. Was medicine, as both Starr and Freidson (1982; 1970a) had hinted, facing challenges to its dominant position? Was it being proletarianized, de-professionalized, corporatized or simply losing some aspects of its previous control? (McKinlay and Arches 1985; Haug 1973; Navarro 1988; Salmon 1991; Tousijn 2002). Some of these descriptions were brought together by Hafferty and McKinlay in The Changing Medical Profession: An international Perspective (1993). …

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