Bryan S Turner. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
Introduction: A Typology of Health Concepts
Concepts of health and illness stand at the core of the social values of human society because they give expression to many of our fundamental assumptions about the meaning of life and death. A description of health, therefore, tends necessarily to offer a description of ‘the good life’ as a moral state of affairs. Although we attempt in the social sciences to avoid the confusion between the notions of ‘norm’ as a prescriptive standard and ‘normal’ as a description of an average state of affairs, in the everyday world these separate notions tend to merge because the description of an average provides a convenient measure of morality. In addition, the conception of illness as disease is drived from the old French word aise meaning ‘comfort,’ and it indicates the fact that an illness involves discomfort or lack of ease; it is comfort as to strengthen or to fortify. The discomfort of disease is the loss of power we experience in situations that are otherwise comfortable or homely. Discomfort and disease both express our subjective sense of alienation, which follows the disempowerment of illness, while ‘normal’ provides a lay benchmark for things that are both healthy and moral (King 1982: 119).
Medical terms are frequently employed as metaphors to describe society, as in a ‘sick society,’ or to categorize deviancy in individuals, as in a ‘sick mind.’ Corporations or national economies that are financially sound are often referred to as being ‘healthy.’ It is hardly surprising, therefore, that concepts of health tend to be highly contested because they involve struggles over the moral significance of life. Conceptions of health tend to merge into or be based on fundamental religious and moral views about existence, and differences in orientations towards health tend to reflect or to express basic structural and cultural differences in power relations in society. The result is that there is little consensus about what constitutes ‘health’ and ‘illness,’ which are and remain ‘essentially contested concepts.’
Given these basic conflicts in beliefs about health and illness, it is not possible to give an authoritative account of the history of these concepts. It would be more appropriate to talk in the plural about the histories of the many conceptualizations of human well-being and suffering. In order to simplify the problems, I shall start with a general model of the historical development of concepts of health and illness. My argument is that beliefs about health and illness in traditional or premodern societies were inextricably caught up with notions of religious purity and danger. As Mary Douglas (1966) has demonstrated, primitive notions of pollution and taboo were not about hygiene because there was simply no knowledge about such principles; concepts about scientific hygiene simply did not exist. The dietary prescriptions of the Old Testament are recommendations about religious not hygienic behaviour. In other words, medical concepts were directed at the health of the soul rather than the body.
A taboo, which for example divides the world into acceptable/not acceptable in terms of the couplet edible/not edible, is a conceptual mechanism for giving the world structure and meaning. People got sick, not because of a breach of hygienic regulations, but because they had transgressed a social norm or taboo that separated the sacred from the profane. Sickness and health were often associated with taboos about bodily fluids where contact, for example with menstrual blood, could cause illness in an individual or disaster for a tribe. For instance, Polar Eskimos explained personal misfortune, illness, and failure to catch food in terms of transgressions of taboos (typically surrounding ritualistic organization of menstruation). These misfortunes and sicknesses were treated through shamanistic practices such as seances, where a ‘confession’ took place to purify the individual and the group (Hepworth and Turner 1982: 71).
In such a system of meaning, sickness was associated with evil forces that attacked human beings through, for instance, the agency of witchcraft and demonic possession. Concepts of illness functioned within a cosmology of good and evil forces, and they were explanatory devices that described, and possibly justified, evil and misery. Notions of illness have typically been set within a general theodicy, namely a system of beliefs that attempts to explain and justify the presence of human disease and suffering. When people fall victim to disease and sickness, there is almost inevitably the question: Why me? Concepts of health and disease have typically provided an answer to that type of question. The dominant assumptions of disease were located within a discourse of sacred phenomena.
With the process of modernization, health and illness were transferred to more secular paradigms and eventually became embraced by various scientific discourses. In Western medicine, disease entities became increasingly differentiated and disease states more specified as the human body is itself differentiated into its component parts. Microbiology offered an account of minute viruses that invade the body and overtly have no connection with the moral or religious status of the individual. As scientific concepts of disease replaced traditional notions of the quasireligious state of illness, the status of the medical professional increased, and the status and role of traditional healers (medicine men, wise women, and midwives) decreased (Flint 1989). There was, in addition, a differentiation between physical and mental health which in turn relied on a basic division between mind and body. This mind/body dualism was associated with the empiricist revolution in philosophy, namely rationalist Cartesianism. The notions of ‘mental illness’ were subsequently elaborated by separate developments in clinical psychology, psychiatry, and psychoanalysis (Foucault 1971). Finally, the social sciences of health and illness were themselves part of the growing complexity of the contemporary model of sickness, where medical sociology, for instance, distinguishes among various levels, such as the illness experience in the individual, cultural categories of sickness at the social level, and finally health-care systems at the societal level (Turner 1995: 5).
