PolyU-Hong Kong Community College

AD Scheme in Health Studies

CCN2040 Sociology for Health Studies
Lecture6-7 Medical Dominance and its Challenges
•What is “profession”?
•Different views of profession
•Medical dominance and Medical
autonomy
•Professionalisation
•Challenging medical professional
dominance:
Complimentary and Alternative
Medicine
Corporatization
McDonaldization
Deprofessionalization
 Functionalism: 4 Traits of Professionalism
Professionalism requires a body of systematic knowledge that can
be applied to a variety of problems.
Professionalism involves a concern for the interests of the
community rather than self-interest. Thus the primary interests of
the professionals is public service rather than personal gain.
The behavior of professionals is strictly controlled by a code of
ethics, which is established and maintained by professional
associations and learned as part of the training required to qualify
as a professional.
The high rewards, which include professional prestige and
earnings, received by professionals are symbols of their
achievements. They denote the high regard in which professionals
are held and reflect the values of their contribution to society
Functionalist Approach (Traits Approach)
Medical profession is an important occupation
and must attract the most capable people to fill
up the position. For society to run smoothly and
effectively, medical profession should adhere to
the values of universalism and being affective
neutral.
High status and good financial reward has to be
given to medical professionals so as to attract the
intelligent people to receive the specialized skills
and training, and and to adhere to the pattern
variables.
Medical Dominance Nowadays
Medical dominance: Medical profession dominates every aspect
of health care service, particularly other health professions:

Only doctors can diagnose and sign birth and death

certificates, and have significant control over access to non-
medical benefits

Doctor’s control of diagnosis and treatment means that they

have administrative and financial authority over other health
professions.

Doctors are overrepresented on hospital management boards,

health policy advisory bodies, and the bodies that fund
research.
 Medical Autonomy
Medical autonomy: authority to direct and evaluate the
work of others without in turn being subject to formal
direction and evaluation by them.

1.Economic autonomy: to set their pay rates (fee-for-

service)

2.Political autonomy: to make policy decisions as experts

in health matters

3.Clinical autonomy: to set professional standards about

treatment (which directly affects hospital expenditure and
the work of other health care workers)
 Conflict Perspective
What makes physician a profession?
What makes biomedicine dominant?


It has more to do with the relative power and
organization of biomedicine and its competitors.
 Conflict Perspective on
Professionalization
Professions can be seen as occupational groups
that have succeeded in controlling and
manipulating the labour market to maximise their
rewards.
Freidson (1970): Medical professions operate in
order to gain social closure i.e. restricting
membership of their group to a few.
Turner: Professionalization by doctors is only an
“occupational strategy to maintain certain
monopolistic privileges and rewards”.
 Conflict Perspective on Professionalization
Biomedicine controls over the healthcare market
through:
a) Exclusion: denying legitimacy to alternative
health practitioners 

b) Subordination: control other health workers under
the direct authority of doctors
c) Incorporation: absorption of occupational
territory into medical practice
Distinction between orthodox medicine and
alternative medicine has more to do with relative
power & organization of these two types of treatment
 Rise of Medical Professional Dominance
Before mid-19th century:

Physicians (i.e. allopath) were only a small percentage of the total number of healers

Most physicians were barely considered professionals. Their credentials were relatively easy
to achieve (or even fake); the body of medical knowledge was skimpy; medical techniques
were rather dangerous, even until early 20th century.

In the mid-19th century: Professionalization of biomedicine in the West

Consolidate the apothecaries (pharmacists), surgeons and physicians and achieve cohesion
within the profession

Raise the standard of entry into the profession and prohibit “unqualified persons” from
practicing

Convince the state to grant a monopoly over medical practice, including the right to define
what constitute disease and how to treat it

Professional body (e.g. General Medical Council in UK, American Medical Association in US)
is formed. They are conferred with power to control who could practice medicine and
autonomy to regulate their own profession.

20th century: Medical dominance

Medical profession had achieved significant autonomy and control over health and illness
matter
Despite the effort in maintaining
dominance, biomedicine has never
completely dominated health care. 

Challenges to Medical Dominance

Biomedicine has never completely dominated health care.

