Today, professional power is clearly threatened by increasing evidence of the counterproductivity of its output. People are beginning to see that such hegemony deprives them of their right to politics. The symbolic power of experts which, while defining needs, eviscerates personal competence is now seen to be more perilous than their technical capability, which is confined to servicing the needs they create. Simultaneously, one hears the repeated call for the enactment of legislation that might lead us beyond an age dominated by the professional ethos: the demand that professional and bureaucratic licensing be replaced by the investiture of elected citizens, rather than altered by the inclusion of consumer representatives on licensing boards; the demand that prescription rules in pharmacies, curricula, and other pretentious supermarkets be relaxed; the demand for the protection of productive liberties; the demand for the right to practice without a license; the demand for public utilities that facilitate client evaluation of all practitioners who work for money. In response to these threats, the major professional establishments, each in its own way, use three fundamental strategies to shore up the erosion of their legitimacy and power.
The self-critical hooker
The first approach is represented by the Club of Rome. Fiat, Volkswagen, and Ford pay economists, ecologists, and experts in social control to identify the products industries ought not to produce, in order to strengthen the industrial system. Also, doctors in the Club of Kos now recommend that surgery, radiation, and chemotherapy be abandoned in the treatment of most cancers, since these treatments usually prolong and intensify suffering without adding to the life of the treated. Lawyers and dentists promise to police, as never before, the competence, decency, and rates of their fellow professionals.
A variant of this approach is seen in some individuals or their organizations, who challenge the American Bar Association, British Medical Association, and other power brokers of the establishment. These claim to be radical because, 1) they advise consumers against the interests of the majority of their peers; 2) they tutor laymen on how to behave on hospital, university, or police governing boards; and 3) they occasionally testify to legislative committees on the uselessness of procedures proposed by the professions and demanded by the public. For example, in a province of Western Canada doctors prepared a report on some two dozen medical procedures for which the legislature was considering a budget increase. All the procedures were costly, and the doctors pointed out that they were also very painful, and many were dangerous, and that none could be proven effective. For the time being the legislators refused to act on such medical advice, a failure that, provisionally, tends to reinforce the belief in the necessity of professional protection against professional hubris.
Professional self-policing is useful principally in catching the grossly incompetent – the butcher or the outright charlatan. But as has been shown again and again, it only protects the inept and cements the dependence of the public on their services. The ‘critical’ doctor, the ‘radical’ lawyer, or the ‘advocacy’ architect seduces clients away from his colleagues, who are less aware than he of the vagaries of fashion. First liberal professions sell the public on the need for their services by promising to watch over the poorer layman’s schooling, ethics or inservice training. Then dominant professions insist on their rightful duty to guide and further disable the public by organizing into clubs that brandish the high consciousness of ecological, economic, and social constraints. Such action inhibits the further extension of the professional sector but strengthens public dependence within that sector. The idea that professionals have a right to serve the public is thus of very recent origin. Their struggle to establish and legitimate this corporate right becomes one of our most oppressive social threats.
The alliance of hawkers
The second strategy seeks to organize and coordinate professional response in a manner that purportedly is more faithful to the multifaceted character of human problems. Also, this approach seeks to utilize ideas borrowed from systems analysis and operations research in order to provide more national and all-encompassing solutions. An example of what this means in practice can be taken from Canada. Some years ago, the Minister of Health launched a campaign to convince the public that spending more money on physicians would not change the country’s patterns of disease and death. He pointed out that premature loss of life-time was due overwhelmingly to three factors: accidents, mostly in motor vehicles; heart disease and lung cancer, which doctors are notoriously powerless to heal; and suicide combined with murder, phenomena that are outside medical control. The minister called for new approaches to health and for the retrenchment of medicine. The task of protecting, restoring, or consoling those made sick by the destructive life-style and environment typical of contemporary Canada was taken up by a great variety of new and old professions. Architects discovered that they had a mission to improve Canadians’ health; dog-control was found to be an inter-departmental problem calling for new specialists. A new corporate biocracy intensified control over the organisms of Canadians with a thoroughness the old iatrocracy could hardly have imagined. The slogan ‘better spend money in order to stay healthy than on doctors when you get sick’ can now be recognized as the hawking of new hookers who want the money spent on them.
The practice of medicine in the United States illustrates a similar dynamic. There, a coordinated approach to the health of Americans has become enormously expensive without being especially effective. In 1950, the typical wage-earner transferred less than two weeks pay per year to professional health care. In 1976, the proportion was up to around five to seven weeks pay per year: buying a new Ford, one now pays more for worker hygiene than for the metal the car contains. Yet with all this effort and expense, the life expectancy of the adult male population has not sensibly changed in the last one hundred years. It is lower than in many poor countries, and has been declining slowly but steadily for the last twenty years.
Where disease patterns have changed for the better, it has been due principally to the adoption of a healthier life-style, especially in diet. To a small degree, inoculations and the routine administration of such simple interventions as antibiotics, contraceptives, or Carman tubes have contributed to the decline of certain diseases. But such procedures do not postulate the need for professional services. People cannot become healthier by being more firmly wedded to a medical profession, yet many ‘radical’ doctors call for just such an increased biocracy. They seem to be unaware that a more rational ‘problem-solving’ approach is simply another version, though perhaps more sophisticated, of affirmative action.
The professionalization of the client
The third strategy to make dominant professions survive is this year’s radical chic. As the prophets of the sixties drooled about development on the door-steps of affluence these myth makers mouth about the self-help of professionalized clients.
In the United States alone since 1965, about 2700 books have appeared that teach you how to be your own patient, so that you need see the doctor only when it is worthwhile for him. Some books recommend that only after due training and examination should graduates in self-medication be empowered to buy aspirin and dispense it to their children. Others suggest that professionalized patients should receive preferential rates in hospitals and that they should benefit from lower insurance premiums. Only women with a license to practice home birth should have their children outside hospitals since such professional mothers can, if necessary, be sued for malpractice. I have seen a ‘radical’ proposal that such a license to birth be obtained under feminist rather than medical auspices.
The professional dream of rooting each hierarchy of needs in the grassroots goes under the banner of self-help. At present it is promoted by the new tribe of experts in self-help who have replaced the experts in development of the sixties. The universal professionalization of clients is their aim. American building experts who last autumn invaded Mexico serve as an example of the new Crusade. About two years ago a Boston professor of architecture came to Mexico for a vacation. A Mexican friend of mine took him beyond the airport where, during the last twelve years, a new city had grown up. From a few huts, it had mushroomed into a community three times the size of Cambridge, Massachusetts. My friend, also an architect, wanted to show him the thousands of examples of peasant ingenuity with patterns, structures, and uses of refuse not in and therefore not derivable from textbooks. He should not have been surprised that his colleague took several hundred rolls of pictures of these brilliant amateur inventions that make the two-million-person slum work. The pictures were analyzed in Cambridge; and by the end of the year, new-baked United States specialists in community architecture were busy teaching the people of Ciudad Netzahualcoyotl their problems, needs, and solutions.