Freidson recognised that it is a privilege particular to professions that they are able to make a living while controlling their own work and that this privilege cannot exist if the tasks that they perform and the knowledge they use to perform them are not so specialised and important that they are unable to be regulated by anyone other than themselves.130 He examined the process of acquiring power that went beyond the acquisition of specialised knowledge alone. He considered the relationship between professions and the law, including the mechanism of self-regulation; the interrelationships between the provision of occupational credentials and the accreditation of educational programs; professional- product standards; and the authority granted to doctors to provide public and private benefits to clients based on professional discretionary judgement (e.g., certifying people as eligible for sick leave). He demonstrated how different professions were able to gain their protected positions within society via these legal processes.131 He noted that legal protection from economic and political pressure was afforded to ‘professions’ like medicine, law and dentistry. The law provided legal protection from other occupations encroaching on the domain of the professions and it stopped the professions from encroaching on one another.132 He noted that this legal protection came from the implementation of statutory requirements relevant to the practice of the profession including licensing, certification, accreditation and credentialing. Those laws still have the effect not only of protecting the group from unwanted members and the power to establish their own standards of conduct and competence, but also protecting their independence to judge, criticise or refuse ‘employers, patrons and the laws of the state’ on the grounds that they do not conform to a fundamental value or purpose of the discipline.133
Larson, and later Andrew Abbott,134 suggested that a profession can use what it knows (its system of abstract knowledge) and what it does (its labour practices)135 to acquire legal
130 Eliot Freidson, Professionalism: The Third Logic (Polity Press, 2001) 17.
131 Eliot Freidson, Professional Powers. The Study of the Institutionalization of Formal Knowledge
(University of Chicago Press, 1986).
132 Eliot Freidson, ‘The Reorganization of the Professions by Regulation’ (1983) 7(2/3) Law and Human
Behavior, 279–290.
133 Eliot Freidson, Professionalism: The Third Logic (Polity Press, 2001) 221.
134 Andrew Abbott, The System of Professions: An Essay on the Division of Expert Labor (University of
Chicago Press, 1988).
rights that enable the profession to pursue, develop and maintain the closure of that group from outsiders (monopoly protection) for the purpose of maintaining the occupational self- interest—in terms of their salary, status and power—of each practitioner within that group.136
This notion of the law and professional power was examined by Australian sociologist, Evan Willis. Willis examined the relationship between professional power and the law by examining the Australian medical profession in the late 1980s. He identified that at that time, the medical profession maintained control over the division of labour in the healthcare sector because medicine controlled not only its own work, but the work of other health groups and the broader health sector, including policy and law makers.137 He referred to this power as ‘medical dominance’. Building on Freidson’s work,138 Willis made particular note of the fact that it was the state that granted doctors this monopoly by passing legislation that protected them from competition. He argued that any attempt to limit the dominance of medicine in the healthcare workforce was rebuffed by medicine, which utilised its professional associations to make appeals to society’s dependence on their expert knowledge—including the use of modern medical technology—and appeals to moral authority on the basis that the profession always acted in the public interest by relying on a set of universal norms. He argued that this ideology was used to legitimise medicine’s claim to authority over patients but also over other health workers.
In 1994 Willis argued that the power of the medical profession had three core elements that were critical for any occupational group aspiring to acquire the professional power of medicine: autonomy (that they are not under the direction or control of another occupation); authority (the power to direct other health workers); and medical sovereignty (doctors are considered the experts on health-related matters).139
136 Magali Sarfatti Larson, The Rise of Professionalism: A Sociological Analysis (University of California
Press, 1978); Andrew Abbott, The System of Professions: An Essay on the Division of Expert Labor
(University of Chicago Press, 1988).
137 Evan Willis, Medical Dominance (Allen & Unwin, 1983).
138 Eliot Freidson, ProfessionalDominance: The Social Structure of Medical Care (Transaction Publishers,
1970).
139 Evan Willis, Medical Dominance (Allen & Unwin, 1983); Evan Willis, Illness and Social Relations
Ellen Annandale140 critiqued the notion of medical dominance further and found that only some doctors become dominant, as do only some nurses. She noted that governments (as law makers) can and do challenge these professions in response to political, economic, cultural and social demands for change, which means that although professional privileges like ‘market shelters’141 or monopolies as Larson referred to them, could be provided by the law, they could also be removed. There was no discussion of the particular circumstances in which this might happen, but medical scandals and a shortage of healthcare workforce resources are two examples that have since arisen that have led to structural and legislative reform that supports Annandale’s position.142
The structural changes in the Australian healthcare landscape that began around this time included the shift of nursing training from the ‘following doctor’s orders’, vocation-based hospital training that nurses had historically undertaken, to critical thinking, autonomous professional training in universities and a decade later to civil liability legislation. This has resulted in a slow but significant lessening of medicine’s professional dominance in Australia.143
The work of Wilensky, Freidson, Larson, Abbott and Willis identified that there appears to be a typical pathway or process that is followed for an occupational group to gain professional status and that this process intersects with the acquisition of a number of common characteristics. For example, the acquisition of a monopoly over work is often attained via the law but political power gained through sovereignty over work and specialist knowledge associated with work is required to lobby for those legal changes. However, Annandale acknowledged that those legal changes can materialise in response to other factors including political imperatives. In the case of the professionalisation of health professionals in Australia, the issue of public interest in public safety and economic factors drove the political imperative to reform healthcare workforce legislation in Australia. This is discussed further in Chapter 5. Despite the suggestion that the professions serve
140 Ellen Annandale, The Sociology of Health and Medicine: A Critical Introduction (Wiley, 1998).
141 Eliot Freidson, ‘Occupational Autonomy and Labor Market Shelters’ in Phyllis Steward and Muriel
Cantor (eds), Varieties of Work (Sage, 1982) cited in Julia Evetts ‘Trust and Professionalism: Challenges
and Occupational Changes’ (2006) 54 Current Sociology 515.
142 See, for example, the ‘scandals’ associated with legislative reform in Australia.
143 A PC inquiry into Australia’s healthcare workforce in 2005 highlighted the effect and inefficiencies of
maintaining medical dominance. These were addressed by Nicola Roxon when she was appointed as health minister in 2007. This are discussed in more detail in this thesis in later chapters.
predominately their own interests before the public’s interest, the professions remain a particular group of workers in society. Freidson was curious as to why.