Professions, marginality
and inequalities
Mike Saks
University Campus Suffolk, UK
abstract Professional ideologies generally commit to addressing inequalities among clients and/or the
public. Sociologists of professions in the Anglo-American context have written on the extent to which this
commitment is honoured. This contribution, however, reviews the literature on inequalities between professional groups from a neo-Weberian perspective through the concept of marginality, focusing on the
health context. With particular reference to the case of complementary and alternative medicine, it highlights that future research needs to focus more on how this affects inequalities outside the professions.
keywords
complementary and alternative medicine
neo-Weberianism ◆ professions
Introduction
◆
health
◆
inequalities
◆
marginality
◆
1990). Making reference to the health field and the
case study of complementary and alternative medicine, this article outlines such inequalities and notes
that there is a significant gap in the research literature
exploring the implications of inequalities within professions for inequalities without.
It is often assumed in the sociological literature
that professions as single occupational groups are
homogeneous entities, when, as classically pointed out
by Bucher and Strauss (1961), there is considerable
diversity and conflict of interest within professional
groups. This conception of in-fighting within specific
professions, which includes tensions between the professional elite and the grassroots as well as competing
status hierarchies of sub-specialisms, is at odds with
many codes of professional ethics and associated ideologies which typically foster the idea of professions as
collegial groups forming communities of equals serving the good of the client and/or the wider public (see,
for example, Abbott, 1983). However, if the notion of
professions as communities of equals serving the public interest in single professions may be considered a
myth (Saks, 1995), this is also true of the relationship
between professional groups which is often distinctly
hierarchical, as highlighted by the concept introduced
here of marginal and marginalized professions. With
illustrations drawn from health, it is noted that such
Professions for many sociologists have become a key
part of the occupational structure in the social stratification system of the modern western world
(Macdonald, 1995), with a mission typically
expressed in their ideologies to serve the public interest – including addressing issues of social inequality
(Saks, 1995). Accordingly, a substantial amount of the
literature in the Anglo-American sociology of professions has examined the role of professions – from doctors and nurses to accountants and lawyers – in
tackling inequalities amongst client groups and the
wider public. This is illustrated by longstanding work
in the United States both generally (see, for instance,
Krause, 1971) and in specific fields (see, for instance,
Navarro, 1986). It is also apparent in more recent
work on professions on enhancing social inclusion
and citizenship in Britain and the rest of Europe covering dimensions such as social class, ethnicity and
gender (as illustrated by Matthies et al., 2000; Saks
and Kuhlmann, 2006). This contribution, though,
considers the literature on inequalities within professions themselves from a neo-Weberian perspective,
and in particular the hierarchical relationships
between professional groups in the Anglo-American
context where professions are characterized by the
greatest degree of self-regulatory autonomy (Collins,
Sociopedia.isa
© 2014 The Author(s)
© 2014 ISA (Editorial Arrangement of Sociopedia.isa)
Mike Saks, 2014, ‘Professions, marginality and inequalities’, Sociopedia.isa, DOI: 10.1177/205684601411
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Professions, marginality, inequalities
Saks
sional groups and sub-groups in particular decisionmaking situations (Saks, 1995).
More pointedly in relation to this contribution,
though, is the hierarchy of professions which has
emerged in particular countries linked to different
patterns of professional social closure. In this hierarchy, professions like law and medicine are classically
seen to be at the apex in the Anglo-American setting
– albeit with their own internal sub-specialist rankings which can be illustrated in Britain by the longstanding division between higher status barristers
and solicitors in the English legal system (Burrage,
2006) and between elite consultants in niche specialisms and general practitioners in the National
Health Service (Klein, 2010). Other professions variously lie below these groups in a pecking order
resulting from legally embedded patterns of referral,
oversight and other arrangements in relation to top
tier professional groups – which are also typically
reflected in differential financial and related rewards.
The position of such middle and lower order professions has been conceptualized in neo-Weberian work
as ‘dual closure’, where such occupational groups as
nurses and teachers take on the characteristics of
both exclusionary and usurpationary closure, the latter of which is more typical of union action in the
working class (Parkin, 1979). Some other occupations, moreover, have not gained full legally
enshrined social closure and are in the process of professionalizing – and may be governed by voluntary
rather than statutory regulation which places them
still further down the occupational pecking order
(Saks, 2003a). Importantly, it should be stressed in
setting out the regulatory inequalities between professional and proto-professional groups that the
interrelationship between professions is not static,
but shifts over time (Abbott, 1988).
In terms of social theory it should also be noted
that the neo-Weberian approach to the professions
adopted here has not been beyond criticism. It has
been variously criticized for lacking empirical rigour
(Saks, 1983), being excessively negative about professional groups (Saks, 1998) and failing to link its
analysis to the wider occupational division of labour
(Saks, 2003b). These criticisms, however, relate more
to the inappropriate way in which the approach has
been implemented than its intrinsic structural weaknesses (Saks, 2010). It is, however, worth noting that
advocates of the neo-Weberian perspective – because
of its focus on the interplay of competitive group
interests in the market – tend to take a more critical
approach to professions and the way in which their
myriad of privileged monopolistic positions have
originated and developed. As such, neoWeberianism stands in a common stream with interactionism (see, for example, Becker, 1962), Marxism
inequalities between professions may have considerable implications for clients and the public in liberal
democratic societies such as Britain and the United
States, especially as regards patterns of inequality.
