A review of theories of professions and power
The concept of power is at the heart of the consideration of the nature and role of professional groups in society, from the classic professions of law and medicine to other professional occupations, including accountancy, architecture, nursing and social work. The centrality of this concept has been highlighted by its significance in the work of sociologists of professions in the range of theoretical analyses of professions that have been produced to aid the interpretation of both the historical and contemporary activities of professional groups. These analyses underline that not only is the definition of a profession fundamentally contested, but – most importantly in this context – so is the concept of power itself in terms of the origins of professions and their relationship to other bodies in and beyond the division of occupational labour.
This chapter is illustrated through examples from different countries in the modern world inside and outside organizations and in the public and private sectors, as well as across a number of professional groups at the macro and micro level. Here particular, but not exclusive, reference to the Anglo-American context is made to exemplify key points. The analysis starts by outlining chronologically the mainstream theoretical perspectives in sociology on professions. It focuses specifically on the various ways in which the concept of power is employed in each, against the backcloth of a rapidly changing world and debates about the shifting power of professional groups.
In this exploration, it is argued that a neo-Weberian approach to professional power linked to the self-interests of professional groups, with relevant counterfactuals, might be seen to have a number of advantages compared to other theoretical analyses. Having examined some of the benefits of a neo-Weberian approach, the chapter considers in more detail through a neo-Weberian lens the meaning of the concept of power. This is seen to be multidimensional and to operate at varying levels. The chapter then examines from the standpoint of power the shifting relationship both within and between professional groups in the context of the state and the market – against the backcloth of the growing voice of citizens.
In this regard, the chapter will ask, amongst other things, whether the power of professions can be seen to be waning – particularly in the context of contemporary neo-Weberian debates about deprofessionalization. In a related manner, it considers the new forms that professions may now be taking in organizational and other contexts and the extent to which the rise of the new public management (NPM) and other developments have affected their power in a fast-changing international socio-economic climate. In so doing, it recognizes that professions and power can also be analysed at a micro level in terms of professional–client relationships in a manner related to wider structures of professional power.
Sociological theories of professions and power
Key theories of professions in the Anglo-American context span historically from the relatively benevolent taxonomic approach to more critical perspectives – including symbolic interactionism, Marxism, Foucauldianism and discourse analysis. In examining chronologically how these approaches conceive of the relationship between professions and power at a macro and micro level, the chapter reviews such contributions and assesses the theoretical and methodological issues they have posed in the development of the sociology of professions. As such, the purview of the chapter is broad, ranging from the analysis of more supportive to more challenging theories of the professions.
The benevolent taxonomic approach to professions
The taxonomic approach to professions, which was particularly influential in the 1950s and 1960s, focused on the positive differences of professions from other occupations – which were defined in terms of characteristics like high-level expertise and a public-interest orientation. There were two variants, the first of which was the trait approach, which largely consisted of atheoretical listings of various attributes of a profession, from altruistic codes of ethics to the educational qualifications required for entry – as illustrated by Greenwood (1957) in relation to social work. This approach need not detain us here as power did not figure explicitly except in so far as the features of professions bolstered the authority of professionals over clients.
Nonetheless, power was more central to the second variant of taxonomy, that of structural functionalism. Functionalists like Goode (1960) gave a more theoretically cogent account of professions like psychology and medicine in industrial societies – in which it was argued that there was a functional relationship between professional groups and the wider society. In this sense, the elevated position of professions in the social system – underwritten by the state – was typically seen as related to their esoteric knowledge of great importance to society. This high standing was given in return for ensuring the protection of the public, not least through the establishment and implementation of professional codes of ethics.
In this functionalist account, power was very important as its exercise was seen as a system property designed to realize collective ends. This was highlighted by Parsons (1967: 308), who saw power as the ‘generalized capacity to secure the performance of binding obligations by units in a system of collective organization when the obligations are legitimized with reference to their bearing on collective goals and where in case of recalcitrance there is a presumption of enforcement by negative situational sanctions’. A profession was therefore seen as facilitating the performance of functions in, and on behalf of, the social system – exercising power in collective goal fulfilment, based on value consensus.
