Between formal and enacted policy: changing the contours of boundaries

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Between formal and enacted policy: changing the contours of boundaries Nissim Mizrachia,, Judith T. Shuvalb a

The Gershon H. Gordon Faculty of Social Sciences, Department of Sociology and Anthropology, Tel Aviv University, Ramat Aviv, P.O.B. 39040, Tel Aviv 69978, Israel b School of Public Health, Hebrew University of Jerusalem, Jerusalem 91120, Israel Available online 5 November 2004

Abstract This study examines the strategies of the biomedical discourse vis-a`-vis the growing public demand for alternative medicine by comparing formal and informal claims for jurisdiction. The analysis is based on two main sources of data from Israel: (a) two formal position statements, and (b) a series of participant observations and interviews with practitioners in clinical settings where biomedical and alternative practitioners collaborate. At the formal level, the biomedical discourse seeks to secure its dominant position by drawing strict cognitive and moral lines differentiating ‘‘proper biomedicine’’ from ‘‘improper alternative medicine.’’ At this level alternative medicine appears morally ‘‘contaminated’’ and its knowledge-base delegitimized by extreme forms of boundary-work. At the informal level, the contour of boundaries change. In the hospital field where alternative and biomedical practitioners are collaborating, mutual respect was expressed even as social and symbolic boundaries were being demarcated. Modifying the forms of boundary-work appears to be biomedicine’s reactive strategy in the field to changing environmental and market demands. It is a strategy that allows biomedical discourse to absorb its competitor within its professional jurisdiction with no battle, while retaining absolute epistemological hegemony and Institutional Control. r 2004 Elsevier Ltd. All rights reserved. Keywords: Alternative medicine; Biomedicine; Boundary-work; Israel

Introduction Modern professions often face the need to defend their turf. The ability of a profession to secure its position, to maintain its autonomy, and to defend its jurisdiction changes over time and across cultural and geographic borders. Professional boundaries constantly change their contours, forcing professions to make jurisdictional claims in various social forms and in different social arenas (Abbott, 1988; Gieryn, 1983, 1999). In The System of Professions, Abbott identifies Corresponding author. Fax: +972-3-909-3053.

E-mail address: [email protected] (N. Mizrachi).

three major social arenas in which jurisdictional claims are made: public opinion, the law (where the most formal definition of professional jurisdiction takes place), and the workplace. He points to the considerable difference and inconsistency between the public and the legal arenas on the one hand, and the workplace on the other. The public and legal arenas are characterized by formal and rigid forms of jurisdictional claims focusing primarily on defining strict knowledge boundaries and behavioral regulations, whereas the informal workplace is shaped to a larger extent by action and practice (Abbott, 1988). The present study examines the nature of the incongruity between formal and informal jurisdictional

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2004.08.016

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claims. We consider jurisdictional claims as a large repertoire of formal and informal procedures by which boundaries of professional practice and knowledge are marked. The paper is part of a broader inquiry by the authors into the recent phenomenon of alternative health care practitioners working together with their biomedical colleagues in hospitals and other clinical settings in Israel. By ‘‘alternative medicine’’ we refer to a ‘‘heterogeneous set of practices that are offered as an alternative to conventional medicine for the preservation of health and the diagnosis and treatment of healthrelated problems’’1 (Murray and Rubel, 1992, p. 61). Jurisdictional claims of biomedical authorities with regard to alternative medicine have taken place in the public and legal arenas in reaction to the growing public demand for alternative medicine in Israel (Shuval, 1999; Shuval, Mizrachi, & Smetannikov, 2002; Mizrachi, Shural, & Gross, 2005; Shmueli & Shuval, 2004a, b). The recent collaboration between the two medical systems enabled us to explore processes of boundary demarcation and jurisdictional claims in the workplace. In view of the scientific nature of biomedical knowledge (Freidson, 1988; Abbott, 1988; Larson, 1977; Foucault, 1994; Good, 1994), we find Gieryn’s notion of boundary work particularly useful for examining processes of jurisdictional claims at both formal and informal levels. Boundary-work according to Gieryn is ‘‘the discursive attribution of selected qualities to scientists, scientific methods, and scientific claims for the purpose of drawing a rhetorical boundary between science and some less authoritative residual non-science’’ (Gieryn, 1999, p. 4–5). We seek to identify typical strategies of jurisdictional claims and boundary-work in formal and informal arenas. We first consider two statements regarding the formal policy of two high-status medical care organizations concerning the relations between alternative and biomedicine, and examine the views expressed in written, publicly accessible documents. We then present research findings based on the observed informal behavior and attitudes of relevant actors in a variety of health care contexts in which biomedical and alternative practitioners work in common practice settings under formal biomedical auspices. We conclude with a discussion of the implications of the two forms of jurisdictional claims. By identifying forms of jurisdictional claims in both formal and informal arenas, we seek to shed new light on the nature of the close connection between power and knowledge, which we consider fundamental to the theory of professions. We find Magali Larson’s recent attempt to incorporate Foucault’s theoretical view into 1 Alternative practitioners have been referred to as complementary, holistic, unorthodox, unconventional, natural, and fringe (Bombardieri and Easthope, 2000, p. 480).

the sociology of professions to be particularly helpful. Unlike Anglo-Saxon sociology, which restricts the term discourse to forms of speech or texts, in the Foucauldian notion of discourse, language is interwoven with practice (Prior, 1988). We find two major characteristics of professional discourse to be particularly germane to the present analysis: (1) Procedures of exclusion, primarily interdictions and the distinction between true and false. In the context of boundary-work the following critical questions need to be posed: ‘‘What types of knowledge do you want to disqualify in the very instant of your demand: ‘Is it a science’?’’ (Foucault, 1986. p. 85). (2) The ways in which ‘‘the control of knowledge always ultimately depends on controlling the subjects who know’’ (Larson, 1990. p. 32). In other words, controlling knowledge in a professional field involves monitoring, regulating, differentiating and restricting actors who carry different forms of knowledge. Procedures of exclusion and forms of controlling social agents in the field are presented as two intertwined dimensions through which formal and informal professional claims of jurisdiction take shape.