This relatively unexplored dimension of the sociology of professions is therefore an important topic for
future research.
Professions, hierarchies and
inequalities
From the interest-based neo-Weberian perspective
adopted in this article, professions are defined in the
Anglo-American context in terms of exclusionary
social closure in the market based on the establishment of legal boundaries creating ranks of insiders
and outsiders, with associated privileges accruing to
insiders in terms of income, status and power
through credentialism (Saks, 2010). This said, professions are conceptualized in various ways related to
exclusionary closure in the contemporary neoWeberian literature – from having direct market
control of services (Parry and Parry, 1976) to possessing in a more derivative way occupational independence over technical decisions and work organization
(Freidson, 2001). Most importantly, though, in this
context, the professions are centred in practice on
different forms of legally underpinned exclusionary
social closure linked to their operation in specific
societies (see, for example, Moran and Wood, 1993).
In Britain, for instance, following the passing of the
locally based guilds, there is a national system of professional regulation, whereas a state by state pattern
of licensure is more prevalent in countries like the
United States (Krause, 1996). Similarly, a de facto
professional monopoly based on protection of title
while still allowing wider practice under the
Common Law characterizes professions such as medicine in Britain, compared to the more prevalent de
jure monopolies in the United States, related to different sociohistorical circumstances (Berlant, 1975).
There is also now increasingly an international
dimension to the delineation of the boundaries of
exclusionary closure in a single profession in neoWeberian terms – as exemplified by the opening up
of geographical mobility with the mutual recognition of qualifications in the European Union which
could lead in future to some degree of convergence
of national professional regulatory regimes (Bianic
and Svennson, 2010). Moreover, all of these different
patterns of regulation have potential implications for
the way professions operate in terms of both client
groups and the broader public because of the different conjunction of interests that they generate – in
terms of the balance of benefits and costs to profes-
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tionalist writers have been accused of reflexively mirroring in building such positive features of a profession into the very definition of their operation
(Roth, 1974).
Johnson (1972) also provides an alternative perspective on middle and lower ranking professional
groups, which suggests that the assumed ‘natural’
order of the professional division of labour may not
always be rational. More specifically, after disparaging the expertise of general medical practitioners and
lawyers as being based more on interpersonal than
technical skills in terms of their ability to relate
warmly to clients, he notes that:
(see, for instance, Carchedi, 1975) and
Foucauldianism (as illustrated by Johnson, 1995),
which view the hierarchical position gained by professions as respectively based on their skills in negotiating the acquisition of an honorific label, their role
in fulfilling the global functions of capital and the
not always progressive process of governmentality.
The main distinction, however, is that the framework of the neo-Weberian approach – with its focus
on exclusionary closure as the touchstone of professionalism – lends itself more strongly to analysing
particular professions in a more open way, avoiding
the problem of other more critical approaches of
building in an excess of tautological and other theoretical assumptions that are not in principle
amenable to empirical examination (Saks, 2010).
As part of the more critical perspectives on professions, neo-Weberianism also differs markedly
from the largely deferential earlier trait approach
which painted a more positive picture of professions
(Millerson, 1964). In the trait approach professional
groups are defined as based on features such as high
levels of expertise and rationality (see, for example,
Greenwood, 1957) – and even bulwarks of democracy (Lewis and Maud, 1952). This analysis is particularly developed in functionalist work where it is
usually held that there is a trade-off, in which professions with knowledge that is very important to society are provided with a privileged position in
exchange for committing to use this knowledge to
the public benefit (see, for example, Barber, 1963).
The functionalist theoretical approach is also used to
explain inequalities between the professions in the
analysis of Etzioni (1969), who differentiates what
he labels as ‘semi-professions’ like social work and
teaching from more fully fledged professions on
account of their weaker development of professional
characteristics like expertise and altruism. This clearly departs from the earlier neo-Weberian work of
Johnson (1972), who sees the lofty position attained
by medicine and law in the professional pecking
order in terms of power and interest and is highly
sceptical of the claims of such groups to serve the
public interest, not least in tackling social inequalities. Here he queries, for example, the extent to
which lawyers’ interests allow them to represent
those who seek radical change to the existing order,
but also notes that the services of practising lawyers
are very unequally distributed. Little seems to have
changed to judge by recent reports from Britain and
the United States about substantial differences in
access to legal services by geography, as well as by low
income, disabled, elderly and ethnic minority groups
despite legal aid schemes (Robins, 2011; Sandefur
and Smyth, 2011). An antidote is therefore provided
to the professional ideologies which trait and func-
The emergence of a succession of subordinate ‘professions auxiliary to medicine’ in Britain is the history
of how physicians have been able to define the scope
of new specialised medical roles, and cannot be
regarded as … a product of the most rational utilisation of human resources. (Johnson, 1972: 35–6)
This illustration raises many questions about the
potential existence of unjustified inequalities
between professions, as well as their impact on the
public interest in the Anglo-American context – and
in particular in this context their implications for
inequalities. Not least of these from a neo-Weberian
perspective is how far the limits on both the definition of, and delegation to, allied health practitioners
have reduced access to medical care further than it
needs to be in less well-served populations (Saks,
2003a). This leads neatly on to a discussion of marginality in the professions, the literature on which
will now be considered more specifically in the
health field to highlight further inequalities among
professional groups and their potential significance
for exacerbating or otherwise divisions in the stratified societies in which they work.
