Inequalities, Marginality and the Professions

This section is compiled by Frank M. Painter, D.C.
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FROM:   Current Sociology Review 2015;   63 (6):   850–868 ~ FULL TEXT


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Professional ideologies generally commit to addressing inequalities among clients and/or the public as part of their altruistic ethos. Sociologists of professions in the Anglo-American context have written on the extent to which this commitment is honoured by professional groups, either in a positive or more critical light. This article, however, argues that professions cannot be conceptualised as equal, homogeneous entities and are best seen as hierarchically differentiated groups based on varying forms of exclusionary social closure. As such, it reviews the literature on inequalities between professional groups from a neo-Weberian approach – which is favoured over other perspectives – through the concept of marginality, primarily using the illustrative context of health care.

With particular reference to the case of complementary and alternative medicine, the article highlights that future research needs to focus more on how positions of marginality influence inequalities beyond the professions – in other words, on how inequalities within professions affect inequalities without.

KEYWORDS:   Complementary and alternative medicine, health, inequalities, marginality, professions

From the FULL TEXT Article:


Professions have become a key part of the occupational structure in the social stratification system of the modern western world, with a mission typically expressed in their altruistic ideologies of serving 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 lawyers and teachers – in addressing inequalities among client groups and the wider public. This is illustrated by longstanding work in Britain and the United States both generally [see, for example, Krause, 1971; Macdonald, 1995] and in specific fields [see, for example, Fine et al., 1979; Navarro, 1986]. It is also apparent in more recent work on professions on enhancing social inclusion and citizenship covering dimensions such as social class, ethnicity and gender [as exemplified by Matthies et al., 2000; Saks and Kuhlmann, 2006].

This article, 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 characterised by the greatest degree of self-regulatory autonomy [Collins, 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 usually 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 specific 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 marginalised professions that are located at the contested and unstable peripheries of longer established professions [Butler et al., 2012].

With illustrations drawn from health care, it is noted that such 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, in which the relational forms of regulation of particular professions and their wider implications are considered, 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]. As such, professionalisation can be viewed as a strategy to limit and control the number of entrants to preserve or increase the market value of an occupation [Parkin, 1979]. This said, professions are conceptualised in various ways related to exclusionary closure in the contemporary neo-Weberian literature – from having direct market control of services through self-governing associations [Parry and Parry, 1976] to possessing in a derivative manner control by the producer over the consumer including the manner in which their needs are to be addressed [Johnson, 1972] and legitimate occupational independence over technical decisions and the organisation of work [Freidson, 2001]. Most importantly, though, in this context, the professions can be seen to be centred in practice on different forms of legally underpinned exclusionary social closure in particular societal contexts [as highlighted comparatively by Moran, 1999; Moran and Wood, 1993].

Thus, 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 characterises professions such as medicine in Britain, compared to the more prevalent de jure monopolies in the United States, related to different socio-historical 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 neo-Weberian 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 Svensson, 2010]. Moreover, all of these different patterns of regulation have potential implications for the way professions operate as regards both client groups and the broader public because of the different conjunction of interests that they generate – in terms of the balance of objective benefits and costs to professional groups and sub-groups thereof in specific decision making 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, 2013]. Other professions variously lie beneath these groups in a pecking order resulting from legally embedded patterns of referral and oversight arrangements in relation to top tier professional groups – which are also reflected in differential financial and related rewards. The position of some middle and lower order professions has been conceptualised in neo-Weberian work as ‘dual closure’. Here 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 by the working class [Parkin, 1979]. Some other occupations, moreover, have not gained full legally enshrined social closure and are in the process of professionalising – and may be governed by voluntary rather than statutory regulation which further reduces their ranking [Saks, 2003a]. It should also be stressed in setting out the regulatory inequalities between professional and proto-professional groups that the inter-relationship between professions is not static, but shifts over time [Abbott, 1988].