Background and context Our objective was to explore the typical dynamics of boundary demarcation at both formal and informal levels. But the meaning of these processes can vary in different social contexts and local cultures. We believe that exploring these processes in any particular context can shed light on the nature of the interplay between power and knowledge. The fundamental structural similarities between Israel and other Western countries make the present case comparable with Western societies in which research findings have been reported. In Israel, as in most Western countries, the biomedical system enjoys prestige, legitimacy, and exclusivity as the provider of medical care. Despite the hegemony of the biomedical discourse in the health care system in Israel, a significant increase in the use of alternative medicine has been recorded from 1994 to 2000 (Bernstein, Shmueli, & Shuval, 1994; Bernstein & Shuval, 1997; Israel National Center for Disease Control, 2000; Ronnen, 1998), including patients who have been referred to alternative practitioners by physicians during the 1990s (Borkan, Neher, Anson, & Smoker, 1994; Schachter, Weingarten, & Kahan, 1993). In line with other Western countries. The growing public demand for alternative medicine in Israel has become a considerable economic force affecting health policy. (Aldridge, 1990; Cooper & Stoflet, 1996; Shuval, 1992; Shuval & Anson, 2000; Siahpush, 1999; Eisenberg, Kessler, & Foster, 1993; Lewith and Aldridge, 1991). Over 20 forms of complementary medicine are in widespread use in Israel. In 2003, the professional

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organizations of alternative practitioners in Israel estimated that a total of 8800 persons were engaged in full- and part-time practice (Personal Communication, 2003). About 10,000 persons are currently participating in a variety of training programs; about half attend 3–4 year programs in six large schools, the remainder a variety of short courses. (Bernstein et al., 1994; Bernstein & Shuval, 1997; Chen, 1998; Ronnen, 1998; Shmueli & Shuval, 2004a, b). Among biomedical family practitioners in Israel, between 42% and 60% have reported referring patients to alternative practitioners (Borkan et al., 1994; Schachter et al., 1993). The most recent survey data concerning the use of alternative medicine in Israel is based on two samples of Jewish urban population aged 45–75: in 1993 (n ¼ 2203) and in 2000 (n ¼ 2505) (Shmueli & Shuval, 2004a, b). In 1993, 6.1% of the population reported consulting non-conventional medical practitioners at least once during the previous year; in 2000, that proportion increased to 9.8%. Increases are observed in several socio-demographic groups: women, younger people, persons having 12 or more years of schooling, persons with higher than average economic status, and residents of large cities. There is a significant inverse relationship between levels of overall satisfaction with specialists in conventional medical care and the propensity to use alternative medicine; this relationship is stronger in 2000 than in 1993. The main reason for turning to non-conventional medicine was a reluctance to ingest too many medications or to undergoing invasive procedures. Large groups use conventional medicine and alternative medicine concurrently or alternatingly. In 1993, 60% of patients reported that alternative treatment helped them; in 2000, 75%. The majority of patients of alternative medicine stated that dissatisfaction or disappointment with conventional treatment was the main reason for consulting alternative providers. Between 1993 and 2000, non-conventional medicine in Israel has changed from an industry in its infancy into a mainstream health commodity (Shmueli & Shuval, 2004a, b).

Sources and method The analysis is based on two sets of data referring to formal and informal social arenas in which jurisdictional claims take place. Formal arena The first set of formal data is based on the report of a public committee appointed in 1988 by the Israel Minister of Health to examine all aspects of ‘‘natural

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medicine’’ including ‘‘homeopathy, acupuncture, reflexology, chiropractic, etc’’. (Israel Ministry of Health, 1991, p. 1). The committee was composed of 12 persons, nine physicians and three from the legal profession. The Chair, Professor M. Alon, was Deputy President of the Supreme Court (the committee was referred to as the Alon Committee). Nineteen witnesses appeared in the course of 22 meetings. Almost all the witnesses were practitioners or specialists in one of the alternative professions. The committee submitted its report in 1991 but to date little has been done by the Ministry of Health to implement its findings. While the report was never accepted formally by any legislative or ministerial body, it is viewed for the purposes of this study as a proposed policy formulated by a formally appointed, highly qualified and respected group. (Abbott, 1988, p. 63). Another empirical source related to the formal arena was published 6 years after the Alon Committee report: it is a statement of the Israeli Medical Association (IMA) with regard to alternative medicine published in one of its widely circulated publications: ‘‘Michtav LaChaver’’ (‘‘Letter to Members’’). In 2003 an additional statement appeared on the internet site of the IMA (Israel Medical Association, 2003). The 1997 statement is more detailed and most of the following analysis is based on it, but the 2003 statement introduces a few modifications which will be noted. (Israel Medical Association (1997), page references below are to this source; Israel State Comptroller’s Annual Report No. 46, 1996; Yishai, 1999). For the formal portion of the analysis, we will focus on a content analysis of jurisdictional claims as they appear in these public statements. Informal arena Data were collected between 1999 and 2001 in ambulatory clinics where alternative care is practiced and in hospitals where alternative care is provided for hospitalized patients. (1) Ambulatory clinics specializing in alternative care have been established in one third of the public hospitals and by all four sick funds in Israel. Of the 11 alternative ambulatory clinics run by hospitals, two were chosen; two community-based ambulatory clinics associated with the sick funds were also chosen. Seventeen practitioners were approached by telephone in the above four ambulatory clinics and 14 agreed to participate. Of the 14, 9 were licensed physicians practicing an alternative specialty; 5 were trained only in an alternative area. (2) Data were also collected in 4 Jerusalem hospitals where hospitalized patients were treated. In these settings two types of practitioners were included: alternative practitioners and their principal biomedical colleague or host.