However, the taxonomic approach has been heavily criticized – not least in terms of its uncritical view of professions, which seemed to be rather more oriented towards legitimating professional ideologies as opposed to depicting how professions operate in practice (Roth 1974). This is generally fair comment on the functionalist variant of this approach on which this section focuses, albeit with the exception of sophisticated contributors like Parsons (1967), who adopted a model of professions based on ‘ideal types’ against which judgements about their operation might be made, rather than endeavouring to depict some kind of immutable professional reality.
For critics of functionalist analyses of professions, though, this deferential view of such occupational groups gave an all too starry-eyed interpretation of the operation of power. This is because the starting point for functionalist conceptualizations was centred on a presumption about the existence of professional communities as part of a societal consensus, rather than as elements of a conflicting landscape characterized by zero-sum games. As such, the exercise of professional power at a structural level was seen as a platform for meeting system needs, rather than as a resource underpinning struggles with other groups in society – in a manner comparatively blind to internal divisions within professions.
Having said this, a more critical view of professions and power was precipitated by wider socio-political changes in Britain and the United States associated with the rise of the 1960s and 1970s counterculture. This was driven by attacks on scientific progress, in which a subculture emerged that was sceptical about technocratic solutions to problems and sought alternative lifestyles – embracing everything from mysticism to hallucinogenic drugs (Roszak 1995). As a result, established professions in areas from architecture and education to law and medicine were variously assailed, amongst other things, for not only their lack of effectiveness but also the dehumanization and disempowerment they evoked.
Critical perspectives on professions
Paradoxically, the initial main group of critics of the taxonomic view of professions and power came not from a macro, but a micro, perspective – in the form of symbolic interactionism, which particularly reacted to the reification of professions by functionalist writers. Instead of stressing the differences of professions from other occupations, interactionists like Hughes (1963) emphasized the similarities of professional groups like doctors and lawyers to more stigmatized workers such as exotic dancers and janitors. These groups, it was argued, faced parallel dilemmas in managing their occupational roles and identities – with the concept of a profession being seen simply as an honorific label won in the politics of work.
This micro-orientation, though, did not mean that the concept of power disappeared from the landscape. On the contrary, as Dennis (2005) has argued, in the front-of-stage analysis of interactionists it was acknowledged that political and economic power was important in shaping the way that rules were set and labels established. Here he notes that power was manifested in the relationships established at a micro level – not least between professionals and their clients. Thus, for example, within interactionist studies in Britain and the United States, teachers and other educational professionals were seen as having the power to define situations for their students and to impose identities on them.
As such, interactionism as an approach to the professions has primarily focused on the local use of power in the negotiation over the ascription of labels of professionalism – with all the implications that these carry for their occupational incumbents in practice. Revealing as this is in stripping away reflexive assumptions about professionals and their ideologies, and providing insights into the symbolic politics of work, it came with a price. This was that too little attention was given to detailing the historical background and wider structures of power that influence success or failure in gaining and sustaining professional standing (Saks 2012). Such a gap, though, was addressed in other more critical emerging perspectives.
In terms of the operation of professions and power, the neo-Marxist approach can scarcely be accused of shirking from undertaking historical and macro-structural analyses in Western capitalist societies. The approach itself, though, masks differentiation and diversity – centrally including on which side of the divide between capital and labour specific professions should be placed theoretically. In this respect, leading professions have variously been viewed as either a ‘professional-managerial class’ acting as agents of capitalism in surveillance and control functions for the bourgeoisie (Ehrenreich and Ehrenreich 1979) or a part of the capitalist class itself, without themselves necessarily owning the means of production in the classic Marxist idiom (Navarro 1986).
What is clear, though, is that the typically privileged position of professional groups, from accountants and architects to doctors and social welfare occupations, is seen as derived in a different way from structural functional contributors. For neo-Marxists, as has been seen, the power underpinning professions is linked to their role in the class relations between the bourgeoisie and the proletariat rather than as a system resource directed towards societal goal attainment. Thus, for example, Poulantzas (1973: 104), in his structural neo-Marxist account, defined power as ‘the capacity of a social class to realize its specific objective interests’ in the class struggle, in which professional privileges stem from serving the dominant class.