Inequalities and marginality in the
health professions
Current work on the health professions indicates
that they, no less than other professions in the
Anglo-American setting, contain their own share of
specific internal inequalities – such as in the divide
between specialists and generalists in both medicine
and nursing as discrete professions and indeed
between specific specialisms which are more or less
highly ranked in the pecking order (Klein, 2010). In
medicine in Britain and the United States there can
be seen to be an elite group driving the profession
which has meant that there are also internal divisions
in relation to grassroots practitioners, notwithstanding formal democratic structures for elections. In
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Professions, marginality, inequalities
Saks
and radiographers who take on delegated tasks from
doctors in the orthodox division of labour. Despite
their lower positions in the pecking order compared
to physicians, marginalized health professions have
nonetheless gained through professionalization official legal recognition and legitimation as well as associated benefits, including protection of title linked to
enhanced income, status and power (see, for
instance, Allsop and Saks, 2002). This separates all
shades of orthodox health professions from marginal
health professions which lie mainly outside stateendorsed frameworks and are viewed by Turner
(1995) as being based on ‘exclusion’ rather than ‘limitation’ or ‘subordination’ within the health care division of labour. Examples of marginal health
professions include elements of aspiring groups like
health support workers who are striving to professionalize – such as, most recently, operating theatre
practitioners in Britain (Saks, 2008).
This categorization and the hierarchal ordering of
professions becomes more politically charged if the
position of marginal or marginalized health professions are not seen to be based on their level of expertise and contribution to the wider society, but rather
on dominant medical professional interests in the
neo-Weberian frame of reference. This is precisely
what was being suggested by Johnson (1972) in
pointing to his view of the ‘irrational’ utilization of
resources in analysing the comparative position of
allied health professions in the division of labour.
This view, however, contrasts with the lofty pedestal
on which the medical profession is placed relative to
groups like nurses by functionalist theorists who
argue equally fiercely that their privileged position
has been gained, amongst other things, by its possession of knowledge of vital importance to the public
(Etzioni, 1969). The question of whether the medical profession is to be condemned or applauded for
its exalted position in the division of labour ultimately must, of course, be resolved through empirical investigation rather than simply by fiat. What
should be said, though, is that the division into
either dominant, marginalized or marginal professions in terms of the unequal hierarchy of health professions is inevitably fluid – it was after all little more
than a century and a half since doctors themselves
were professionalized, in the mid-nineteenth century
in Britain and the early twentieth century in the
United States, and even later when nursing, midwifery and other allied health professions emerged as
marginalized professions (Saks, 2003a). Before this
time in the nineteenth century in both societies there
was a relatively open field in which practitioners of
all types – including some of those who are now
defined as complementary and alternative medicine
(CAM) therapists – competed in the market on a
Britain this includes the leaders of the British
Medical Association and the Royal Colleges – particularly the Royal College of Physicians and Royal
College of Surgeons. In the United States a similar
pattern exists primarily through the leaders of the
American Medical Association. Amongst other
things, such groups predominantly define and
uphold the mainstream scientific practice of orthodox biomedicine through the management of curricula, career structures, research funding, journals and
other means (Saks, 2003a). However, the focus here
is on the relationship between, rather than within,
professions – to which the analysis of the literature
now turns with the tenet that, despite various challenges, including from the state in Britain and corporatism in the United States, the medical profession as
a whole still stands in a dominant position in orthodox health care (Ham, 2009; Stanfield et al., 2011).
In this respect, in terms of inequalities, there has
been a recent resurgence of interest in the sociology
of professions in marginal professions in the division
of labour, particularly in the health field (see, for
instance, Saks, 2008) building on strong historic
roots from the early analysis of the role strains of chiropractic as a marginal profession in the United
States (see Wardwell, 1952). In this context, the categories of ‘marginalized professions’ and ‘marginal
professions’ have recently been defined in the literature (Saks, 2014 forthcoming) which helps to conceptualize the relationship with dominant
professions and underline the position of other professions in the pecking order. As such, ‘marginalized
professions’ have a less well accepted standing within orthodox ranks, which is typically reflected in different levels of income, status and power, but still
have some form of legally enshrined exclusionary
social closure. ‘Marginal professions’ in contrast are
professionally aspiring occupations largely operating
outside the state-supported orthodox division of
labour. The resulting inequalities between professions are at their greatest in relation to dominant
groups with respect to these two categories and provide the strongest potential for generating, or at least
exacerbating, inequalities without – from patterns of
geographical dispersal to the nature, sufficiency and
affordability of practitioners operating in particular
health fields.
