by Peter Morrell
Professionalisation
We can define a profession as an occupation
which has gained certain important and characteristic features. These are that it has
developed its own body of theoretical knowledge and expertise; established associations to
identify and clarify, secure and represent its membersĺ interests; opened training schools
to provide standardised education, training and qualifications; gained state recognition for
its claim to professional status; adopted strategies to gain occupational and market control
of its skills, services and personnel; established demarcation or closure from competing or
adjacent occupations; gained independence, a form of autonomy (self-control), and obtained
security in its line of work. Professions may be self-controlled, seek control from the
State, or end up with a mixture of both.
Ĺ…the normative dimension covers the service orientation of
professionals, and their distinctive ethics, which justify the privilege of
self-regulation granted them by society; the evaluative dimension implicitly compares
professionals to other occupations, underscoring the professionsĺ singular
characteristics of autonomy and prestige.ĺ [Larson, 1977, x]In the study of professions, Freidson
focused mainly upon exploring the methods professions adopt to achieve occupational autonomy
and freedom from restrictive intervention [Spero, pp.283-5], while Johnson, among others,
has described some of the economic and political aspects of professional power [Spero,
pp.286 & 292; Johnson, 1972].
It is important to remember that all
professions, like Law, Medicine, Dentistry, Pharmacy, etc. started out as unregulated
occupations which gradually, often turbulently, went through a similar process. Lay
homeopathy today is merely going through a process that medicine itself went through in the
1840-60 period. There is no occupation that automatically or naturally has conferred upon it
the high status of a profession. It must work at it and go through the professionalisation
process in order for it to become so elevated.To distinguish it from a mere occupation, a
profession tends to contain certain features which were largely absent from medicine until
1858 in England. These features include:* high status;
* unified teaching facilities, qualifications and registration
procedures which contrive to restrict entry to the profession* challenging entry requirements;
* a code of ethics which regulates membersĺ conduct;
* Ĺoccupational closureĺ: systems which bar entry to the
unqualified.* self-regulation or autonomy;
* highly rewarding and technical skilled work;
* a generally high income;
* membership, licentiateship, associateship of or registration with
prestigious professional bodies which regulate the profession.However, the 2 key features of a profession
which seem to stand out from all the rest, at least to me, are exclusive entry only through
holding the correct qualifications and self-regulation. It is this exclusivity and
self-regulation that seem to demarcate a true or fully-fledged profession from a mere
occupation. The occupation now becomes closed to all except the suitably qualified, there is
no longer any place within it for the unqualified amateur. Self-regulation means that the
people within the profession control their own boards of ethics and education. Boards of
control are composed of members of the profession itself. This applies to established
professions like dentistry, opticians, pharmacy, medicine, accountancy, etc. All professions
are regulated in this way.In exchange for these privileges, members
of a profession must abide by certain rules, regulations and codes of conduct, all of which
tend to legally restrict the members. Some of these rules may be legally binding and are
therefore mandatory, while others are merely voluntary. Failure to comply with such
regulations leads to stigmatisation [ostracisation] by other members of the profession or
even disciplinary action by the professional body which can, ultimately, lead to expulsion,
perhaps permanently, from the profession and thus inability to practice ever again. This
particularly applies to doctors, dentists, solicitors, accountants and architects where the
privileged status of their job opens them to the temptation of some forms of abuse of their
position, through misdemeanours like improper conduct, financial gain, abuse and
exploitation of clients, etc.
The Professionalisation Process
Based upon the above definition of
profession, professionalisation can be defined as the process whereby occupations become
professions.
‘Professionalisation has been described as an historical process in
industrialising countries, whereby one professional group organises itself as an
autonomous body, especially with a standardised training which it controls itself and
often with a certain group consciousness including professional interests. Its aim is to
distinguish itself from other groups and to keep non-professionals socially at a
distance.’ [Dinges, in Juette Risse and Woodward, 1998, p.173]As
implied earlier, the process tends towards greater and greater reliance upon qualifications,
training and the setting up of statutory bodies to oversee and regulate the profession. Such
bodies preside over a wide range of issues pertinent to the profession and make decisions
about standards and educational aspects of training, registration procedures, codes of
conduct for members, dismissal of members for misconduct, etc. An occupation becomes a
profession by this process of demarcation which separates the registered and
legitimate members [a credentialised elite] from the unregistered and unqualified
proletariat.