The neo-Marxist approach to professions and power, however, has itself been open to criticism. Although this approach takes several forms, one issue is that it usually adopts a tautological view of state power under capitalism as inevitably functioning in the long-term interests of the capitalist class. As a result, the neo-Marxist approach often shields from empirical assessment conflicting claims about both the operation of the state and the nature and role of professional groups that it sanctions (Saunders 2007). The pre-eminence of this approach to the sociology of professions in the 1970s and 1980s also came under challenge with the collapse of socialist regimes in Eastern Europe, including most prominently the Soviet Union in the early 1990s (Saks 2015).
A further approach in Anglo-American sociology in considering professions and power as an antidote to more benevolent views of professionalism was provided by Foucauldianism, initiated by the French philosopher Michel Foucault. Like structural functionalism, this approach sees power as a ubiquitous feature of human activities in terms of its effects, but differs by being rather more cynical about its operation at a macro level. Employing the concept of governmentality – in which Johnson (1995) sees the state as a cluster of institutions, procedures, tactics, calculations, knowledge and technologies related to the outcome of governing – followers of Foucault (1978) have challenged the ideology of the rationality of scientific progress associated with professions in relation to institutional fields such as hospitals, prisons and schools.
Donzelot (1979) provides a good example of the way in which the Foucauldian perspective has been employed to dissect the use of power and knowledge by the professions involved in policing the family, from social workers to psychiatrists. He shows how power has been employed to render populations governable in the previously predominantly private domain of the family. Nettleton (1992), meanwhile, has considered the historical relationship between dental power and knowledge – underlining the role of dentists and dental knowledge in the surveillance, monitoring and normalization activities carried out in the task of governing. In this way, both studies highlight that power is not simply exercised by a particular class, as is so often portrayed in neo-Marxist accounts, but pervasively permeates everything from actions and attitudes to discourse, learning and everyday lives.
Nonetheless, Foucauldianism too has its frailties in its intriguing archaeological excavation of power and knowledge in the process of governance. In studying professions from this perspective, for example, the approach is difficult to operationalize as it is based on a model in which the state and the professions are seen as inextricably intertwined following the political incorporation of expertise (Saks 2012). Foucauldians have also been held to treat data in cavalier fashion and to pitch their analyses at too high a level of abstraction (Macdonald 1995) – again opening up claims about pursuing self-fulfilling arguments. In sum, its critical analysis of professions and power, while presenting a refreshing if chilling view of a complex modern world, has sometimes been conducted without sufficient attention to methodological rigour.
But if questions remain about the operationalization of Foucauldian studies of professions and power, more recently a number of sociologists of the professions have retreated from ‘big picture’ theories to micro-oriented discourse analysis in countering the positive macro theorising of the functionalists. Although the study of discourse is a central part of the Foucauldian idiom, this form of analysis has more in common with the earlier symbolic interactionist perspective (Gubrium and Holstein 2003). Fournier (1999) pioneered this approach in her consideration of recruitment and advertising – examining the way in which groups like managers and supervisors use the notions of professions and professionalism to defend or extend their power in the workplace.
As with interactionism, discourse analysis is based on a less rigid categorization of professional groups than in some other theoretical approaches. It has since been employed in a wide span of areas, from architecture (Cohen et al. 2005) to executive coaching, medicine and psychotherapy (Graf, Sator and Spranz-Fogasy 2014). In the former case, the authors examined the accounts given by architects of the workings of their profession in different organizational contexts, including the enhancement of power through emphasizing creativity and expertise. The latter case meanwhile brings more clearly into vision the micro focus of the approach in understanding power relations in practitioner–client interaction.
In this sense, discourse analysis illuminates the culture of professionalism in terms of power and extends the range of occupations that are open to examination as part of the study of professions. Its focus on narratives in ground-level relationships in private and public sector settings is both a strength and weakness – as, like interactionism, it risks losing sight of wider structures of power. Against this, though, it is possible to weave discourse analysis into a broader framework by linking the ideologies that it studies to wider professional interests in the politics of work (Saks 2012). A key way in which this can be achieved is through the neo-Weberian approach that is now outlined.