The category of marginalized professions maps
well on to the classification of health professions outside of the dominant medical profession as set out by
Turner (1995). He distinguishes two relevant categories. The first is ‘limited’ health professions such as
pharmacists, dentists and opticians whose practice is
legally restricted to particular parts of the body. The
second category is that of subordinated health professions like nurses and midwives, physiotherapists
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Professions, marginality, inequalities
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CAM therapists in the pecking order for health professions, especially with restrictive codes of medical
ethics inhibiting collaboration between physicians
and CAM practitioners. In Britain, moreover, laws
were passed creating state shelters for medicine in the
first half of the twentieth century initially through
the National Health Insurance scheme and then the
National Health Service. This barrier was augmented by legislation in the same period prohibiting
CAM therapists from claiming to treat a range of
diseases such as diabetes, epilepsy and glaucoma
(Larkin, 1995). The consequence of this and similarly restrictive practices in relation to such areas as
health insurance schemes and hospital attendance in
the United States (Saks, 2003a) was that CAM was
increasingly heavily depleted in face of the rise of the
medical profession by the mid-twentieth century –
not least with the mushrooming growth of a range of
limited and subordinated practitioners in orthodox
health care on both sides of the Atlantic which reinforced the dominance of medicine (Saks, 1999).
Having said this, there was a resurgence of public
interest in CAM both during and after the counterculture of the 1960s and 1970s (Roszak, 1970). This
led to an upsurge of demand such that most members of the public in the Anglo-American context
wanted selected CAM therapies more freely available
by the 1980s and by the start of the new millennium
in Britain one in seven members of the population
were regularly visiting CAM practitioners and in the
United States over four out of 10 Americans reported using CAM (Saks, 2003a). This was related to
such factors as an increasing awareness of the limits
of orthodox medicine, a desire to go beyond a technocratic approach to medicine centred on depersonalization and disempowerment, and a search by
consumers for greater control over their own health
(Saks, 2000). The upshot is that there are growing
pressures from users for access to CAM therapies –
including through the incorporation of CAM by the
medical profession and allied health professions.
This led to some moderation of the stance of orthodox medicine towards CAM, particular in its less
challenging complementary, rather than alternative,
forms (see, for instance, British Medical Association,
1993). It also further promoted the practice of CAM
by health professions in the public and private sector
– the usage of which was backed by political lobbies
in both Britain and the United States, as well as by
health professional bodies and government (see, for
example, Cohen, 1998).
The current position outside medical orthodoxy
is that, while some CAM therapists prefer solo practice to becoming part of a profession, most CAM
therapies have sought professionalization of some
kind. In Britain this has typically been as marginal
relatively level playing field where they were very difficult to distinguish in terms of theories, practice or
repute (Porter, 1995).
This leads on to the consideration of the position
of CAM, which has been one of the most controversial areas in the sociology of professions from the
viewpoint of inequalities within the health professions in the Anglo-American context. Certainly by
far the greatest numbers of those engaged in marginal health professions are CAM practitioners who are
not yet fully professionalized (Saks, 2008). In terms
of the inequalities between professions, it should be
noted that CAM is defined here not in relation to its
intrinsic characteristics, but rather its position of
being largely excluded from the orthodox health care
division of labour underwritten by the state and
based on an increasingly unified biomedical paradigm centred on drugs and surgery. CAM is defined
in this way because it encompasses such a great diversity of practices in the Anglo-American context,
from aromatherapy and herbalism to homoeopathy
and naturopathy. As such, it is impossible to capture
the CAM field through overly simplified concepts
such as holistic and/or traditional medicine which
only relate to a part of its conceptual universe (Saks,
2003a). It is also equally important to note in terms
of inequalities between the health professions that
the orthodoxy of one era can become the CAM of
the next, and vice versa. With these definitional
bridges traversed, the article will now turn to consider the literature surrounding the CAM case study in
the Anglo-American context.
Case study: complementary and
alternative medicine
As Saks (2003a) has documented, the marginal profession of CAM in the contemporary context has
taken shape following a long history of attacks by
medical orthodoxy on both sides of the Atlantic. In
both Britain and the United States, over many
decades, medical elites have striven to reduce the
credibility of CAM through, amongst other things,
enforcing orthodox curricula control in medical
schools, debunking the practices and practitioners of
CAM in the medical journals, limiting access to
medical research funding, and orchestrating career
blockages for collaborators. In Britain, as in the
United States, marginalization meant that the CAM
therapies concerned lacked legitimation. However,
while CAM practitioners in Britain could normally
practise under the Common Law without obtaining
exclusionary closure backed by the state, licensing
was required in the United States (Freidson, 1994).
Nonetheless, the odds were still stacked against
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some CAM therapies qualify for reimbursement
under Medicare, Medicaid and private health insurance schemes and there are often strong restrictions
on such matters as referrals in state licensing for
CAM – which can in itself be quite patchy from state
to state (Saks, 2003a). In sum, even the few CAM
occupations that have gained statutory regulation are
still very much marginalized in the health care division of labour on both sides of the Atlantic – with
generally negative consequences for practitioner
income, status and power.