Countervailing powers that constrain and even oppose

medical dominance exist:

1. Challenge from complimentary and alternative medicine

2. Corporatization and commodification of health

3. McDonaldization of health care service

4. Deprofessionalization
 1. Challenge from complimentary and alternative medicine

Medical Pluralism
Medical pluralism: Different therapeutic modalities coexist with
hierarchical differences

Dominant position:

Biomedicine: A conventional approach to medicine in Western

societies

Subordinate position:

Complimentary and alternative medicine (CAM):


--Complimentary medicine: the alternative medical practices that
complement and collaborate with the orthodox medicine

-- Alternative medicine: the alternative medical practice that stand in
opposition to the orthodox medicine
 Categories of CAM
They are build upon complete systems of theory and
Alternative medical practice that were developed earlier than the
systems conventional medical approach. e.g. homeopathic
medicine; Chinese medicine
They uses a variety of techniques designed to
Mind-body
enhance the mind’s capacity to affect bodily function
interventions
and symptoms. e.g. meditation, art therapy, prayer
They use substances found in nature, such as herbs,
Biologically based foods, and vitamins. e.g. aromatherapy, dietary
therapies supplements, herbal products, use of other natural
therapies
They are based on manipulation and/or movement
Manipulative and
of one or more parts of the body. e.g. chiropractic,
body-based methods
massage
They involve the use of energy fields, but the
Energy therapies existence of such field is not yet scientifically proven.
e.g. qigong
 Different Concepts of Health
Biomedicine CAM
Health as a balance of opposing forces within
Health as the absence of disease
the body
Mind-body dualism/mechanical view of
Holism: A person is a complex blend of body,
body/reductionism: 

mind and spirit. Diagnosis focus on the
Disease as defined as dysfunction of
“reading” of body as a whole.
specific part of the body.

Self-healing: The body has “natural” ability to heal

Technological imperative: The reliance of itself and maintain homeostasis.
medical technology to treat the disease Self-help: Patient has to take responsibility for his/
her own health

Therapy aims at strengthening patients’

vitality. Treating the patients is more
important than managing symptoms. Each
Therapy focus on managing symptoms
person is unique.
and suppress disease
Symptoms are the product of the body’s
attempts to get rid of its toxic substances.
 Why choosing CAM?

The limits of biomedicine:

The failure and impotence of orthodox medicine to

cure chronic diseases and serious illness like cancer.

Biomedicine does not place enough emphasis on

the causes of illness and is preoccupied with
relieving symptoms.

Clinical iatrogenesis: the invasive and drastic

biomedical treatment and their harmful side effects
 Why choosing CAM?
The benefits of CAM:
Alternative medical cosmologies better explain the meaning of illness
in terms of patient’s personal context.
A more egalitarian healer-patient relationship
Offers an alternative to “high-tech” medicine
Treats the whole person
Encourages individuals to take greater responsibility for their health
Towards the postmodern society and reflexive modernity:
Stronger emphasis of agency: Express a greater desire for self-
determination, choice and self-help.
Consumerism: Reflects a general trend for maintaining body through
the purchase of consumer goods and services.
Stronger reflexivity: Challenge the cultural dominance of biomedicine
 Medical Pluralism
Inequalities between different therapeutic
modalities in terms of:

Structural superiority: power, status and

wealth in society

Functional strength: how extensive is the

healing tradition being adopted by the
public and thus serving the social functions
 Medical Pluralism in HK: Biomedicine and Chinese Medicine

mid-19th C late-19th C

Prevalence of Chinese Medicine (CM) Rise of Biomedicine (BM)

•1850 Government Civil Hospital (BM) •1894 Plague
•set up by government, not popular •The government officials and
•1872 Tung Wah Hospital (CM) foreigners blamed CM for its inefficacy
•setup and run by Chinese • 1896 Replace the head of Tung Wah
philanthropists, very popular
 with a BM-trained doctor

 •Introduction of biomedicine practice

 in Tung Wah Hospital

 •Decline of CM in Tung Wah groups
•More BM hospitals were built
•Structural Superiority
 •1887 Set up of the Hong Kong College
Political power: BM > CM
 of Medicine
Status and wealth: BM< CM •Structural Superiority: BM
•Functional Strength: CM > BM •Functional Strength: CM > BM
 Medical Pluralism in HK: Biomedicine and Chinese Medicine
mid-20th C
Dominance of BM
•Cancellation of CM service in hospital during
Japanese occupation
•Widespread use of antibiotics after war and
growing public’s acceptance of BM in managing
infectious disease
•State funding help lowers the price for BM
medicine and service
•Leaders of Colonial department of health
received BM training
•The Medical Council of Hong Kong and
Medical Development Advisory Committee were
led by doctors
•Registration required for doctors
•No registration system for CM practitioners
•Limitation of CM practitioners: Cannot use the
title of “dr,” medical techniques and
technologies.
•Structural Superiority: BM > CM
•Functional Strength: BM > CM
late-20th C
Revival of CM
• CM is the complementary medicine 「中藥為主、西藥為副」
•Political handover and Basic law let the SAR
government to decide on its Chinese and Western medical
development-> Government takes a more proactive
approach to reform CM
•Poisonous herbs called for attention of monitoring of
CM herbs
• Set up of School of Chinese Medicine in HKBU(1998)
and CUHK (1999)
•1995 Registration of CM practitioners
•1999 Chinese Medical Council of Hong Kong
• Several university research centers on CM were set up
--> Incorporation of CM into BM
•CM is not included in the Medical functional
constituency
•Structural Superiority: BM > CM
•Functional Strength: BM> CM
•But both SS and FS of CM are on the rise
 Medical Pluralism
Public Values