Ĺ..the distinction between an occupation and a profession is not
something that simply and naturally Ĺoccursĺ. The process…is usually contentious…a
profession is a group with control over its members and a degree of autonomy in
determining its own modes of training and criteria for membership, it claims a certain
kind of power and that power may not be accorded easily.ĺ [Sharma, 1992, p.116]The
professionalisation process seems to be largely ‘market-driven’ in the sense that it is
through competition between providers within the occupational market-place that a ‘natural
sorting’ of providers into ‘good’ and ‘poor’, in terms of the service they offer to clients,
i.e. their competence, begins to emerge. This in turn creates a need for some kind of
professional body through which the client can judge the relative skill and value of a
potential provider. Membership of the professional body thus confers upon the provider a
kudos and status that is easily perceived by the client and thus the client, being reassured
by this, chooses the services of a ‘qualified’ provider rather than an unqualified one [i.e.
a non-member of the professional body].
ĹProfessions lay claim not only to a special ethical orientation but
to a special expertise. In doing so they run the risk that a gap may open between what the
professional claims and what it can actually deliver.ĺ [Sharma, 1992, p.115]We
can identify four phases of this process. Professionalisation begins with a laissez-faire
situation in which no-one within the occupation is necessarily superior to anyone else and
work proceeds based mainly upon recommendations between clients. This is a Ĺlevel
playingfield’ situation in which all providers appear to their clients as homogeneous in
quality and worth. The client is unable to discern the good from the bad, or maybe the need
for this sort of discernment has not arisen.In the second phase, controlling bodies
arise on meritocratic grounds, in order to sort the good from the bad providers, in order
for clients to identify the good providers so that the client can judge, without prior
payment, which providers are better than others, regardless of fee. Professional regulation
or Ĺcontrol’ does not begin as the sole function of a controlling body, it also arises as
a device by which the client can appraise the worth of a provider among many who are
offering their services within the same market-place. In effect it is a labelling method
which strives to identify those Ĺbetter’ providers from the less worthy unqualified ones.
ĹThe non-registered and unqualified [dentists] therefore formed their
own associations, thereby creating an additional division in the profession.ĺ [Spero,
1985, p.272]The need for a controlling body also arises
from the market-place situation, as it is from the volume of work in an expanding
market-place that differences in quality of service between providers first emerge. This in
turn elicits greater discernment on the part of the clients. In this phase the more numerous
Ĺunqualifiedĺ are tolerated and only appear as slightly subordinate to the qualified.
Registration with professional bodies in this phase, is thus entirely optional.
ĹAmerican dentists still do not have the equivalent of a
self-regulating body as have the dentists in England and France.ĺ [Spero, 1985, p.275]The regulating Ĺfeedbackĺ influence of
Ĺclient powerĺ in the development of a profession is also discussed in Johnson [1972,
pp.77-86]. It is an important moulding force, which subtly fine-tunes the profession by
reminding them of the interests of their clients. Ultimately, members of a profession must
please their clientele or pretty soon they will have none. This blunt truth feeds back to
temper the arrogant and monopolistic tendencies of all professions.However, once a controlling body has
emerged, it rapidly acquires considerable power of its own. This power derives chiefly from
its ability to differentiate the good from the poor providers, from the viewpoint of the
clients. Those providers who pass examinations, gain certificates and letters after their
name are considered by clients to be superior to those who cannot [or will not] or those who
have not passed such examinations, gained certificates, etc. Thus membership of the
controlling body takes on a status of great importance for the clients, but also for the
providers.
ĹProfessions have little control over the demand for their services,
but they can assay control over the supply side through restricting access [to the
profession]. Raising the level of educational qualification necessary for entry into
training or prolonging the training itself are strategies which have the added advantage of
enhancing the credibility of the groupĺs claims to esteem and expertise…ĺ [Sharma,
1992, p.117]Prolonging
the training period also has the added advantage of allowing sufficient time to thoroughly
inculcate the Ĺoccupational normsĺ of the profession [Johnson, 1972, p.55] This has the
effect of creating cohesion of identity and roles amongst its members [Johnson, 1972, p.56]
as well as being connected to the size of the eventual financial rewards conferred [ibid.,
p.59].Thus a situation soon develops in which the
market becomes dominated by the qualified, and the unqualified diminish numerically
and become marginalised. All providers then wish to become qualified in order to get
work, make a living and serve their clients. Without the qualification they appear to the
clients [and to their own kind] of being unqualified, lower status, unworthy and inferior
amateurs. Thus those practitioners who possess qualifications tend to take over any further
control or development of the profession, while the unqualified largely relinquish any right
of consultation about its future.