In terms of social theory it should be observed too that the neo-Weberian approach to the professions adopted here has not stood above criticism. It has been variously criticised 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, neo-Weberianism stands in a common stream with interactionism [see, for example, Becker, 1962; Hughes, 1963], Marxism [see, for example, Carchedi, 1975; Esland, 1980] and Foucauldianism [as illustrated by Foucault, 1979; 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 as agents of the dominant class and their part in the not always progressive process of governmentality. The main distinction, however, is that the neo-Weberian approach – with its focus on exclusionary closure as the touchstone of professionalism – lends itself more strongly to analysing 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 contemporary perspectives on professions, neo-Weberianism also differs markedly from the largely deferential taxonomic approaches which were very much in vogue in earlier years that painted a much more positive picture of professions [Millerson, 1964]. In the trait variant of the taxonomic approach professional groups are defined as being based on features such as high levels of expertise and rationality [see, for example, Greenwood, 1957; Wilensky, 1964] – and even as serving as bulwarks of democracy [Lewis and Maud, 1952]. This analysis is particularly developed in more theoretically sophisticated 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 socio-economic position in exchange for using this knowledge to public benefit [see, for example, Barber, 1963; Goode, 1960]. The functionalist variant of the taxonomic approach outlined here is also employed to explain inequalities between the professions. This is best illustrated by the analysis of Etzioni [1969], who differentiates what he categorises as ‘semi-professions’ like social work and teaching from more fully fledged professions, on account of the weaker development of professional characteristics like expertise and altruism. He contentiously sees this apparent relative weakness as necessarily limiting the position of these groups in the hierarchical social stratification system [Saks, 2012].

As such, the trait and functionalist approach clearly departs from the earlier neo- Weberian work of Johnson [1972], who views the lofty position attained by medicine and law in the professional pecking order in terms of power and interest. He is consequently highly sceptical of the claims of such elite professions, which are duly reinforced by taxonomic writers, to serve the public interest – not least in terms of tackling social inequalities. Here he queries, for example, the extent to which lawyers’ interests allow them satisfactorily to represent those who seek radical change to the existing order. He also notes that the services of practising lawyers are not equally relevant to all citizens and are actually very unequally distributed between classes and status groups. Although there is some evidence of an increasing public interest orientation being exhibited by the legal profession through such mechanisms as the pro bono work undertaken by practitioners [see, for example, Granfield and Mather, 2009; Paterson, 2012], little seems to have changed in terms of access to legal services according to geographical location, as well as by low income, disabled, elderly and ethnic minority groups. Here there are still substantial differences in provision despite the existence of legal aid schemes, to judge by recent reports from Britain and the United States [Robins, 2011; Sandefur and Smyth, 2011]. This is therefore an antidote to the professional ideologies that trait and functionalist writers have been accused of reflexively mirroring as ‘dupes’ of the professions by building such positive features of professional groups into the very definition of their operation [Roth, 1974].

Johnson [1972] also provides an alternative perspective on middle and lower ranking professional groups, suggesting 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 as regards their ability to relate warmly to clients, he notes that:

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: 35–36]

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 social inequalities. Not least of these from a neo-Weberian perspective is how far the limits on both the scope of practice 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 in the health field to highlight inequalities among professional groups and their potential significance for exacerbating or otherwise divisions in the stratified societies in which they operate.

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 internal inequalities – such as in the hierarchical divide between specialists and generalists in medicine as a profession. In recent times there has been restratification within the medical profession in Britain with general practitioners gaining ground on hospital specialists as they have increased their authority over funding with the growing emphasis on primary care within the state health care system [Calnan and Gabe, 2009]. But traditionally in Britain and even more pervasively today in the United States the ever expanding number of specialists have held sway within medicine – as increasingly have specialist groups in nursing and other less illustrious health professions [Saks, 2003a]. In medicine in fact there are also hierarchies in terms of income, status and power between specific specialisms, which are more or less highly ranked in the pecking order. In Britain consultants in specialist fields like cardiology and neurosurgery are at the top of the medical stratification order, while practitioners in Cinderella areas such as geriatrics and mental health lie in the lower reaches of medicine as a profession [Klein, 2013]. In the United States meanwhile a similar hierarchy prevails in an even more variegated specialist arena, in which generalists have formed an increasing minority of medical practitioners, in more marketised socio-political conditions [Weisz, 2006].

