Medical Dominance and Its Role in Australian Health Care

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Medical dominance in Australia
Within Australia, medicine has traditionally dominated
every facet of health care delivery (Germov, 2002;
Willis, 1989). The professional status that medicine
holds in Australia has been gained by means of its
historical and political advantages (Germov, 2002;
Willis, 1989). Willis’s (1989) seminal work on medical
dominance provides an extensive review of medical
relationships and the power that medicine yields.
Historically, in Australia, medicine gained its position
of political and economic power through its relationship
ARTICLE IN PRESS
1064 A. Kenny, S. Duckett / Social Science & Medicine 58 (2004) 1059–1073 with the state (Willis, 1989). The state was dependent on
medicine for knowledge and skill and in turn, the state
supported the rise of medicine to a position of
organizational dominance by sanctioning medicine’s
control through licensing laws and the regulation of
other health professionals. It has been argued that the
primary reason for medicine’s dominance in this country
is the authority that it has attained ‘to direct and
evaluate the work of others without in turn being subject
to formal direction and evaluation by them’ (Friedson,
1970, p. 135). The traditional dominance of medicine
over health care in Australia has resulted in a situation
where doctors are over represented on other health
professionals registration boards, health policy advisory
boards, hospital boards and funding bodies for research
(Germov, 2002). The advantages that have been
achieved have resulted in a situation where medicine
occupies a ‘legally or otherwise formally created
position, one which entails a monopoly over a set
of services and accessories required’ (Friedson, 1970,
p. 127).
Historically in Australia doctors have primarily been
associated with conservative politics. It is argued that
these political forces ‘favour free enterprise and private health insurance arrangements’ and have supported the
development of medical dominance (Germov, 2002,
p. 287). Willis (1989) provides detailed consideration of
the development of medicine’s monopoly in this country
and claims that it has been secured and maintained by
government support for fee for service, self-regulation
and the sustained control over the health workforce.
Within the literature, there has been some suggestion
that government support of self-regulation and fee for
service has resulted in a situation where medicine have
sought to maintain dominance and power for the pursuit
of profit (Germov, 2002). This issue is not isolated to
Australia. Navarro (1986, 1988, 1992) has caused a great
deal of controversy in questioning whether clinical
management by medicine is motivated by altruism or
financial gain.
Challenges to medical dominance
Whilst it has been claimed that medicine has
dominated the health division of labour ‘economically,
politically, socially and intellectually’ (Willis, 1989, p. 2) and that the hospital is ‘symbolic of the social power of
the medical profession’ (Turner, 1995, p. 153), in the last two decades, there has been increasing debate about the
extent to which contemporary social trends challenge the
continuation of medicine’s dominant position. Some
argue, that medicine’s power and dominance over the
health care systemis being eroded (Barnett, Barnett, &
Kearns, 1998; Freddi & Bjorkman, 1989; Gabe,
Kelleher, & Williams, 1994; King, Churchill, & Cross, 1988; Kletke, Emmons, & Gillis, 1996; Light, 2000;
Rappolt, 1997) whilst others challenge the extent to
which this reduction in power is reality (Friedson, 1994;
Scarpaci, 1990).
Internationally, emerging social trends such as
McDonaldization, deprofessionalization and proletarianization are presented as major challenges to medical
power (Germov, 2002; Light, 2000). The termMcDonaldization
was coined by Ritzer (1993) and refers to the
emergence of corporately owned ‘fast food type’...
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