Ĺ…non-medically qualified dentists were excluded from holding
teaching posts in the hospitals and universities…the dental profession remained open
until 1921.ĺ [Spero, 1985, p.271]In this third phase of the process there is
a large gap opening up between the qualified and the unqualified. The latter are more
marginalised and stigmatised than tolerated [as they were in phase 2] and are certainly of
secondary importance to the registered.
Ĺ…the layperson does not share the specialised knowledge used by
the professional. Most modern societies tend to treat professional interpretations as
vastly superior to lay understandings. Medical professionals tend to demean lay
conceptions, often labelling them as superstition, ignorance, foolishness…ĺ [Freund
and McGuire, 1995, p.170]
The last phase of the process is marked by occupational
closure, i.e. the emergence of a profession entirely dominated by the qualified and
regulated by a controlling body derived therefrom. This phase goes further than just
marginalising the unqualified, they become outlawed altogether. Membership of the
professional body, which becomes a statutory prerequisite for entry to the profession, is
allowed only upon production of the appropriate qualifications [or apprenticeship] from an
approved or designated institution and thus the total control of entry to the profession
becomes effected. The right to practice becomes enshrined in law and the non-qualified are
disbarred from entry to the profession. At this point also, regulation of the profession is
conducted, in whole or in part, or at least overseen by the State.
‘Prior to 1942 the French dental profession was like all other
professions, controlled by the state…from the evidence it appears that the profession
never wanted it to be otherwise. It seemed appropriate for the state to control the
professions in order to inhibit and contain any tendencies to monopoly power.’ [Spero, 1985,
p.293]
The controlling body also takes on the
important function of policing disputes between providers or between provider and client.
The issue of good and bad service, ethical control of the profession and the implementation
of a code of practice for members also become urgent aspects of the professional body. The
professional body acts to identify and protect all the interests of its members, and thus to
regulate the profession generally, deal with dissemination of information and act in a
consultative capacity both with the public and with government bodies or ministers.
Professionalisation in Medicine
Medicine is frequently held up as a
classical example of a profession and of the professionalisation process. This is because it
was one of the earliest to undergo this process.
ĹThe orthodox medical profession took time to grow from an association
of several professions, each formerly having its own separate institutions and
interests…[it may not be]…realistic to expect the non-orthodox professions to achieve
the same degree of unity in a shorter space of time…ĺ [Sharma, 1992, p.215]
Throughout the 1840s and 1850s due to
long-standing disputes, the different professional bodies for surgeons and physicians were
jockeying for position, due in large part to entrenched mutual encroachment and
poorly-defined roles and identities. These conflicts were eventually resolved in the 1858
Medical Act, which Ĺcreated a high degree of unity in the profession.ĺ [Wallis
and Morley, 1976, p.12].
ĹThe pivotal 1858 Medical Registration Act sealed the process of
professional closure and set up a single register of legally recognised practitioners with
self-regulatory powers and a monopoly over not only the title of Ĺdoctorĺ, but also
state medical employment.ĺ [Saks, 1992, p.5]
The true regulation of the profession stems
from that date.
ĹAlthough allopathy is only one approach to doctoring…its has
attained a virtual monopoly of medical education, licensing, and practice in the United
States and Canada. It is also the dominant form of medicine practiced in most of Europe,
although some non-allopathic approaches have greater legitimacy and freedom there than in
north America.ĺ [Freund and McGuire, 1995, p.181]Ĺ…this legislation for the first time formally defined, in a
consolidated manner, the scope of alternative as well as orthodox medicine on a national
basis.ĺ [Saks, 1992, p.5]
Professionalisation in Alternative Medicine
Saks
makes the good point that defining what is alternative can be problematicv, especially in
the last century:
Ĺ…it was therefore difficult at this time to talk about a distinct
medical orthodoxy and hence to define what constituted alternative medicine, particularly
in an era in which a greater emphasis seems to have been placed on self-help…ĺ [Saks,
1992, p.5]
But
in modern times, the distinction between Ĺalternativeĺ and Ĺorthodoxĺ is much
clearer. Until recently nearly all alternative therapies were in early phases, in which
anyone could set up in practice. This was not true of herbalists and osteopaths, who had
professional bodies [National Institute of Medical Herbalists [NIMH] and the British
Osteopathic Association [BOA], formerly the British Naturopathic and Osteopathic Association
[BNOA] which were set up in the first half of this century.