In addition, in medicine in Britain and the United States at a macro level there can be seen to be an elite group driving the profession which has meant that there are internal divisions in relation to grassroots practitioners, notwithstanding the existence of formal democratic structures underpinned by elections. In Britain this elite includes the leaders of the British Medical Association and the Royal Colleges – particularly the Royal College of Physicians and Royal College of Surgeons – while in the United States there is a parallel distinction between the leaders of the American Medical Association and the rank and file. Even in the United States, though, where the profession has arguably been deprofessionalised to some degree in recent years by such factors as growing corporatisation in a more privatised economy [see, for example, McClelland, 2014], these elites predominantly define and uphold the mainstream scientific practice of orthodox biomedicine through the management of curricula, career structures, research funding, journal entries and other means [Saks, 2015a]. However, the focus here is on the relationship between, rather than within, professions and – despite various other challenges to professional power, not least from the state and users of services – the medical profession as a whole in Britain and the United States still stands in a dominant position in orthodox health care [Ham, 2009; Stanfield et al., 2011].

In this respect, in terms of the analysis of inequalities, there has been a recent resurgence of interest in examining the position of marginal professions in the division of labour, particularly in the health field [see, for example, Saks, 2008] – after an intensive focus by sociologists on studying medicine as a classic profession [see, for example, Collyer, 2012]. This has built on historic roots including the early pioneering analysis by Wardwell [1952] of the role strains of chiropractic and its subsequent social adjustment as a marginal profession – at a stage when some of its exponents were being jailed for practising in various parts of the United States. In this context, the categories of ‘marginalised professions’ and ‘marginal professions’ have since been more precisely defined in the literature [Saks, 2014], which helps to conceptualise the relationship with dominant professions and underline the position of other professional groups in the pecking order. As such, ‘marginalised professions’ have a less well accepted position within orthodox ranks, which is typically reflected in different levels of income, status and power, but still have official standing through forms of legally enshrined exclusionary social closure. ‘Marginal professions’ in contrast are professionally-aspiring occupations typically operating in a more precarious situation outside the legitimated state-supported orthodox division of labour.

The associated inequalities between professions are at their greatest in relation to the position of ‘top dog’ professional groups as regards both these categories. Although there may be benefits in the existing health care division of labour, it is argued here that such professional hierarchies provide strong potential for generating, or at least exacerbating, challenging issues for clients and the wider public – including most centrally the creation of inequalities without driven by inequalities within. In terms of negative consequences, at one level marginality may affect the degree to which inter-professional collaboration is able to take place from the viewpoint of joined up care between dominant and marginalised professional groups in health and related spheres [Reeves et al., 2010]. Marginality may also adversely affect cooperation in the interests of the client between such orthodox professional groups and those practising in marginal professions – who may be stigmatised and isolated from the mainstream, as well as imperilled [Butler et al., 2012]. More substantively as regards this article, though, inequalities in particular health fields may result based on factors ranging from the patterns of geographical dispersal of practitioners to their nature, sufficiency and affordability. At this point it may be helpful to outline further the nature of ‘marginalised professions’ and ‘marginal professions’ in the context of the broader health system.

The category of ‘marginalised professions’ maps well on to the hierarchical classification of health professions set out in the work of Turner [1995], to which reference is often made. For him, the ‘dominant’ profession of medicine lies at the pinnacle of the hierarchy of health professions in modern western societies. Although there may have been subsequent shifts in the boundaries delineating its position in the changing socio-political climate – as exemplified by the relative autonomy of midwives in some international contexts [see, for example, Borsay and Hunter, 2012; Bourgeault et al., 2004] – he distinguishes two relevant types of health professions. The first is ‘limited’ health professions such as pharmacists, dentists and opticians whose practice is legally restricted to specific therapeutic methods or particular parts of the body, which are contained within their own boundaries. The second category is that of ‘subordinated’ health professions like nurses, physiotherapists and radiographers who take on sub-delegated tasks from doctors in the orthodox division of labour. Despite their lower positions in the pecking order compared to physicians, marginalised health professions have nonetheless gained through professionalisation official legal recognition and legitimation as well as associated benefits, including protection of title linked to enhanced income, status and power [see, for example, Allsop and Saks, 2002; Cockerham, 2012].