What, then, of the impact of inequalities between
marginal and marginalized CAM professions and
more orthodox health professions on inequalities
without – namely, for clients and the wider public?
There certainly seems to be a major impact on geographical access – particularly as CAM has largely
been driven into the private sector with little central
planning in Britain and there is sporadic state licensing in the case of some CAM therapies in the United
States (Saks, 2003a). Moreover, there are associated
financial barriers to access in terms of support for
visits to many types of CAM therapy in a predominantly private market, in which there may in both
societies be particularly significant negative effects
for lower class groups in light of their ability to pay
(see, for instance, Fitzpatrick, 2008). In addition,
there are issues for minority groups in relation to
ethnicity and gender which should not be ignored
given the concentration of white males in higher
positions in the dominant health professions (see, for
example, Kuhlmann and Annandale, 2012) – a pattern which is interestingly also replicated in the
pecking order for CAM professionalization in which
the predominantly white male professions of
osteopathy and chiropractic are in receipt of the
greatest state support for their practice in Britain and
the United States. Such inequalities in access and
availability have been systematically examined by
Saks (1995) in relation to the predominant rejection
by the medical profession in Britain of acupuncture
and the subsequent hierarchical position of medical
and CAM practitioners of this therapy over many
decades – which he concludes after careful scrutiny
has not been in the public interest. In this respect,
there are other dimensions to the public interest in
liberal democracies than egalitarianism, including
liberty and the general welfare – which in the case of
CAM may not be best served by the often limited
knowledge of CAM by orthodox health professions
in referral networks and the untoward effects of positioning in the health professional pecking order on
the quality of recruits to CAM practice.
Notwithstanding rising public demand for CAM,
such implications become more defensible if there
are major health hazards with CAM or evidence that
professions without the statutory backing required
for full exclusionary social closure (Saks, 2014 forthcoming). Thus, a number of CAM therapies currently operate with voluntary forms of self-regulation,
including setting out minimum educational standards and codes of ethics. In Britain acupuncture has
taken this step through the British Acupuncture
Council and British Acupuncture Accreditation
Board and homoeopathy has done so too through
the Society of Homoeopaths (Saks, 2006). In the
United States sporadic state licensing for CAM practice as in the case of naturopathy is more of the
norm, except in self-help contexts. Some types of
CAM, moreover, have now gained systematic statutory underwriting on both sides of the Atlantic –
most notably, that for osteopaths and chiropractors
(Saks, 2003a). In this regard, there was earlier licensing for these CAM practices in the United States followed by the Osteopathy Act and the Chiropractic
Act in Britain setting up a professional register and
giving protection of title in the 1990s – bringing
them more into the realm of marginalized, not marginal, professions. Moreover, the British government
is currently considering setting up similar registers
for herbalists and traditional Chinese medicine practitioners in light of licensing requirements in the
European Union which may otherwise mean the end
of such practice in Britain (Hansard, 2011).
In terms of the implications of the inequalities
between groups of professionalizing and professionalized CAM practitioners and more orthodox health
professions, the impact of CAM simply being a marginal profession without statutory regulation is very
significant as there is less legitimacy, less private and
public funding support and certainly no legal protection of title – despite attempts by relevant CAM
practitioners to put in place voluntary regulation
(Saks, 2006). However, even for those CAM practitioners who have gained statutory licensing and have
therefore become marginalized rather than marginal
professions, there are still major disadvantages in the
hierarchy of more orthodox health professions.
Although they do have protection of title, they share
a highly restricted presence in the orthodox medical
curriculum and mainstream medical journals and are
rarely in receipt of official research grants – even if
more research funding opportunities have opened up
recently, through the National Center for
Complementary and Alternative Medicine in the
United States (Adams et al., 2012). Moreover, there
remain legally enforced limits on the claims that can
be made for treatment in both societies and in
Britain the ability of CAM therapists to practise in
the National Health Service is restricted – even if the
ethical restrictions on medical collaboration have
slackened. In the United States meanwhile only
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inequalities through the marginalization of CAM in
health professional hierarchies because such practice
is typically more restricted and usually based on
much shorter training as compared to that undertaken by non-orthodox CAM practitioners themselves
(Saks, 2003a).
CAM therapies are ineffective in particular cases. In
this respect, Wallis and Morley (1976) argue from a
functionalist perspective that CAM has been marginalized in the health care pecking order because its
therapies lack scientific evidence in comparison to
orthodox medicine. However, this is not entirely
credible when the conditions under which medicine
first gained statutory standing as a profession are
considered. When the Medical Registration Act was
passed in the mid-nineteenth century in Britain,
there was little to differentiate doctors from their
competitors; medicine was primarily classificatory
rather than curative; neither anaesthesia nor aseptic
and antiseptic techniques were in use; and hospitals
were associated with death (Saks, 2003a). Of course,
the licensing of physicians in the United States took
place some five decades later when a little more medical progress had been made and there have since
been further medical advances in a range of fields,
from the use of antibiotics against bacterial infections to cataract and hip surgery (Le Fanu, 2011).