Medical Hierarchical
Professionalism Coexistence

State Action
李沛良。(2000)。「醫療多元格局的社會文化因素：以香港中西醫療變化為
例」。《香港社會學學報》第一期，頁1-28。
2. Corporatization of Healthcare
Commodification of health: In capitalist societies, health is
regarded as commodities to be bought and sold under market
conditions in the pursuit of profit maximization.

Rise of medical-industrial complex: a profit-oriented corporations

in health care which may own a chain of health services, such as
hospitals, clinics, and radiology and pathology services.

Corporate ownership may place constraints on doctors’ clinical

and financial autonomy through restrictive work practices and
revenue quotas.

Many doctors employed by the industry are “captive

professionals” , whose medical autonomy is compromised by
corporate goals and organizational regulations.
 Medical Fraud
Charging for work never done or for services more extensive
than those provided

Over-servicing

Unnecessary referral to other specialists as a result of fee-

splitting arrangements

Unfairly giving private patients priority over public patients in

public hospitals because of the increased revenue they provide.

Self-regulation of health system provides an incentive for some

doctors to pursue profit at patient and public expense.
3.McDonaldization of Healthcare
McDonadlization of society: the rational principles governing
fast-food restaurant come to dominate increasing areas of society.

Four rational principles:

1. Calculability: an emphasis on the quantitative aspects of
products sold (portion size, cost) and service offered (the time
it takes to get the product). Quantity equals quality.

2. Predictability: the assurance that their products and services

will be the same over time and in all locales.
3. Control: through the substitution of nonhuman for human
technology.

4. Efficiency: the optimum method for getting from one point to

another.
McDonaldization of Healthcare
Increase of bureaucratic and managerial control of doctors’ work to constrain
doctors’ clinical autonomy

McDonaldization of healthcare

1. Calculability: the quantification of medical work through continual

performance evaluation

2. Predictability: the use of detailed regulations to ensure the delivery of health

services is uniform, irrespective of the practitioner

3. Control: the use of technology to replace human judgement and human labour

4. Efficiency: an overriding concern with using the cheapest means to deliver

more services

Irrationality of Rationality: ‘Perhaps the ultimate irrationality of

McDonaldization is the possibility that people could ultimately lose control
over the system and it would come to control us’ (Ritzer, 1998; p.58).
4. Deprofessionalization
Deprofessionalization is the process by which medicine’s
monopoly over knowledge and its authority over patient is
reduced as a result of increased public knowledge and
influence over the health system.

The rise of patient rights: Patients are now considered as

health consumers who is assertive, knowledgeable, critical
and prepare to shop around for the best deal.

Displacement of medical autonomy in favour of patient’s

autonomy: More emphasis on patients’ rights of choice of
treatment, access to information, and informed consent
 Conflict Perspective

Image of society: 

Society is divided into dominant and
subordinate groups competing for valuable
resources. It is characterized by varying
degree of social inequality.

Social order mainly serves the interests of

dominant group
Health care issues are political

Biomedicine dominates healthcare delivery, health

policy and the nature of health practice.

Competition of resources and statuses among different

therapeutic traditions: Biomedicine vs CAM

Power over patient by health care professionals

Medical professional dominance in modern capitalist

society is being challenged: CAM, corporatization,
McDonalidzation and deprofessionalization.
 References
李沛良。(2000)。「醫療多元格局的社會⽂化因
素：以⾹港中西醫療變化為例」。《⾹港社會
學學報》第⼀期，⾴1-28。

Germov, John. (ed) (2009). Chapter 19 and

Chapter 21 in “Second Opinion: An
Introduction to Health Sociology”. 4th Ed.
South Melbourne, Vic.: Oxford University
Press.