This separates the broad spectrum of orthodox health professions from the category of ‘marginal professions’ which mainly lie outside state-endorsed frameworks and their concomitant rewards. These occupations 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 certain groups of practitioners of complementary and alternative medicine (CAM) who are engaged in professionalisation either by forming voluntary associations as an initial stage in the process or by directly seeking statutory underwriting of their claims [Saks, 2003a]. Although not all CAM practitioners have valued the professional route because of its threat to their values, including their organisational independence [see, for example, Saks, 2001], they are a key exemplar of marginal professions and will be analysed in more detail in the case study that follows. In addition, it should be noted that health support workers form an important parallel example of marginal professions [Saks, 2008], particularly with international pressures imposed by cost containment and dealing with the increasing amount of home care for the growing number of elderly suffering from long-term conditions [Blank and Burau, 2010]. Among the very large cluster of health support workers are groups striving to professionalise – such as the instance of operating theatre practitioners who recently successfully took this step in Britain [Saks and Allsop, 2007].

This categorisation and the hierarchal ordering of professions in the contemporary western world becomes more politically charged if the position of marginal or marginalised 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’ utilisation 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, among other things, through the 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 central 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 marginalised or marginal professions in terms of the unequal hierarchy of health professions under the current hegemony of medicine is inevitably fluid – and, irrespective of competing knowledge claims, needs to be analysed in neo-Weberian terms from the standpoint of the interplay of power and interests in the market [Saks, 2014].

It was after all little more than a century and a half since doctors themselves first became professionalised and assumed their position of dominance in the Anglo-American context [Starr, 1982; Waddington, 1984]. Such professionalisation occurred in the midnineteenth century in Britain and the early twentieth century in the United States – and it was even later when nursing and other allied health professions emerged as marginalised 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 – from the forerunners of modern physicians to fairground hucksters [Janik, 2014] – competed in the market on a relatively level playing field with little regulation and without any group possessing the monopolistic state underwriting that now exists for professions. As such, these earlier practitioners were both formally and substantively very difficult to distinguish in terms of their education and training, theories, practice and repute [Porter, 1995]. Those involved in this earlier, more pluralistic, marketplace included therapists like herbalists and homeopaths who have since become cast in a marginal role as exponents of CAM [Cant and Sharma, 1999]. This leads on to the consideration of the position of CAM, which has in the last few decades been one of the most controversial areas in the sociology of professions from the viewpoint of inequalities related to health professional groups in Britain and the United States.

Certainly the greatest number of those in marginal health professions who far outstrip the numbers of doctors are CAM practitioners, who are by no means fully professionalised [Saks, 2008]. In terms of the inequalities between professions, it should be noted that CAM is defined here in relation not to the intrinsic characteristics of the practices involved, but rather to its position of being largely excluded from the orthodox health care division of labour legitimated by the state and based on an increasingly unified biomedical paradigm primarily involving drugs and surgery [Saks, 2015b]. CAM is defined in this way because it encompasses such a great diversity of practices in the Anglo- American context, from aromatherapy and acupuncture to naturopathy and osteopathy. In this regard, 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 now turns to examine the literature surrounding the CAM case study in the Anglo-American context.

Case study: Complementary and alternative medicine

      The development of professional marginality

As Saks [2003a] has documented, the professionally marginal area of CAM in the contemporary context has taken shape following a long history of attacks on it by medical orthodoxy on both sides of the Atlantic. In Britain and the United States, over many decades, medical elites have striven to reduce the credibility of CAM through, among other things, enforcing orthodox curricula control in medical schools, debunking the practices and practitioners of CAM in the medical journals, limiting access to official medical research funding, and instigating career blockages for those collaborating with unorthodox practitioners. In Britain, as in the United States, marginalisation therefore meant that the CAM therapies concerned lacked legitimation and were variously regarded as ‘charlatanism’, ‘cultism’ and ‘quackery’ – serving as potential threats to both individual clients and the wider public at the gendered periphery of the health system [Cant and Watts, 2012]. However, while CAM practitioners in Britain could normally practise under the Common Law without obtaining exclusionary closure backed by the state [Larkin, 1995], licensing was required in the United States [Freidson, 1994]. This changed the level of threat posed to medical interests by CAM practitioners with a competing knowledge base in the two societies and may help to explain why CAM was more readily and more rapidly incorporated into medical orthodoxy in the United States as compared to Britain [Saks, 2015b].