Nonetheless, while more systematic research may
need to be conducted into CAM (Ernst et al., 2008),
orthodox medicine has arguably become rather too
heavily fixated on randomized controlled trials
which do not fit many CAM therapies as evaluative
tools and have not been applied pervasively to orthodox health care – accentuating the need for more
flexibility in the use of qualitative and quantitative
health research methods (Richardson and Saks,
2013).
In this light, given the threat that CAM has posed
to elite and other medical interests particularly in
relation to CAM therapies presented as panaceas
with counter-posed philosophies to biomedicine –
such as traditional forms of acupuncture based on
needling underpinned by yin-yang theories and
meridians (Saks, 1992) – it is difficult to believe
from a neo-Weberian perspective that such interests
are not a central explanation of the general orthodox
medical resistance to CAM. There is in such
instances a real challenge to professional income, status and power – except of course when incorporation
is an attractive option for orthodox health professions in the marketplace where non-threatening
CAM opportunities exist. These circumstances apply
when, for instance, CAM is adopted within medical
orthodoxy in limited form to enhance private practice for generalists or provide innovative career profiles for more established medical specialists – as in
the case of consultants adopting formula acupuncture to treat specific conditions based on neurophysiological explanations of its modus operandi (Saks,
1995). It should be stressed, though, that the incorporation of CAM by orthodox health practitioners
does not significantly mitigate the exacerbation of
Conclusion
In conclusion, the review of the literature undertaken here suggests that inequalities between the professions as illustrated in the case study of CAM – and
facilitated by the concepts of marginalized and marginal professions outlined – seem to have had a substantial impact in exacerbating such external
inequalities as those based on geography, class, gender and ethnicity in both Britain and the United
States, especially in relation to access to services for
individual clients and the wider population. At a
time when governments are more sensitive than ever
to the principles of equality and diversity, it is therefore very important that they are alive to the policy
implications of the hierarchical professional designations of the workforce, including the impact of sanctioning different relational forms of social closure in
the health field and elsewhere. Following on from
this review, additional research from a neo-Weberian
perspective would be very helpful in health and other
professional domains to understand more fully the
implications of inequalities and marginality between
professional groups – in a complementary way to the
further study of inequalities within particular professions. This would be most apposite at a time when
much of the sociological literature to date has
focused more on ‘top dog’ rather than middle and
lower order professions and has not always sufficiently considered their roles in the context of the wider
occupational division of labour. This is critical not
only in terms of the responsiveness of professions to
clients, but also in relation to the broader public
interest. As this contribution indicates in highlighting the need for further research in this area, currently the ideologies of professional groups may not be
appropriately representing their activities to government and the wider community in terms of the
impact of their hierarchical interrelationship on societal inequalities.
Annotated further reading
Kuhlmann E and Annandale E (eds) (2012) The Palgrave
Handbook of Gender and Healthcare, 2nd edn.
Basingstoke: Palgrave Macmillan.
This edited volume is significant because it illustrates
7
Professions, marginality, inequalities
Saks
well one dimension of inequality in relation to the
health professions, their clients and the wider public
– bringing together contributions from authors on
gender and health care in a range of international
contexts.
Macdonald K (1995) The Sociology of the Professions.
London: Sage.
This book provides a useful overview of various
theoretical perspectives on professions and the
operation of a wide range of professional groups in
the stratification system, drawing on studies of
professions in Britain, the United States and Western
Europe.
Saks M (2003) Orthodox and Alternative Medicine:
Politics, Professionalization and Health Care. London:
Sage.
This book is important because it covers the
integrated history of orthodox and alternative
medicine in Britain and the United States over the
past 500 years – examining dynamically some of the
key issues of marginality and inequality amongst the
health professions.
Saks M (2010) Analyzing the professions: The case for
the Neo-Weberian approach. Comparative Sociology
9(6): 887–915.
This article is helpful as it comprehensively explores
the nature, strengths and weaknesses of the neoWeberian approach to the Anglo-American sociology
of the professions adopted here – as well as its
comparison to other theoretical perspectives on the
professions.
British Medical Association (1993) Complementary
Medicine: New Approaches to Good Practice. London:
BMA.
Bucher R and Strauss AL (1961) Professions and process.
American Journal of Sociology 66: 325–34.
Burrage M (2006) Revolution and the Making of the
Contemporary Legal System: England, France and the
United States. Oxford: Oxford University Press.
Carchedi G (1975) On the economic identification of
the new middle class. Economy and Society 4(1):
1–86.
Cohen M (1998) Complementary and Alternative
Medicine: Legal Boundaries and Regulatory
Perspectives. Baltimore, MD: Johns Hopkins
University Press.
Collins R (1990) Market closure and the conflict theory
of the professions. In: Burrage M and Torstendahl R
(eds) Professions in Theory and History: Rethinking the
Study of the Professions. London: Sage, pp. 24–43.
Ernst E, Pittler MH, Wider B and Boddy K (2008) The
Oxford Handbook of Complementary Medicine.