The neo-Weberian approach to professions and power
Main aspects of the neo-Weberian approach
It is claimed here that the now widely adopted neo-Weberian approach can be highly fruitful in analysing professions and power in the Anglo-American context on which this chapter primarily focuses. The reason for this is that it addresses the main vulnerabilities of the theoretical perspectives so far considered. In the first place, it allows the exercise of power in the professions to be empirically examined, avoiding the benevolent presumptions about professional groups typically embedded in the trait and functionalist variants of the taxonomic approach. Neo-Weberianism also transcends the micro focus of interactionism and discourse analysis by enabling a macro structural analysis based on an understanding of the historical processes involved in generating front-of-stage activities.
Moreover, in developing a neo-Weberian approach to professions and power, the analysis is helpfully based on the interests of professional groups and other stakeholders within a sophisticated theoretical, conceptual and methodological framework – with a more open view of the state as an institution that has power in its own right and does not necessarily represent in ongoing fashion particular groups or classes (Smith 2009). As such, the strait jacket provided by limiting neo-Marxist assumptions surrounding the operation of the state under capitalism can be circumvented, as can the tendency of Foucauldians to base their analyses on less than systematic analyses of historical and other evidence. Without denying the insights offered by other perspectives, this provides a persuasive basis for adopting a neo-Weberian assessment of power in relation to professions.
The neo-Weberian approach is derived from the work of Max Weber and is centred on the concept of exclusionary social closure in the market (Parkin 1979). This is pivoted on occupational groups winning and sustaining formal legal boundaries, sanctioned by the state, defining a profession – with a single register based on credentialism creating a limited group of eligibles and ranks of insiders and outsiders. The process of gaining a professional monopoly is driven by the exercise of macro political power in a competitive marketplace where successful occupations typically enhance their position in terms of income, status and power, privileging themselves as against other occupational groups in the division of labour.
This should not mask differences in approach within a neo-Weberian perspective as, amongst other things, not all such contributors directly link their analyses to the concept of social closure. However, in such cases, their frame of reference is at least derivable from market closure. Thus, for example, Johnson (1972) sees professional groups as defined by collegiate producer control over the consumer, in contrast to patronage and mediative relationships. Similarly, Freidson (1994) sees professionalism as centred on legitimate, organized autonomy over technical issues and work organization. Nonetheless, all neo-Weberian analyses are rooted in the exercise of power, even if this is less explicitly articulated in the work of Freidson as compared to other contributors (Macdonald 1995).
In medicine, the neo-Weberian approach to professions and power is well exemplified by Berlant (1975), who argues that the de facto and de jure monopolies that emerged in Britain and the United States respectively came into being as a result of the tactics of competition employed by doctors and the different socio-political conditions that they faced in a liberal era. In the no less classic case of law, the approach is illustrated by the use of professional power to form the bar associations in early nineteenth-century America that acted as a platform to winning market control (Halliday 1987) and the political in-fighting that led to legal monopolies of solicitors and barristers in Britain under the authority of the Law Society and the Bar Council (Burrage 2006).
Criticisms of the neo-Weberian approach
Despite the comparative strengths of neo-Weberianism in understanding the dynamics of professions and power in the Anglo-American setting, as Saks (2010) has documented, it does not itself stand above criticism. One issue is the need for greater empirical rigour in applying the approach. This is highlighted by the much-cited work of Johnson (1972), who does not evidence his claim that doctors – having established a professional monopoly – used their power to irrationally constrain the roles of professions auxiliary to medicine in their own interests. Perucci (1973) also gives little basis for his view that professions use their power to protect their own interest when this conflicts with the public welfare. Paradoxically, this is the mirror image of the benevolent and unsubstantiated assumptions of taxonomy that have been so heavily attacked in the sociology of professions.
A second related weakness of the neo-Weberian approach is that its proponents are unduly disparaging about the self-interested use of power by professional groups. In the case of law, for example, Johnson (1972) reflexively claims that the politically inspired work of the legal profession lacks relevance to black and feminist groups, while similarly denigratory and unsubstantiated remarks are made by Beattie (1995) about the adverse effects of professional tribalism in health care. This flies in face of evidence about professional power being used for the public good through the pro bono activities of American lawyers (Granfield and Mather 2009) and the activities of British midwives and nurses – despite tensions between them – as ‘knowledgeable doers’ in serving clients (Borsay and Hunter 2012).
