Introduction

As medical professionals, physicians in Canada have among the greatest extent of self-regulatory powers internationally. They have gained what can be described in neo-Weberian terms as a dominant form of exclusionary social closure in a competitive marketplace. Here their interests have prevailed in so far as they have managed across Canadian provinces and territories to create a legally enshrined group of insiders based on registration, with distinctive market advantages over outsiders (Saks, 2010). As this chapter will argue, the consequence of this social closure has been to make this a group, which – while differentiated by specialism and other factors and subject to variations in its statutory underpinning across provinces and territories – has generally managed to increase its income, status and power in the occupational pecking order. This has been a common pattern in the modern Western world, although in Canada this standing has been arguably more open to challenge by public opinion. This is likely to have occurred in Canada, as compared with the United States (US), because of scandals around professional discipline (Donovan, 2016) and the policy constraints surrounding an affordable and universal health care system (Nadeau et al, 2014).

Whether or not this professional self-regulation in medicine and the gains to its beneficiaries are justified and effective in terms of the public interest has increasingly been the subject of a debate driven by both internal and external actors, including physicians themselves, the state, citizens, the popular media and multinational corporations (Kuhlmann and Saks, 2008). There is no doubt, though, about the political drive for a healthier Canadian society, including through medical practice (Hutchison et al, 2011; Deber and Mah, 2014). As a result of this, medicine has become more focused on quality and the reformulation of quality as process and outcomes rather than just inputs or structures, and in the case of Ontario as an inclusive notion of health system performance. Moreover, critics as well as the public advocate increased regulatory engagement in physician oversight, lay community contribution to and awareness of governance, and analysis of the inadequacies of the current health care system. To some extent, therefore, medical regulation has been increasingly incisively analysed – not just in the wake of the 1960s and 1970s counterculture, but also beyond (Saks, 2000).