Oxford: Oxford University Press.
Etzioni A (1969) The Semi-professions and their
Organization. New York: Free Press.
Fitzpatrick R (2008) Organizing and funding health
care. In: Scambler G (ed.) Sociology as Applied to
Medicine, 6th edn. Oxford: Saunders Elsevier, pp.
313–27.
Freidson E (1994) Professionalism Reborn: Theory,
Prophecy and Progress. Chicago: University of Chicago
Press.
Freidson E (2001) Professionalism: The Third Logic.
Cambridge: Polity Press.
Greenwood E (1957) The attributes of a profession.
Social Work 2(3): 45–55.
Ham C (2009) Health Policy in Britain, 6th edn.
Basingstoke: Palgrave Macmillan.
Hansard (2011) Written ministerial statements:
Acupuncture, herbal medicine and traditional
Chinese medicine. Hansard, 16 February.
Johnson T (1972) Professions and Power. London:
Macmillan.
Johnson T (1995) Governmentality and the
institutionalization of expertise. In: Johnson T,
Larkin G and Saks M (eds) Health Professions and the
State in Europe. London: Routledge, pp. 7–24.
Klein R (2010) The New Politics of the NHS. Oxford:
Radcliffe Publishing.
Krause E (1971) The Sociology of Occupations. Boston,
MA: Little, Brown and Co.
Krause E (1996) The Death of the Guilds: Professions,
States and the Advance of Capitalism, 1930 to the
Present. New Haven, CT: Yale University Press.
Kuhlmann E and Annandale E (eds) (2012) The Palgrave
Handbook of Gender and Healthcare, 2nd edn.
Basingstoke: Palgrave Macmillan.
Larkin G (1995) State control and the health professions
in the United Kingdom: Historical perspectives. In:
Johnson T, Larkin G and Saks M (eds) Health
Professions and the State in Europe. London:
Routledge, pp. 45–54.
References
Abbott A (1983) Professional ethics. American Journal of
Sociology 88(5): 855–85.
Abbott A (1988) The System of Professions: An Essay on
the Division of Expert Labour. Chicago: Chicago
University Press.
Adams J, Andrews GJ, Barnes J, Broom A and Magin P
(eds) (2012) Traditional, Complementary and
Integrative Medicine: An International Reader.
Basingstoke: Palgrave Macmillan.
Allsop J and Saks M (eds) (2002) Regulating the Health
Professions. London: Sage.
Barber B (1963) Some problems in the sociology of
professions. Daedalus 92: 669–88.
Becker H (1962) The nature of a profession. In:
National Society for the Study of Education (eds)
Education for the Professions. Chicago: University of
Chicago Press, pp. 27–46.
Berlant JL (1975) Profession and Monopoly: A Study of
Medicine in the United States and Great Britain.
Berkeley: University of California Press.
Bianic T and Svensson LJ (2010) Professions and
European regulation and integration: Case studies of
architects and psychologists. In: Svensson LG and
Evetts J (eds) Sociology of Professions: Continental and
Anglo-Saxon Traditions. Gothenburg: Daidalos, pp.
189–209.
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Professions, marginality, inequalities
Saks
Le Fanu J (2011) The Rise and Fall of Modern Medicine,
2nd edn. London: Abacus.
Lewis R and Maude F (1952) Professional People.
London: Phoenix House.
Macdonald K (1995) The Sociology of the Professions.
London: Sage.
Matthies A, Järvela M and Ward D (eds) (2000) From
Social Exclusion to Participation: Explorations across
Three European Cities. Jyväskylä: University of
Jyväskylä Publishing.
Millerson G (1964) The Qualifying Associations. London:
Routledge and Kegan Paul.
Moran M and Wood B (1993) States, Regulation and the
Medical Profession. Buckingham: Open University
Press.
Navarro V (1986) Crisis, Health and Medicine: A Social
Critique. London: Tavistock.
Parkin F (1979) Marxism and Class Theory: A Bourgeois
Critique. London: Tavistock.
Parry J and Parry N (1976) The Rise of the Medical
Profession. London: Croom Helm.
Porter R (1995) Disease, Medicine and Society,
1550–1860, 2nd edn. Cambridge: Cambridge
University Press.
Richardson J and Saks M (2013) Researching orthodox
and complementary and alternative medicine. In:
Saks M and Allsop J (eds) Researching Health:
Qualitative, Quantitative and Mixed Methods, 2nd
edn. London: Sage, pp. 319–35.
Robins J (2011) Unequal before the Law? The Future of
Legal Aid. London: Solicitors Journal, The Justice
Gap Series.
Roszak T (1970) The Making of a Counter Culture.
London: Faber and Faber.
Roth J (1974) Professionalism: The sociologist’s decoy.
Sociology of Work and Occupations 1(1): 6–23.
Saks M (1983) Removing the blinkers? A critique of
recent contributions to the sociology of professions.
Sociological Review 31(1): 1–21.
Saks M (1992) The paradox of incorporation:
Acupuncture and the medical profession in modern
Britain. In: Saks M (ed.) Alternative Medicine in
Britain. Oxford: Clarendon Press, pp. 183–98.