If this argues for greater balance in understanding the relationship between professions and power, a third area of criticism of neo-Weberian accounts is that they often fail to consider professions in the wider occupational division of labour. Thus, for instance, practitioners of complementary and alternative medicine (CAM) and health support workers have been little studied by neo-Weberians compared to doctors, in part because of their marginal standing (Saks 2008). Yet, having largely failed to professionalize, these groups shed valuable light on explaining the outcome of attempts to gain professional social closure in terms of power and interests. However, this does not undermine the neo-Weberian approach any more than the foregoing criticisms, as they relate to its application rather than the utility of the analytical tools provided.
A brief comment here is finally needed on the view of Sciulli (2005) that the neo-Weberian concept of exclusionary social closure is limited mainly to Britain and the United States in the modern world in addressing the relationship between professions and power. Formal professional independence from the state is certainly less common in continental Europe, where professionals in areas such as health and education are largely employed by, and have managerial accountability to, public sector bureaucracies (Evetts 2006). But even here there is great variability – in Germany, for example, professional social closure has been achieved in law in a similar fashion to medicine (Rogowski 1995), paralleling the position of doctors in societies such as Australia, Canada and New Zealand (Allsop and Jones 2008).
Conceptualizing the extent of such closure on a sliding scale, therefore, the neo-Weberian approach remains one of the more potent theoretical frameworks for examining professions and power internationally – from understanding the political forces that lead to the establishment of professional monopolies to charting the privileges that derive from the power generated in the market through professionalization. Having said this, more discussion is needed about the meaning of the concept of power within this frame of reference, including its link to professional interests – not least regarding how such interests are theorized and, even more significantly, how they can be effectively operationalized.
The concepts of power and interests in analysing professionalism
Considerations about power – whether in a neo-Weberian or some other theoretical sense – can essentially be defined in terms of the ability to achieve a desired outcome, which typically includes the capacity to influence others. However, as the analysis of theoretical perspectives in the sociology of professions demonstrates, when the inquirer moves beyond the neo-Weberian notion of power as the realization of the interests of the powerful and the capacity to produce favourable effects in terms of such interests, the universe becomes fuzzier and more contestable – not only as regards studying power conceptually, but also in understanding it empirically (Smith 2009).
This is well highlighted by Lukes (2005), who argues that there are three competing dimensions of power. The one-dimensional view of power is based on the well-known analysis by Dahl (1961) of issue areas in a city in the United States in which professions were involved – urban redevelopment, public education and political nominations. In order to assess empirically the exercise of power, Dahl used subjectively expressed views to represent interests and compared these to outcomes to gauge which party or parties prevailed in political decision making. His conclusion from studying observable conflicts of policy preferences was that American society had a pluralistic power structure rather than a system run by one or more dominant elites in professional, corporate or other areas.
However, the positivist approach taken by Dahl was famously considered biased, superficial and restrictive by his critics Bachrach and Baratz (1970). They outlined a two-dimensional conception of power which takes into account that some issues may never be explicitly aired in the first place because of the exercise of power. Their framework therefore does not simply emphasize initiating, deciding and vetoing proposals, on which Dahl focused, but also recognizes that power may be exercised by confining the scope of decision making to relatively safe issues. As such, by adopting a wider concept of interests than Dahl, Bachrach and Baratz encompassed both decision making and non-decision making.
Nonetheless, as Lukes (2005) notes, this approach is also flawed. Its difficulties arise from the fact that, first, it adopts a methodologically individualistic view of power based on the probability of specific participants realizing their wills and, second, it again relies on identifying the exercise of power in observable, overt or covert, conflict. As such, it excludes the possibility of false or manipulated consensuses by definitional fiat – in which potential as well as actual issues are kept out of political debate. The issue here then becomes how interests are to be ascribed on the three-dimensional view of power. Lukes acknowledges that this is not straightforward, but believes that insights can be drawn from considering how people behave in abnormal times when hegemony is removed.
Lukes (2005) is right to highlight the possibility of actors generally and professional groups in particular mistaking their interests and to draw attention to issues of false consciousness in analysing the operation of power. He is also wise to avoid the dangers of simply imputing interests to such actors without empirical reference, as is common in relation to class interests among Marxist writers (see, for instance, Poulantzas 1973). However, his own position in seeking relevant counterfactuals for gauging interests by observing how professional and other groups act when the wider apparatus of power is removed or relaxed is fraught with problems. Even if the influence of other sources of power is ruled out, any inferences will absurdly be drawn philosophically from a barren asocial arena.