Despite such incorporationism, the odds were still stacked against CAM therapists in the pecking order for health professions, especially as the introduction of restrictive codes of ethics by the medical profession provided for disciplinary action inhibiting collaboration between physicians and CAM practitioners [Saks, 2005]. In Britain, moreover, laws were passed creating large-scale state shelters for orthodox health professions through the funding arrangements for medicine in the first half of the twentieth century, initially under the auspices of 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 cancer, diabetes, epilepsy and glaucoma [Larkin, 1995]. The consequence of this and similarly restrictive practices in relation to such areas as eligibility for financial support from health insurance schemes and hospital attendance rights for practitioners 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. Moreover, the mushrooming growth of a range of limited and subordinated practitioners in orthodox health care on both sides of the Atlantic served to reinforce the dominance of medicine [Saks, 1999].

Having said this, there was a resurgence of public interest in CAM both during and after the counter-culture of the 1960s and 1970s [Roszak, 1995]. 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 [Saks, 2003a]. Moreover, by the early years of the new millennium in Britain close to half of the population were employing CAM at some point in their lives [Posadzki et al., 2013], while in the United States almost two-fifths of adults used one or more forms of CAM each year – with some $34 billion spent on CAM, of which one-third was paid for visits to practitioners and two-thirds expended on self-care products [Nahin et al., 2009]. This striking rise in user demand has been 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 depersonalisation and disempowerment, and a search by consumers for greater control over their own health [Saks, 2000]. The upshot is that there has been increasing pressure 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, particularly in its less challenging complementary, rather than alternative, forms. In a scathing report the British Medical Association [1986] had initially dismissed ‘alternative therapy’ as being based on witchcraft and superstition and used by an ill-informed public, in face of the progressive march of scientific medicine. However, soon after it was prompted in a further report to reconceptualise CAM as ‘complementary medicine’ and to encourage its inclusion within the undergraduate medical curricula, while urging a relaxation on CAM relationships with unorthodox practitioners providing that they were overseen by doctors [British Medical Association, 1993]. This paralleled the earlier absorption into the orthodox medical fold of rival CAM groups like the osteopaths from the 1960s onwards on a state-by-state basis in the United States as alternative medicine moved more into the mainstream [Ruggie, 2004]. It also further promoted the practice of various forms of CAM by doctors, nurses and other health professions in the public and private sector – the employment of which was backed by political and associated lobbies in Britain and the United States, as well as by health professional bodies and government [see, for example, Cant and Sharma, 1999; Cohen, 1998].

The current position outside medical orthodoxy is that, while some CAM therapists prefer solo practice to becoming part of a collective profession, most CAM therapies have sought professionalisation. In Britain this has typically been as marginal professions without the statutory backing required for full exclusionary social closure [Saks, 2014]. 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, osteopathy and chiropractic [Saks, 2003a]. In this regard, there was earlier licensing for these CAM practices in the United States followed by the Osteopaths Act and the Chiropractors Act in Britain in the 1990s setting up a professional register and giving protection of title – and bringing them more into the realm of marginalised, not marginal, professions. Moreover, the British government is currently planning to set 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].

      The implications of professional marginality

This leads directly on to the consideration of the impact of the professional marginality of CAM. In terms of the implications of the inequalities between groups of professionalising and professionalised CAM practitioners and more orthodox health professions, the impact of CAM simply being a marginal profession without statutory regulation is particularly significant. Among other things, there is dramatically less public financial support and resourcing from third party funders in the private sector. Moreover, in terms of legitimacy, there is no state underwriting of the claims of practitioners or the nature and scope of their practice as there is no legal protection of title – despite attempts by some CAM practitioners to put in place voluntary regulation, including minimum training and qualification standards and ethical codes [Saks, 2006]. Indeed, in the United States the practice of CAM unless officially licensed is typically forbidden other than through selfhelp – as was the position in the past in many states for the chiropractors who, as a result of the lobbying of the American Medical Association, risked going to jail for their pains [Wardwell, 1992]. However, even for those CAM practitioners who have gained statutory licensing through the formal legislative process and have therefore become marginalised rather than marginal professions, there are still major disadvantages in the hierarchy of more orthodox health professions.