Acupuncture was one of the earlier natural
therapies to set up a series of professional bodies, training schools and qualifications and
to regulate itself as a profession [see Inglis, 1964, pp.123-30]. In the 1930s Osteopaths
attempted to gain accreditation through Parliament, but this was blocked by the medical
profession [Sharma, 1982, p.181; Inglis, 1964, pp.94-122; also Quen, 1975, pp.151-3; and
Saks, 1995, pp.121-3]. Herbalists also established themselves as a Ĺquasi-professionĺ
around the same time with the formation in 1927 of a Society of Herbalists [Griggs, 1981,
p.271; Inglis, 1964, pp.66-73].
At present, lay homeopathy and reflexology
show distinct signs of the professionalisation process [Sharma, 1992, pp.187-9]. Likewise
Bach Flower Therapy, whose centre in Oxfordshire now run a very popular training course and
have set up a register of approved practitioners.
Ĺ…from about the later 1970s…there was suddenly a proliferation
of Ĺlayĺ practitioners and colleges providing training for people without medical
qualifications.ĺ [Sharma, 1992, p.184]
This
fits in with my own impressions, but Saks places this revival much earlier:
Ĺ…there can be no doubt about the dramatic expansion of interest in
alternative approaches to health care in Britain since the early 1960s.ĺ [Saks, 1992,
p.8]Ĺ…there was a proliferation of practitioners with no medical
background from whom, on the whole, medical homeopaths tended to distance themselves. Lay
homeopaths on the other hand stressed their right to practise…ĺ [Sharma, 1992, p.184]
One of the chief reasons for alternative
therapies undergoing professionalisation is that some people may feel they are being
exploited or overcharged by therapists of dubious knowledge or ability. This suspicion comes
not only from the public but also from the ranks of conventional medicine, some of whom
accuse alternative medicine of becoming a ‘bandwagon’ upon which anyone can climb. It is
thus widely regarded as an unregulated free-for-all within which ‘anything goes’.
One of the chief aims of and justifications
for professionalisation within alternative medicine, therefore, would be to ‘clean it up’
and regulate it, purge it of any ‘cowboy element’. Thus there is currently a rush within all
these therapies to get qualified, to register, to enrol at a college, complete a course, get
letters after your name, and likewise there is a rush by therapists to set up codes of
practice, professional bodies, setting up colleges, setting and unifying teaching curricula,
etc.
ĹContemporary versions of naturopathy as well as homeopathy appear to
be increasingly used in the United States and Britain, perhaps as a result of
dissatisfaction with the dominant, allopathic medical system (Sharma, 1992; Taylor, 1984).ĺ
[Freund and McGuire, 1995, p.182]
Osteopaths and Acupuncturists have more
recently received legal status in the Osteopaths Act of 1993 and the Chiropractors Act of
1994. It is widely expected that lay homeopaths will eventually take the same route.
Professionalisation within Homeopathy
The question has often been asked why
someone should train in allopathy first before they can become a homeopath:
ĹThe other alternative would be to let the perquisites of
respectability go; establish independent training colleges, like the osteopaths’; and start
again at the bottom of the social ladder. A homeopathic medical school would not require a
wholly new curriculum…to some extent the allopathic case needs to be mastered even by
those students who are going to reject it; but this is not the same as insisting that a
student who wants to become a homeopath must first complete the full allopathic course. To
compel him to do so is as illogical as it would be to compel a judo trainee to complete a
full professional training as a boxer before he can begin to learn judo. The homeopath needs
to know quite a lot about allopathy, but he should not be required actually to qualify in a
method with which he is fundamentally in disagreement.’ [my emphasis, from Brian Inglis,
1964, p.93]
Since 1985 a process has been ongoing
within British homeopathy for it to attain a form of professional status and recognition
within medicine generally. This has taken the form of trying to gain accreditation for the
colleges and the courses of training which they offer and also to obtain degree status for
the courses [see Sharma, 1992, p.186]. There has also been a push to gain parity status
between homeopathic practitioners [professional homeopaths, as they prefer to be known] and
medical doctors who practise homeopathy. Those have been the main lines of development along
this front.
There is much talk currently within
homeopathy about the words ‘profession’ and ‘professional’ as opposed to ‘lay’ or
‘non-medically qualified practitioner’ [NMQP]. There is a good deal of confusion about the
meaning of these terms. It is true that lay and NMQP appear to many as pejorative terms in
the sense that they imply an underlying amateurness and lack of qualification for the job.
But the terms profession and professional are also less than clear. There is as yet only
limited restriction of entry [see Sharma, 1992, p.117].