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Fifteen persons practicing with hospitalized patients were interviewed: 7 alternative practitioners who were also biomedically trained; 5 non-biomedically trained alternative practitioners and 3 biomedical authorities who are not practicing alternative medicine; In addition to the above, data were obtained from 7-months of participant observation conducted in a university-affiliated government hospital in Tel Aviv where alternative practitioners were working with hospitalized patients. Observations were supplemented by informal interviews with biomedical and alternative practitioners working together in the hospital. All 12 alternative practitioners working with hospitalized patients were practicing acupuncture. Four of them were MDs. In all the above settings, a set of open-ended questions provided a basic framework for the semi-structured interviews. These referred to the interviewee’s work experience, formal and informal status in the workplace, remuneration patterns, modes of interaction with colleagues and views on the place of alternative practice in a biomedical setting. In addition to the interview protocols, characteristics of the workplace were closely observed, and written material about the practice setting was collected.

Analysis In the following analysis we examine different forms of jurisdictional claims at both formal and informal levels by identifying procedures of exclusion and modes of social control over knowledgeable agents. Procedures of Exclusion By ‘‘procedures of exclusion’’ we refer to epistemological axioms shaping social practice and rhetoric by which ‘‘true knowledge’’ is differentiated from ‘‘false’’. Procedures of exclusions grow out of the cognitive foundation of the field. In the case of biomedicine’s response to alternative medicine, science provides the ultimate epistemological authority. Boundary work: the epistemic authority of science Formal arena ‘‘Is it a science?’’ (Foucault, 1986. p. 85) is the pivotal question enabling the biomedical discourse to subordinate non-biomedical alternative forms or differentiate itself from them. Using the authority of science to differentiate alternative from conventional medicine is most pronounced at the formal level of jurisdictional claims. The epistemological authority of scientific medicine, as it appears in these documents, is absolute. In a dramatic opening declaration in 1997, the Israeli Medical Association (IMA) states that ‘‘there is only one

form of medicine that deals with care of human beings and only physicians are permitted to practice it’’. Much of the Alon report focuses on two boundaryreinforcing issues along the binary scientific–nonscientific lines: (a) spelling out the biomedical scientific markers that confer legitimacy on medical work (b) spelling out the non-conformity of all forms of alternative practice to these criteria. The following texts are drawn from the IMA report, which lists the characteristics of both conventional and complementary medicine. Conventional medicine is based mostly on (Israel Ministry of Health, 1991, p.10) 1. Scientific data based on laboratory experiments on the structure and functioning of the human body. 2. Observations made to determine causal relations between diagnosis and therapy. The data are obtained by: reports of single or multi case studies; case control studies; cohort studies; prospective experiments based on randomized experimental and control groups. 3. Continuous research based on the awareness of the possibility of error expressed in on-going efforts at objective examination of treatment methods and openness to the possibility of change. Complementary medicine is based on (Israel Ministry of Health, 1991, p. 11) 1. Anecdotal evidence of ancient vintage (in the case of Chinese medicine) or of recent times (reflexology). 2. Theories based on anecdotal evidence, which have been transformed into ‘‘ideological axioms,’’ (homeopathy). 3. The principal evidence for validation of theories are single anecdotal cases or at most a series of cases. The scientific basis for complementary medicine is poor or non-existent and does not meet the accepted standards of Western science and conventional medicine. This also explains the great differences among various methods of complementary medicine with regard to the training of practitioners. On a cognitive level, these characteristics may be viewed as boundary markers for biomedicine defining unambiguously who is in and who is out. The territory of biomedicine is demarcated by its scientific infrastructure: laboratory experiments, a list of scientific methods used to establish causal relations and predictive power, on-going research, and the scientific ethos of skepticism (see Merton, 1973). By contrast, complementary medicine is portrayed as based on anecdotal evidence, some of which is ancient, meaning not up to date, and dogmatism, which uses the same anecdotal evidence to develop theories. Informal arena All biomedical practitioners in the field2 perceived science as the ultimate reference point for medical truth. 2 ‘‘All practitioners in the field’’ refers to our interviewees and observed actors only.