Although marginalised professional groups in CAM, like orthodox health professions, normally 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. 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 some CAM therapies qualify for reimbursement under Medicare, Medicaid and private health insurance schemes, together with the often strong restrictions on such areas as medical referrals in the licensing of 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 marginalised in the health care division of labour on both sides of the Atlantic, with generally negative consequences for the income, status and power of practitioners.

What, then, of the impact of inequalities between marginal and marginalised CAM professions and more orthodox health professions on inequalities without – namely, for clients and the wider public? There certainly seems to have been 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 for 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 adverse effects for lower class groups in light of their ability to pay [see, for example, Fitzpatrick, 2008; Hoffman, 2012]. In addition, there are issues for minority groups in relation to gender and ethnicity which should not be ignored given the concentration of white males in higher positions in the dominant health professions [see, for example, Annandale, 2000; Barr, 2014] – 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 have been in receipt of the greatest state support for their practice in Britain and the United States [Saks, 2003a].

The existence of such inequalities in access and availability are increasingly important as users of health care both individually and collectively have become ever more significant players in the market in health policy internationally [Banaszak-Holl et al., 2010; Tritter et al., 2010]. The specific issue of the inequalities associated with the marginal position of CAM has been systematically examined in an earlier study [Saks, 1995] in relation to the predominant rejection by the medical profession in Britain of acupuncture and the subsequent hierarchically structured position of medical practitioners and CAM exponents of this therapy over many decades. The study concludes after careful scrutiny that this has not been in the public interest when judged against the criterion of social justice in terms of the consequent unequal class and regional availability of this marginal therapy in both the state and private sector. In this respect, there are other value-based dimensions of the public interest in liberal democracies aside from egalitarianism – not least including liberty and the general welfare. Here it can be argued that the case of CAM may not be best served by such factors as the typically 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 CAM therapies are relatively ineffective [Saks, 2015a]. In this respect, Wallis and Morley [1976] argue from a functionalist perspective that CAM has been marginalised 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 seen as gateways to 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 to cataract and hip surgery [Le Fanu, 2011]. Nonetheless, while more systematic research into the effectiveness of CAM is undoubtedly required [Ernst et al., 2008], orthodox medicine in its much more substantially funded ongoing research agenda has arguably become rather too heavily fixated with randomised controlled trials. These do not readily fit many CAM therapies as evaluative tools and have not been applied pervasively to orthodox health care – accentuating the future 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 part of the explanation of the general medical resistance to CAM. There can in such instances be 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 less 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 to 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 inequalities generated through the marginalisation of CAM in health professional hierarchies. This is because, among other things, such practice is typically more restricted and usually based on much shorter and less intensive training as compared to that undertaken by non-orthodox CAM practitioners [Saks, 2003a].


In conclusion, the review of the literature undertaken here suggests that inequalities between the professions as illustrated in the case study of CAM – facilitated by the concepts of marginalised and marginal professions that have been outlined – seem to have had a substantial impact on access to services for users. This may exacerbate external inequalities based on geography, class, gender and ethnicity in both Britain and the United States. The significance of this can be underlined at a time when governments are more sensitive than ever to the principles of equality and diversity – where particular fears have arisen about the future of the state-funded National Health Service in Britain [Davis and Tallis, 2013] and the American government has introduced Obamacare to counter disconcertingly wide gaps in health insurance coverage [Starr, 2013].

It is therefore very important that political leaders are alive to the policy implications of the hierarchical professional structure of the workforce, including the impact of legally sanctioning relational forms of social closure in the health field and elsewhere. Yet to date the way in which such inequalities within the labour force can affect inequalities without has not been either greatly studied by sociologists or indeed fully taken into consideration by policy makers in relation to the professions.

The analysis of professionally engendered inequalities should now form a priority agenda for sociological research. In this respect, 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. This would be most apposite at present as much of the sociological literature to date has focused more on ‘top dog’ rather than middle and lower order professions and has not always followed the work of Weber and other classical social theorists in sufficiently considering the role of professional groups in the wider occupational division of labour [Saks, 2003b].

This is critical not only in terms of understanding the responsiveness of professions to clients, but also in relation to the broader public interest. Further work may also extend to the effects of inequalities within specific professional groups as highlighted at the outset of this article – which brings its own form of marginality. As this contribution indicates in highlighting the need for more 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 relationships on societal inequalities.


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.


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