Operationalizing the concepts of power and interests
But if Lukes (2005) does not provide a meaningful solution to the dilemmas posed in terms of empirically operationalizing the concepts of power and interests in considering the relationship between professions and power, there is a more incisive way forward. This has been signposted by Saunders (2007), who argues that professional and other interests should be seen as the objective achievement of benefits and the avoidance of costs in given situations, based on such indicators as income, status and power. Significantly, these are central to assessing life chances in a neo-Weberian approach and have become key touchstones within this perspective of the privileges obtained in professional projects.
Saks (1995) has both developed and applied this approach in his detailed neo-Weberian analysis of the response of the medical profession to acupuncture in nineteenth- and twentieth-century Britain. He argues that the interests of doctors were generally advanced in terms of income, status and power by distancing themselves from, and repelling challenges by, non-medically qualified acupuncturists in the professionalization process. However, this situation changed after the 1960s and 1970s counterculture where a developing client voice and rapidly increasing public demand for CAM made its selective medical incorporation a preferable strategy, in a manner avoiding the legitimation of outsiders and sustaining the dominance of the biomedical paradigm of doctors.
The study by Saks (1995) also significantly involved a more systematic approach to evaluating the role of professional self-interests in decision making, in light of the lack of rigour in previous research. To establish this relationship based on the exercise of power, it was also held to be necessary, amongst other things, to show that the decision reached was consistent with the professional interests concerned; that the profession involved possessed sufficient political resources to have influenced the decision under consideration; and that other plausible explanations could be ruled out – in this case, a range of factors from competing medical priorities and the diffusion of knowledge of acupuncture to the power of the drug companies and its safety and effectiveness.
Current issues about professions and power
However, lest the analysis of professions and power moves too far into the realm of methodology within a neo-Weberian approach, it is time to broaden the chapter to highlight a number of mainstream contemporary areas of focus in this field. The issues briefly covered here from a neo-Weberian perspective include the impact of NPM on professions; organizational professionalism and professionals in organizations; the deprofessionalization and restratification of professions; professional dominance and inter-professional working; and the dynamics of professional practitioner–client interaction. Having given an overview of the territory pervaded by the exercise of power, each of these areas will now be considered in turn – with a final commentary on feminist theory about professions and power.
The impact of the new public management on professions
The NPM which has developed at a time of restricted resources and financial stringency in neo-liberal societies with the explicit aim of increasing the efficiency of public services and providing a greater user focus has challenged the power of public service professions in areas such as health, social services and education. Although it has been a less integrated and uniform force than often presented, its introduction has been seen to increase the accountability and control of professional groups in the market, following practices in the private sector (Dent, Chandler and Barry 2004). As such, it has been held to have significantly impacted on these groups, from imparting new cultural values to increasing flexibility.
However, the extent of the impact of NPM on the power of professions has been much debated. Some have argued that professions have largely been able successfully to resist managerial control (Carvalho 2014). Others have claimed that it has led to hybrid professionalism in which the pattern of occupational control contains both managerial and professional strands (Noordegraaf 2007). It has also been asserted that NPM is well advanced in reining in the autonomy of professions in the neo-Weberian sense – causing new types of control over occupations previously seen as obstacles to change (Evetts 2006). Clearly, this remains a matter for empirical examination in particular countries and professional settings, but the ramifications of this debate have spilt over into the discussion of the power of professions in organizations.
Organizational professionalism and professionals in organizations
In this respect, Evetts (2013) has argued that the shifting balance of power has led to a move from occupational professionalism to organizational professionalism. Here occupational professionalism is taken to involve collegial authority based on trust relationships with employers and clients and discretionary judgements. Organizational professionalism, on the other hand, is seen as a discourse of control centred on rational-legal authority used by managers in work organizations, involving standardization and performance management. Whatever their respective virtues, both of these ideal types of professionalism derive from Weber – where organizational professionalism is associated more with the increasing bureaucratization of modern societies than the concept of exclusionary social closure.