Saks M (1995) Professions and the Public Interest: Medical
Power, Altruism and Alternative Medicine. London:
Routledge.
Saks M (1998) Deconstructing or reconstructing
professions? Interpreting the role of professional
groups in society. In: Olgiati V, Orzack L and Saks
M (eds) Professions, Identity and Order in Comparative
Perspective. Onati: Onati International Institute for
the Sociology of Law, pp. 351–64.
Saks M (1999) The wheel turns? Professionalisation and
alternative medicine in Britain. Journal of
Interprofessional Care 13: 129–38.
Saks M (2000) Medicine and the counter culture. In:
Cooter R and Pickstone J (eds) Medicine in the
Twentieth Century. Amsterdam: Harwood Academic
Publishers, pp. 113–24.
Saks M (2003a) Orthodox and Alternative Medicine:
Politics, Professionalization and Health Care. London:
Sage.
Saks M (2003b) The limitations of the Anglo-American
sociology of the professions: A critique of the current
neo-Weberian orthodoxy. Knowledge, Work and
Society 1(1): 11–31.
Saks M (2006) The alternatives to medicine. In: Gabe J,
Kelleher D and Williams G (eds) Challenging
Medicine. London: Routledge, pp. 85–103.
Saks M (2008) Policy dynamics: Marginal groups in the
healthcare division of labour in the UK. In:
Kuhlmann E and Saks M (eds) Rethinking
Professional Governance. Bristol: Policy Press, pp.
155–69.
Saks M (2010) Analyzing the professions: The case for
the neo-Weberian approach. Comparative Sociology
9(6): 887–915.
Saks M (2014 forthcoming) Marginalized health
professions. In: Cockerham WC, Dingwall R and
Quay SR (eds) Wiley-Blackwell Encyclopedia of
Health, Illness, Behavior, and Society. Oxford: WileyBlackwell.
Saks M and Kuhlmann E (2006) Introduction:
Professions, social inclusion and citizenship.
Knowledge, Work and Society 4(1): 9–20.
Sandefur RL and Smyth AC (2011) Access across America.
Chicago: American Bar Foundation.
Stanfield PS, Hui YH and Cross N (2011) Introduction
to the Health Professions, 6th edn. Burlington, MA:
Jones and Bartlett Learning.
Turner BS (1995) Medical Power and Social Knowledge,
2nd edn. London: Sage.
Wallis R and Morley P (eds) (1976) Marginal Medicine.
London: Peter Owen.
Wardwell WI (1952) A marginal professional role: The
chiropractor. Social Forces 30: 339–48.
Mike Saks is International Research Professor at University Campus Suffolk (UCS) in Ipswich,
UK – having previously been Provost and Chief Executive at UCS, Deputy Vice Chancellor at
the University of Lincoln and Dean of the Faculty of Health and Community Studies at De
Montfort University, UK. He holds Visiting Chairs at the University of Essex and the University
of Lincoln and is the former President (and now Vice-President) of the International
Sociological Research Committee (RC52) on Professional Groups. He has published over a
dozen books on health care and the professions and has been a policy adviser in these areas to
government and professional bodies. [email: [email protected]]
9
Professions, marginality, inequalities
Saks
résumé Les idéologies professionnelles, lorsqu’elles relèvent des missions de service public, prônent
généralement le combat des inégalités parmi les usagers à titre individuel et/ou sein de la population. Les
sociologues des professions dans le contexte anglo-américain se sont penchés sur la question de savoir
dans quelle mesure cet engagement est honoré. Cette contribution offre toutefois une revue de la
littérature sur les inégalités entre les groupes professionnels dans une perspective néo-Wébérienne, en
ayant recours au concept de marginalité et se focalisant sur le secteur de la santé. En faisant
spécifiquement référence au cas de la médecine complémentaire et alternative, on souligne que la
recherche future doit se centrer davantage sur la façon dont cela se répercute sur les inégalités en dehors
des catégories socioprofessionnelles.
mots-clés inégalités ◆ marginalité ◆ médecine complémentaire et alternative ◆ néo-Wébérianisme ◆
professions ◆ santé
resumen Las ideologías profesionales vinculadas con el ejercicio de funciones de servicio público
abogan por el combate de las desigualdades entre los usuarios a título individual y/o el público en general.
Los sociólogos de las profesiones en el contexto anglo-americano han analizado hasta qué punto se verifica
este compromiso. Esta contribución brinda no obstante una revisión de la literatura sobre las
desigualdades entre los grupos profesionales desde una perspectiva neo-weberiana, apelando al concepto
de marginalidad y centrándose en el sector de la salud. Haciendo particular referencia al caso de la
medicina complementaria y alternativa, se destaca que la investigación futura deberá focalizarse sobre
todo en la manera que esto influye sobre las desigualdades al margen de las categorías socio-ocupacionales.
palabras clave desigualdades ◆ marginalidad
weberianismo ◆ profesiones ◆ salud
◆
10
medicina complementaria y alternativa
◆
neo-