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Similarly to the way science is represented in the position statements, all actors in the field referred to science as the exclusive source for evaluating the reliability and efficacy of alternative theories and clinical procedures. Many biomedical authorities, including biomedical practitioners practicing alternative medicine, shared the belief that the only way for alternative practice to gain legitimacy is through the support of scientific evidence. As Gieryn notes: ‘‘So secure is the epistemic authority of science these days, that even those who would dispute another’s scientific understanding of nature must ordinarily rely on science to muster a persuasive challenge’’ (Gieryn, 1999. p. 3). The ethos of evidence-based medicine provides the organizing principle of boundary demarcation between the two medical systems, granting the biomedical practitioners the ultimate epistemological authority to differentiate between legitimate and non-legitimate medical care. The notion of ‘‘evidence’’ is restricted to the realm of visible and biological signs, which can be explored by laboratory and experimental scientific work. In the biomedical form of boundary-work, scientific knowledge is often marked by a direct reference to visible signs necessary for biomedical diagnosis (Kleinman, 1995). Dr. G, an MD practicing complementary medicine in the oncology ward at the same hospital, shared this basic outlook. ‘‘There is only one form of medicine. This is not alternative. There is complementary treatment; supportive’’. Dr. R, MD, practicing in the department of oncology and director of treatment of oncology patients using complementary methods, explained the reasons for establishing this special program: ‘‘First, we got the impression that patients want this treatment, and second, research by a hematologist in this hospital shows that a considerable percentage of patients ask for this treatment’’. The need for scientific approval continues: ‘‘We have decided to conduct prospectiverandom studies focusing on the efficacy of complementary treatment’’. For all key actors in the field, biomedicine belonged to science, focusing on disease intervention, and upheld the evidence-based medical ethos. For the key alternative practitioners who mediated between the two medical systems in the hospital field, the need for scientific verification was a matter of cardinal importance, necessary for any prospective integration of the two systems. Science, as the organizing principle of biomedicine, leaves no room for non-scientific cultural belief systems in the hospital field. As Dr. T, not an MD and head of a complementary unit in a hospital in Jerusalem, pointed out, ‘‘I am not going against the hospital. I do not oppose any medical activity. I do complement such activity. I am not trying to become an MD. I do not make diagnoses’’.

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Caring versus curing Formal arena There is a little space in these statements for the merits of alternative medicine and its potential benefits. The few places where some qualities of alternative medicine are mentioned, these characteristics are either considered to be indicative of their deceptive effect or implicitly acknowledged as beneficial but restricted to the realm of the patients’ personal experiences. In cases of chronic diseases, where biomedical practitioners express considerable ‘‘resistance to affirmation of the patient’s experience of illness’’ (Kleinman,1995, p. 1), alternative medicine is perceived to be particularly attractive according to the Alon committee. ‘‘The people who choose alternative medicine are distressed and often have special emotional needs. These are patients with chronic or terminal diseases who have not found any remedy in medicine’’ (IMA, p. 11). Nevertheless, the Alon Committee is aware of the higher level of patient satisfaction with alternative medicine than with biomedicine. Patient approval of alternative medicine, according to the Committee, stems from the emotional support and personal attention offered to patients, as well as the lack of invasive procedures. The focus of biomedicine on the diagnosis and treatment on ‘‘disease’’, which often requires invasive procedures, is given as a visible boundary between the two systems. Alternative medicine is placed outside the realm of diagnosis and treatment of ‘‘disease’’ by objective, physical, visible, and universal means, and focuses primarily on the patients’ experience of ‘‘illness’’, which is related to the subjective experience of the suffering individual (Conrad and Kern, 1990). This traditional division marks the epistemological boundary between the patients’ experience, which is rated as secondary as far as the medical truth-values are concerned, and the notion of ‘‘disease’’ providing the foundation for biomedical knowledge. Informal arena Alternative practitioners appeared to focus on the patients’ experience of illness: feelings, affective states, the alleviation of pain and suffering, and efforts to improve the quality of life. This restriction, which cut across all biomedical wards and specialties, demarcates strategic areas within the hospital where alternative practitioners were not found to be practicing. These areas included emergency rooms (where initial diagnosis is made), laboratories, radiology and imaging units (where biomedical evidence is created and interpreted). This demarcation was accepted by all actors in the field (physicians, alternative practitioners, and patients alike). However, unlike the formal statements, in the field alternative practitioners have often been perceived by biomedical authorities to be quite successful in

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alleviating patients’ pain. Prof. K. emphasized the alternative practitioners’ complementary role as care providers: ‘‘They can spend time with the patients, time that we don’t havey Complementary practitioners are successful in alleviating painy Complementary medicine can help patients, although the way in which it works is unknown to me’’. Dr. M. demarcated the areas of practice of alternative practitioners in the hospital along the disease-illness lines. He states: ‘‘Complementary medicine can be helpful in cases of pain in general and in post-operative pain in particular, in cases of depression, rheumatism, chronic illness, and breathing difficulties. You cannot introduce complementary medicine to other fields such as intensive care units for example’’. In Dr. M.’s view, therefore, alternative medicine was restricted to the patients’ experience of illness or to their functioning during illness. Dr. G described the role of alternative medicine in the oncology ward: ‘‘When oncologists send us patients with cancer suffering from side effects of chemotherapy we try to help and alleviate the patient’s pain’’. Dr. R emphasized: ‘‘The most important thing we tell the patient is: ‘complementary medicine is complementary rather than a substitute. There is no pretence to cure cancer. Our goal is to alleviate the symptoms of the disease and of the treatment’’. The realm of medical diagnosis and intervention remained well guarded. Boundaries were well maintained by alternative practitioners, as Dr. T. explained: ‘‘I am not allowed to tell a patient ‘don’t do an operation.’ I have made myself clear to the hospital authorities: ‘I am not an MD; I am not doing anything of the kind’’’. The care/cure boundary was evident in the field particularly where alternative practitioners work directly with hospitalized patients inside the stronghold of biomedicine. At the informal level, the efficacy of alternative practitioners in the realm of ‘‘cure’’, particularly their skill in alleviating pain, was recognized by their biomedical colleagues. Unlike at the formal level, alternative practitioners were not being maligned for ‘‘selling false hopes to desperate patients’’, and their positive effect on the patients’ condition of illness was recognized and often respected. The cure/care line, which is religiously observed inside the stronghold of biomedicine, was to some extent crossed in ambulatory clinics serviced by alternative practitioners only, where they were freer to establish their own rules. In these settings practitioners perform both alternative diagnosis and treatment, although ‘‘life saving’’ procedures are not performed even there. Reduction, ranking and framing Formal arena One of the first decisions of the Alon committee (1991) was to clarify its mandate and at the same time