Nonetheless, the direction of change claimed by Evetts (2013) can be contested. Faulconbridge and Muzio (2008), for example, argue that the effects of globalization, technology and competition on professionalism in multinational law firms in Britain are moderated by professional values and interests. Similarly, Jonnergård and Erlingsdóttir (2012) discovered that professional strategies are more significant than organizational affiliations in shaping the adoption of quality reforms in medicine in Sweden – in a situation where Svensson and Evetts (2010) note there has been ever greater convergence between models of professionalism in continental Europe and the Anglo-American setting, through more integrated professional work organizations, as well as increasing marketization.
This context may help to account for the increasing political conflicts identified within a neo-Weberian approach at a meso level between professionals and the organizations in which they are employed – with the former expecting to be self-directing and the latter seeking obedience from subordinates (Thompson and McHugh 2009). The degree of organizational conflict in the exercise of power, however, may be reduced where there are legal restrictions on the provision of professional services – as in the case of areas like medicine, law and accountancy in the United States – which Freidson (1994) has noted can offer some protection to the independence of professionals from direct employer control.
The deprofessionalization and restratification of professions
Another related facet of current debates about professions and power is the wider question of whether in neo-Weberian terms professional groups in modern societies have become increasingly deprofessionalized. This viewpoint was classically presented by Braverman (1974) within the neo-Marxist framework of proletarianization. He claimed that skilled professional and other tasks were being fragmented as a result of managerial endeavours to control the labour process and cheapen the cost of wage labour as capitalism developed. Such issues have resurfaced in a neo-Weberian framework in relation to a number of specific professions – not least law and medicine (Epstein 2013).
The question of the deprofessionalization of medicine has been particularly intensively debated in the Anglo-American context. Saks (2015) argues that physicians in the United States – notwithstanding internal stratification within the profession – have suffered a decline in income, status and particularly power in face of the growing corporatization of medicine and the rise of managed care, which has reduced their control of medical decision making. In contrast, in Britain the medical profession has typically been successful in maintaining its privileges through the strong state shelter of the National Health Service – even if government concern about patient protection has recently led to a more regulated rather than autonomous pattern of self-regulation.
However, in Britain in a differentiated profession, the distribution of power has not remained static. More specifically, over the past two or three decades there has been a restratification of the English medical profession, in which the standing of general practitioners has risen compared to the burgeoning number of hospital-based medical specialists – first through an elevated position in Primary Care Groups and Primary Care Trusts and now through their lead roles in Clinical Commissioning Groups (Saks 2015). Agreeing criteria against which deprofessionalization and/or restratification is to be benchmarked for further research into the power and interests of the medical and other professions, though, remains contentious.
Professional dominance and inter-professional working
This spills on to the next main area of focus in the neo-Weberian analysis of power and professionalism – the question of professional dominance, which has been taken to refer not only to the cultural authority of professions in society and their power over users of services but also to the relational aspects of the power base of professional groups (Elston 2004). In the latter respect, in each professionalized field, there is typically one or more top professions in the pecking order, with professional groups further down the line based on ‘dual closure’. This term is employed by neo-Weberian writers to define semi-professional groups like teachers and social workers, which contain some elements of exclusionary closure mixed with aspects of usurpationary closure centred on union-style collective action (Parkin 1979).
This is traditionally reflected in the stratified hierarchy in health care in Britain and the United States defined by Turner (1995), with the dominant medical profession at the summit. Closely behind in terms of power come limited health professions such as dentists and optometrists, whose operation is restricted to specific parts of the body. Then follow subordinated health professions such as nurses and the professions allied to medicine, and finally excluded health practitioners like many CAM groups which lie outside orthodox medicine. In sketching out this tiered health-care hierarchy, it is again vital to note – as underlined by the rising power of general practitioners in England outlined above – that the comparative position of each profession is fluid and very far from fixed in the politics of work.
In terms of power and its exercise in the marketplace, the notion of shifting territorial relationships is reinforced in Britain, the United States and continental Europe by Abbott (1988) across a much broader system of professions, from accountancy to law. He sees them as vying with each other for the right to control the provision of services and activities in their interrelated occupational jurisdictions. The concept of such turf wars also brings into focus the obstacles related to silo-based power that impedes inter-professional working. These have increased the importance of examining how to facilitate collaboration between health and social care at all levels in providing effective individualized care for clients (Pollard et al. 2010).