draw an unambiguous boundary between the biomedical professions and the alternatives. A simple rhetorical device was used to accomplish this. Rather than accepting the ambiguous term ‘‘natural medicine’’, which was used in naming the Alon committee and specifying its mandate, it was decided to use the term ‘‘complementary medicine’’, because ‘‘the term ‘alternative medicine’ is misleading’’; ‘‘complementary medicine’’ does not presume to be an alternative to conventional medicine but only to complement it (Israel Ministry of Health, 1991, p. 4). The IMA recognizes the heterogeneous array of occupations included under the rubric of alternative medicine and draws a distinction among three types of alternative occupations: 1. Occupations that are acknowledged, ‘‘to provide some small benefit’’: acupuncture, chiropractic, podiatry, meditation, etc. These forms of treatment should be practiced under a the supervision of an MD. The practitioners should undergo some formal training’’ (IMA, p. 9). 2. Occupations that biomedicine does not fully accept as effective but which are acknowledged as a possible mode of care: homeopathy and herbal medicine. These forms should be practiced by an MD only, according to his [sic] professional judgment (IMA, p. 9). 3. Occupations that are completely and unambiguously rejected by conventional medicine. Their practitioners are viewed as charlatans who encourage ‘‘idol worship’’. The example cited for this type is the ‘‘use of manual transmission of electric currents’’. Every deceiving form of medical practice should be forbidden (IMA, p. 9). The three-fold typology is distinguished by the extent to which the occupations are recognized as effective by the biomedical system. There is no clear statement of how effectiveness is established; presumably by ‘‘evidence based’’ research as the principal criterion. Biomedical discourse seems to relax its boundaries and to tolerate alternative practice as long as the effectiveness of alternative medicine can be articulated in biomedical terms, its training can be controlled, and its practice can be supervised by authorized biomedical agents. Informal arena Consistent with the approach of the Alon Committee, all the host organizations have adopted the term ‘‘complementary’’ in the discourse regarding alternative health practitioners and in naming their clinics. The three-tier typology suggested by the IMA ranking of alternative specialties was found to be loosely related to the ways in which alternative medicine was practiced in biomedical settings and perceived by biomedical authorities. Biomedical practitioners working in the same clinical settings knew very little about their alternative

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colleagues’ professional background, credentials and specialty. In the hospital setting, even biomedical practitioners who clearly favored collaborative work between the two medical systems knew hardly anything about the alternative practitioners’ background and credentials. When asked what were the criteria for selecting the ‘‘right’’ alternative specialty, Prof. K answered: ‘‘I simply accepted what Dr. M had to offer’’. In the field, alternative specialties may have gained legitimacy by the extent to which their logic of practice appeared to be similar to biomedicine or reducible to the biomedical logic and epistemology. Dr. M explained the dominance of acupuncture among alternative specialties practiced at the hospital in the same manner: ‘‘Acupuncture is known to be effective and therefore it has become dominant. Like biomedicine, it has a clear physiology, diagnosis, pathology, and treatment. Physicians can grasp this kind of logic. It speaks to them. It is much more difficult for them to accept homeopathy, for example’’. The similarity in practice between biomedicine and chiropractic medicine added to his attitude of approval: ‘‘He [the chiropractor] uses lab tests and X-ray. Only he is not allowed to prescribe medication’’. Prof. F, head of a surgery unit in a prestigious Jerusalem hospital, explained his collaboration with a chiropractor: ‘‘With a chiropractor I have a common language. I understand what he is doing and how he is doing it. With reflexologists, for instance, I do not. I do not send them patients, because I haven’t found a common denominator with them. I believe in what I see’’. The services offered at publicly sponsored alternative outpatient clinics were based on public demand rather than deliberative decisions made by biomedical authorities. They included a variety of practitioners in the fields of acupuncture, shiatsu, homeopathy, chiropractic, reflexology, Feldenkreis, naturatherapy, herbal medicine, biofeedback, Alexander, aromatherapy, alternative nutrition, Paula, and others. The hierarchical rank of alternative specialties, as suggested by the IMA’s three-tier typology, was not recognized in the field and did not seem to have a direct effect on patterns of recruitment, positioning, remuneration, or practice. In the field recognition was gained by work experience. Alternative medicine appeared to be reduced to a paramedical subordinate occupation, as Prof. F indicated: ‘‘Chiropractic can help patients in pain. It includes also physiotherapy treatments. A chiropractor is like a physiotherapist teaching the patient different exercises’’. In the biomedical field, reduction appeared to be the only way for alternative medicine to gain some recognition and legitimacy. Controlling and monitoring knowledgeable social agents This characteristic of professional discourse refers to procedures by which social agents are selected and

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monitored in the field. These procedures create the hegemonic professional discourse as a mechanism of social control by which the line is drawn between ‘‘in’’ and ‘‘out’’, ‘‘legitimate’’ and ‘‘illegitimate’’ professional agents. We consider social boundaries to be ‘‘yobjectified forms of social differences manifested in unequal access to and unequal distribution of resources (material and nonmaterial) social opportunities’’ (Lamont and Molnar, 2002: p. 168).

Demarcating social boundaries: formal restrictions Formal arena Social boundaries provide the mise en scene for the Committee. The dominant group among Committee members were biomedical in their orientation; the remainder were legal experts representing the officially authorized voice of the state. Members of the alternative professions—the objects of the deliberations—were witnesses, i.e. boundary-work provides the legitimacy for reinforcing the legal boundaries. Cognitive boundaries are evoked by references to the absence of demonstrated effectiveness by means of research conforming to the established scientific markers of biomedicine. Thus the conclusions reinforce the existing pattern of exclusion from the boundaries of medical practice by indicating that only when such conformity is established can processes of licensing for alternative practitioners be considered. The recommendations of the Committee address several jurisdictional concerns. The first is to draw the line between ‘‘permitted’’ and ‘‘not-permitted’’ medical practice in view of the growing health care market outside the jurisdiction of biomedicine. The Committee recommends that ‘‘medical treatment that involves risk to the patient should be limited to licensed physicians; treatment in the realm of alternative care which does not involve such risk may be given by alternative practitioners at the patient’s request. As long as treatment does not incur a risk to the individual’s health, people can engage in the occupation of their choice’’ (Israel Ministry of Health, 1991, p. 16). When the division between ‘‘true’’ and ‘‘false’’ medical knowledge appears to be evident, public safety can be secured by making the legal demarcation fit the epistemological hierarchy. The Committee encourages research regarding the effectiveness of alternative medicine within the constraints of acceptable bio medical standards. Therefore, it is premature for the Ministry of Health to develop methods for formal licensing of such practitioners until the biomedical rules are fully accepted (Israel Ministry of Health, 1991, pp. 16–17). Treatment of minors by alternative practitioners requires a physician’s approval, so that the authority of an MD is added to parental judgment

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(Israel Ministry of Health, 1991, p. 16) for those who cannot judge for themselves. Informal arena Actors in the field were barely familiar with the formal definition of position and jurisdiction of alternative practitioners. Boundary demarcation and jurisdictional restriction have taken shape informally through the daily behavior of all actors and through the professional conduct of biomedical practitioners. The empirical evidence indicates that alternative practitioners have gained entrance to hospitals by informal rather than formal bureaucratic processes. There were no public announcements of vacant positions or invitations to qualified persons to submit their credentials. Personal contacts and networking appeared to be the principal mechanisms of recruitment. The informal pattern of recruitments and the lack of attention to the credentials of alternative practitioners marked them as outsiders and placed alternative knowledge outside the legitimate biomedical knowledge system. In the same vein, all alternative practitioners were employed on a part time basis at the clinics and most maintained their private clinics. Patterns of remuneration varied and depended on individual arrangements negotiated by the alternative practitioner with each health care organization. Remuneration was most often on a fee for service basis or through the sick funds. Alternative practitioners working in hospitals and other biomedical clinics in Israel did not hold formal positions. They often volunteered or worked on an ad hoc, individual contractual basis. All work part time, mostly one or two but as many as four days a week. The fees paid by patients to hospital practitioners are a fraction of the fees charged in private practice (Shuval et al., 2002; Shuval & Mizrachi, 2004). In the Tel Aviv hospital where alternative practitioners were found to be working with hospitalized patients all alternative practitioners worked as volunteers. Dr. T explained: ‘‘This clinic is half private. I do not work for the hospital. I am using the hospital space but I am not part of it. They allowed me to stay for a year to see how things are shaping up and then they will decide whether I can stay’’. Physicians practicing alternative medicine often accepted and used the logic of science as the key to gaining institutional legitimacy. Dr. G recounted: ‘‘We entered the hospital through the out-patient clinic. They realized that there is a real need for complementary medicine in oncology because there were studies supporting it. I wish we could enter other department. But for that you need documents and studies to convince the management’’. In all biomedical settings where alternative practitioners work together with their biomedical colleagues their subordination to the biomedical practitioners was

evident. Upon arrival to the ambulatory clinics, patients were examined by an MD who determined which of the alternative forms of practice was appropriate. After a specified series of treatments, each case was reviewed at a full staff meeting headed by an MD and including the non-physician alternative practitioners. In the informal arena organizational boundaries were relaxed, and alternative practitioners entered the hospital space. Although alternative practitioners entering the hospital space was indicative of boundary change, their marginal position in the field marked them as outsiders, and raises considerable social barriers before their participation as equal citizens or even as legitimate residents. Consistent with these structural and social boundaries in the field, in the realm of the symbolic boundaries (Lamont, 2002), unambiguous markers pointed to the unequal status of the two forms of practice. Alternative practitioners were marginalized topographically, as none of the clinics providing alternative care were located in the physical center of the hospital facility. Dr. T: ‘‘When I first came, I heard doctors saying, among other things ‘he is taking up space,’ so I gave it right away to somebody else. I don’t want to become a threat of any sort’’. Similarly, the spacelessness of the alternative practitioners manifested itself in the storage place of their practice instruments. There was no provision for the storage of devices used by alternative practitioners, which were not stored in properly designated places in the hospital but in non-clinical, administrative offices. The tools of alternative medicine, symbolic icons of all medical practice, were kept apart from other biomedical devices in the hospital, further contributing to placing alternative medicine outside the hospital field. Marginalization within the hospital field can also be observed at the level of social encounters, daily rituals, and professional interactions. When alternative practitioners joined the routine rituals of case presentations, the division between the two groups of practitioners emerged clearly. The ritual was conducted by a physician who made the diagnosis and in some cases referred the patient to an alternative practitioner. In the formal arena, the biomedical discourse managed to exclude and at the same time include alternative practitioners by changing the contour of the boundaries. Nevertheless, the epistemological scientific medicine was well guarded by various institutional forms and practices in the field. Epistemological hierarchy of social agents Formal arena A clear epistemological hierarchy of the social agents emerges in the statements. Heirs to the epistemological supremacy of scientific medicine, physicians (MDs), the carriers of the biomedical knowledge, have access to