The dynamics of professional practitioner–client interaction
This highlights that structures of power at the macro and meso level have implications for the interaction between professional practitioners and clients at the micro level. This is illustrated further by Strong (2001), whose study of over a thousand child health consultations in the Anglo-American context showed that the most prevalent mode of interaction was bureaucratic. Here the interaction was framed by the idealized competence and expertise of doctors, while the concerns of parents – who were assumed to lack knowledge – were subordinated to medical interests, notwithstanding the gentility of the consultation. More recent research has shown this pattern of medical power and authority to prevail generally in such interactions and to be supported by legal rules, despite extensions to patient rights (Le Roux-Kemp 2011).
Moreover, in terms of the growing client voice, it is important to note that professionals can still be prey to using their power in patient management in a less than supportive manner on a one-to-one basis. In law, for instance, Bogoch (1997), writing from a feminist perspective, found patterns of dominance in interactions between lawyers and their clients based on language – including such aspects as the control of discourse, interruptions, topic control, and challenges – which were amplified by a greater pattern of deference among female clients towards male lawyers. In a similar vein in terms of minority groups, medical practitioners have been found to discriminate against ‘difficult’ patients such as alcoholics and the mentally ill who fall into the category of ‘dirty work’ (Shaw 2004).
The dynamics of professional practitioner–client interaction underline another key focus in terms of power from a neo-Weberian standpoint – that of inequalities in service delivery and access to services which may be manifested anywhere from the micro to the macro level. Inequalities between social groups have been shown frequently to mirror inequalities of power and position within the professions themselves, not least in health care in Britain and the United States (Saks 2014). This is also exemplified by studies of professional projects in law, teaching and management in Britain by Bolton and Muzio (2008), who discovered patterns of gendered exclusion, segmentation and stratification in these areas.
The latter account is a clear exception to the claim that neo-Weberian studies of the professions are too often gender blind and permeated by masculine visions of such occupations (Davies 1995). In this respect, Witz (1992) classically argued from a feminist perspective that professionalization in medicine and nursing has been a gendered historical process based on the exercise of power by men in a patriarchal society. The need to more explicitly open up the study of professions and power to a feminist lens has more recently been underlined by Kuhlmann and Annandale (2012), who call for greater gender mainstreaming in health care, in which the implications for women of any planned action – whether it be legislation, policies or programmes – are scrutinized such that gender inequality is not perpetuated.
This chapter has now covered much of the central literature on professions and power as they figure in theory and indeed history – encompassing a range of professional groups, countries and issues. As the various sociological contributions considered highlight, both the definition of professions and the concept of power are contested. However, the value of a neo-Weberian approach has been advocated here because – despite some weaknesses in its operationalization – it arguably provides a strong general theoretical framework for the analysis of the relationship between the two. It has therefore been within this perspective that a number of current key issues related to professions and power have been profiled.
Another aspect of professions and power in a political rather than a purely academic sense is the variety of questions that this chapter raises about future policy directions in relation to professional groups in modern societies. These are accentuated within a neo-Weberian perspective by the centrality to professionalism of the achievement of exclusionary social closure, based on successful interest-based lobbying of the state by selected occupational groups. How far, therefore, at a macro level is ongoing state support justified for the privileged position of professions in the market? Or, put another way, to what extent does the power that has made such groups professionalized warrant special underwriting from the state, which is itself subject to many political influences?
Such pragmatic political questions concerning professions and power pertain to each of the different levels of analysis of this area. For instance, in what ways might professionals in interactional contexts be regulated or developed to ensure more sensitive and less disempowering dealings with clients? How far is it defensible for professional expertise to be protected in terms of power within organizational decision making? And how might knowledge of power and interests in the professions be strategically harnessed through informed leadership to advance the public interest in the increasing web of organizational and managerial interests in which they are embroiled in the wider society?
The ‘public interest’ is, of course, a politicized concept which is even more contested than the notions of professions and power. Indeed, it is easy to come to the view that – given the multiplicity of competing interpretations – rather than trying to define the public interest, it may be simpler to consider it purely as an ideology used to advance the cause of the powerful in debate. Despite the difficulties, though, this argument not only entails relinquishing political responsibility but also testifies to the centrality of the concept of power in understanding privileged groups like professions, who regularly deploy altruistic ideologies in support of their interests and actions in ever-changing modern societies.
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