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medicine’s truth-value, and thus can set the standards for medical truth. Alternative practitioners are presented as either incompetents or charlatans. Finally, the patients are portrayed as potential victims who cannot judge for themselves and might be mislead by alternative practitioners, and therefore need protection. The patients’ experiences of illness and treatment are downgraded to a secondary epistemological rank, and their satisfaction with a medical treatment does not attest to the professional value of the method by which they were treated. Growing patient demand for alternative medicine is viewed as determined by social and economic forces. Consumers do not cite explicitly any successes of alternative medicine or what may appear to be the failure of biomedicine to meet their needs. In any case, the decisions of patients do not count as valid counter evidence to the absolute claims for truth of biomedicine. To the contrary, the increase in the number of degenerative and chronic patients—a typical clientele for alternative treatment—is considered to be a result of progress in biomedicine. Informal arena Consistent with the hierarchy expressed in the formal arena, there was a well-maintained hierarchical order by which the patient passes through the biomedical ‘‘filter’’ to be referred to alternative treatment. Physicians must first rule out the possibility of a ‘‘real disease’’ before any other consideration. Alternative medicine has never been found in a gate-keeping position of diagnosis. It may be offered to the patient as a choice in cases of long term-maintenance of chronic diseases, as a way to alleviate pain and to comfort the patient. The epistemological hierarchy manifested itself in the formal decision making process. The diagnostic process was always initiated by a physician who decided which patients should see an alternative practitioner. ‘‘First we ascertain that there is no medical problem, and then we refer the patient to alternative medicine’’, said Dr. M. At this diagnostic stage, if doctor and patient decided to use alternative medicine, the patient needed to sign a consent form and to obtain the doctor’s approval. Among hospitalized patients, when the option of alternative treatment was brought up by a biomedical practitioner, several underlying assumptions were shared by all our interviewees and the observed actors in the field: (a) alternative treatment is a matter of personal belief; (b) it is a matter of free choice offered to the patient, as an item to be purchased rather than a crucial medical component of the treatment; (c) the patient’s refusal to accept alternative treatment is perceived as a legitimate decision. During a daily round, a hospitalized patient was offered an alternative treatment. He replied: ‘‘Thank you, but I don’t believe in it’’. It would have been inconceivable to accept this as a legitimate response to biomedical treatment, but to the

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alternative practitioner it was acceptable. The patient’s response and the practitioner’s reaction were indicative of the uncertain epistemological authority of alternative knowledge and practice. Nevertheless, in the field, the growing power of patients as consumers played a role in legitimizing alternative medicine. The extreme epistemological hierarchy portrayed in the formal arena, viewing patients as passive victims and downgrading their experience as secondary to biomedical knowledge, seemed to be challenged in the field by patient consumption patterns. Physicians practicing alternative medicine often tended to reconcile their commitment to the logic of science with the hierarchical epistemological order and the experience of practice. Dr. G explained: ‘‘You cannot learn a method of treatment for six months and become a doctor. A person who is not a doctor cannot diagnose. It is not that you study some special [bodily] movements and that’s it. You need to know what you are doing. Don’t get me wrong; there are non-physician practitioners who are excellent. But everyone needs to know his place’’. While the positive effect of alternative practitioners on patients is acknowledged by Dr. G, the clear epistemological hierarchy plays a chief role in demarcating social boundaries. Protecting the public: moral ‘‘contamination’’ Formal arena Representing itself as guardian of the public welfare, the Committee highlighted the risks and perils of using alternative medicine. The considerable dangers that complementary practitioners pose to its users are specified as follows (Israel Ministry of Health, 1991, p.11): 1. Direct damage caused by alternative care, e.g., infections, structural injury, discomfort, or harm from inappropriate medication, etc. 2. Delay or failure to use conventional (biomedical) methods of diagnosis can cause a dangerous delay in receiving appropriate treatment. 3. Strong likelihood for misrepresentation and charlatanism because of the absence of training programs and supervision of practice. Placebo effects and suggestion provide an opening for fraud and deceit. The biomedical discourse provides the absolute point of reference from which medical damage can be assessed and the professional and moral conduct of alternative professionals evaluated. There is an unstated assumption that dangers and risks do not occur within the territorial boundaries of biomedicine. By calling attention to risks and dangers in the use of alternative medicine, the biomedical discourse places alternative practitioners outside the legitimate biomedical zone. The boundary-work rhetoric is reiterated emphasizing

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that there is no acceptable proof for the effectiveness of complementary medicine and no system of control or standard maintenance in the training of practitioners. The epistemological hierarchy of the agents reemerges here again and provides the key to the moral demarcation of professional jurisdiction. The position whereby patients cannot judge for themselves and alternative practitioners are either incompetents or charlatans reiterates the statement in the IMA document that alternative practitioners ‘‘delude’’ the public by their promises of ‘‘care and healing’’, which causes the IMA ‘‘great concern’’ because these promises are ‘‘impossible to realize’’ and cause damage as a result of delay in the patients’ obtaining appropriate biomedical care’’ (IMA, p.10). In considering the reasons for the widespread use of alternative medicine, the IMA identifies users as being mainly chronic or terminal patients who cannot be helped by conventional medicine and who are offered false hope and more personal attention than is possible in the public health care system. Informal arena The rhetoric of protecting the public from alternative medicine, which has some condemnatory connotations, was not part of the discourse of biomedical authorities in the field. Claims for restricting alternative practitioners in biomedical settings were primarily made on the name of science. The boundary-work, as reflected by evidence-based medicine, was used by biomedical authorities in the field only to exclude and subordinating alternative practitioners. The biomedical practitioners interviewed in the hospitals expressed support and respect for the alternative practitioners with whom they were associated. Clearly, these were a small minority of hospital doctors and were likely to hold the most positive views of alternative practitioners and of their potential contribution. Objections to alternative medicine in the field, which came primarily from biomedical authorities that were reluctant to collaborate with alternative practitioners, were based on boundary-work rather than moral condemnation. In the field, where moral demarcation grew out of actual social encounters, interactions, and daily routine, moral contamination was less likely to be an ordinary reactive strategy of the biomedical discourse. Moral demarcations, thus, vary and their boundary contours appeared to be contingent upon individual actors and social context. Reactions of biomedical authorities ranged from total acceptance to cautious recognition, as Dr. B, the head of the Cardiological unit at one of the large hospitals in Jerusalem commented: ‘‘I think that it’s excellent. I believe in complementary medicine. Not that I know much about it, but I have a positive attitude

with regard to all ancient traditions. Natural is good. I do not accept everything but I think there is something right about it’’. Dr. B’s expressed sympathy to complementary medicine is not shared by all his colleagues: ‘‘Some doctors in our department have more doubts than others. I think the reason is that we are not familiar with it. If they knew more about it, their attitude would be more positive’’. While the attitudes of physicians toward alternative medicine varied, we found no visible expressions of moral contamination. Moral and professional demarcations, however, were steadily subjected to the supreme authority of science, as the following comment by Dr. R indicates: ‘‘I am not willing to be held accountable for providing alternative treatment instead of medication’’.

Conclusion Boundary-work has been the organizing principle by which the biomedical discourse demarcates its turf in both formal and informal arenas. However, boundaries change their contours. In the formal arena definitions come into view as strict and rigid, moral and cognitive boundaries appear to be fixed and presented in their extreme forms, marking and displaying a hardcore professional ethos and identity. In the field, however, knowledge and professional conduct are reflected and refracted by the agents’ daily practice, and the contours of boundaries are shaped by local forces. Processes of ‘‘workplace assimilation’’ (Abbott, 1988) are facilitated by local forces and shaped by the actions and interactions of actors in the field, and thus, continually transformed by these dynamics. Actors vary in their professional qualifications and the orientations that determine the forms of their reaction to competitors. Biomedical and alternative practitioners, who appear in the formal jurisdictional claims as two monolithic groups, appear in the field in richer colors. Nevertheless, the absolute epistemological authority of the biomedical scientific discourse, manifest in the notion of evidence-based medicine, is best-guarded in both formal and informal arenas. It manifests itself in the way boundary demarcation along the care/cure lines is observed. While the positive effect of alternative medicine in the realm of ‘‘cure’’ is denied, doubted, or restricted at the extreme formal level, at the informal level, biomedical practitioners working together with their alternative colleagues expressed their recognition of the positive effect of alternative treatment on the patients’ experience of pain and suffering. Moreover, in the field, the care/cure line, which is religiously observed inside the stronghold of biomedicine, is cautiously crossed in ambulatory clinics serviced by alternative practitioners only.

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Although the biomedical discourse is not monolithic, in this particular study we have not found a wide variety of reactive strategies to alternative medicine across biomedical specialties. At the same time, formal classifications of alternative medicine into different forms are hardly recognized in the field. Recognition on the part of biomedical practitioners was gained by collaborative work experience. Nevertheless, at both formal and informal levels, reduction of alternative medicine to para-medical status appears to be the prime legitimizing mechanism. Similarly, in contrast to the strict legal restrictions expressed in the position statements, in the field alternative practitioners enter the hospital by informal rather than formal procedures. At the same time, alternative practitioners are excluded and marginalized by local forces in the field demarcating social and symbolic boundaries. Marking the closed and more opened areas in the hospital allows the inclusion and exclusion of alternative practitioners at the same time. Similarly, the strict epistemological hierarchy of agents that appears at the formal level is challenged in the field. In the formal arena physicians, alternative practitioners, and patients hold fixed positions in the power structure: the first hold the ultimate epistemological authority, the second are portrayed as disqualified or charlatans, and the patients are reduced to ‘‘passive victims’’. In the field, patient experience, which has been downgraded by the biomedical discourse to a secondary epistemological level (Kleinman, 1995; Anspach, 1990), appears to wield considerable economic power. The ‘‘passive victims’’ appear to be active consumers shaping de facto the priority of biomedical authorities in the field. Moreover, as opposed to the ‘‘moral contamination’’ of alternative practitioners, which serves as a boundary demarcation mechanism in the formal arena, in the field mutual respect was expressed even as social and symbolic boundaries were being demarcated. Changing the contours of boundary-work appears to be biomedicine’s reactive strategy in the field to changing environmental demands and local forces. Biomedical practitioners’ reactive strategies to alternative medicine represent unintended reactions to conflicting forces and demands in the field. They enable us to differentiate hard-core professional domains from more negotiable areas where the biomedical profession can relax its boundaries. By changing the contours of boundaries in the field, the biomedical discourse manages to absorb its competitor within its professional jurisdiction without a battle, while the absolute epistemological hegemony of biomedicine remains secure. In the field, no moral contamination, deliberate epistemological discussion, strict formal regulations, or formal legal restrictions are necessary for controlling social agents.

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