The historical development of health and illness concepts is characterized by increasing secularization, the rise of scientific theories of health, the separation of mental and physical illness, the erosion of traditional therapies by scientific practices (a process that also involved the colonization of indigenous belief systems), and the differentiation of categories into specific micro-notions. The domain assumptions of health and illness phenomena became predominantly secular, but medical notions continued to evoke and be connected with paradigms of moral behaviour. For example, there is still a strong professional and lay tendency to blame people for their illness, and thus attribute moral responsibility for health status. Western societies have often ‘psychologized’ cancer by believing that at least some specific cancers result from the fact that people cannot or will not express themselves emotionally; they are blamed for their cancer because they do not manage their emotions effectively (Sontag 1978).
This model provides a useful framework for the historical exploration of disease concepts. However, we should also note that there was, even in premodern medical systems, considerable complexity and dispute. For example, in his study of the history of anatomy, Andrew Cunningham (1997) notes that there were radical differences between Plato, Aristotle, Erasistratus, and Galen as to the nature of the human body, its functions and structure, and the purpose of medicine. There is also no neat point in history where secular views came to dominate. While the anatomical works of Versalius were believed to have paved the way towards scientific medicine, Versalius clearly retained a religious view that the ultimate role of medicine is to reveal the hand of God in Nature. These medical sciences remained an important part of Natural Philosophy, namely that branch of knowledge that exhibited the laws of God. As such, scientific medicine frequently carried a covert moral and religious message. The authority of doctors trained in secular and scientific medicine has not been passively accepted by the lay public, and alternative medical systems have always thrived alongside Western allopathic medicine. In the twentieth century, there has been a great revival of alternative systems of medicine and widespread criticism of the claims of allopathic medicine. There are considerable philosophical and ethical problems with the notion of ‘scientific medicine,’ which cannot be regarded as a single, unified, and complete account of disease. In short, we cannot accept a ‘whig theory’ of medical history as the heroic march of reason that resulted in the final triumph of rational science over magical or irrational systems of medicine. We can argue, however, that the overarching religious framework of medicine and disease concepts has gone, just as Natural Philosophy has disappeared from the curriculum of the modern university.
As a heuristic device to provide this chapter with a simple conceptual structure, I argue that health concepts can be analyzed along two dimensions, namely the sacred/profane domain and the collective/individual orientation to health and illness. First, the causes and treatment of disease can be set within a sacred framework in which the ultimate explanations of illness are sought in nonnatural causes (such as divine punishment), and being sick is seen in moral terms, where human beings are held to be responsible for their illness. Alternatively, human illness is explained in natural terms by reference to causal agents such as germs or viruses, and individual humans are not held morally responsible for viral infection. Second, disease can be seen in individual terms, or the causes of human suffering and disease are explained in collective terms by reference to poor environmental conditions, low educational provision, poverty, and so forth. By combining these two dimensions, we can produce a four-cell property-space to illustrate this approach.
The growth of collectivist and secular assumptions about health and illness was characteristic of the public health movements of the nineteenth century, when radicals like Friederich Engels, Edwin Chadwick, and Rudolf Virchow identified the causes of human disease in the deprivations and alienation of working-class slums in a rapidly expanding urban environment. Disease was a collective and secular condition of social existence in emergent capitalism, where morbidity and mortality rates were directly related to the quality of the food supply and income per capita. In the twentieth century, similar concepts of health and illness have been embraced by Marxist medical sociologists such as Howard Waitzkin (1983) and Vincente Navarro (1976), and by radical historians of medicine such as Henry E. Sigerist and his students (Fee and Brown 1997). While social reformers have treated disease as an effect of social deprivation, eugenics policies under national socialism in Germany and similar medical strategies in Stalinist Russia attempted to control the health of society by collective, secular approaches to reproduction to remove biological ‘defects’ from society (Weindling 1989). These approaches to disease are very different from the individualist/secular concepts that form the basis of the allopathic medical approaches of empiricist Cartesian medicine. Illness and disease in this paradigm are seen as consequences of malfunctions in the human organism that are produced by infections. Treatment is based on allopathic strategies that attempt to control these infections through medical interventions (drugs, rest cure, surgery, and so forth). Health is improved by personal hygiene, isolation from germs and viruses, and the presence of a highly trained cohort of professional doctors with the support system of universities, medical faculties, and general hospitals. Within this individualistic and specialized context, private health insurance is a crucial responsibility of the patient if he wants an effective response to his acute condition. By contrast, socialized medical health is thought to encourage a lack of responsibility on the part of the individual and to increase the burden of the ‘undeserving poor’ on the taxpayer and the state. Socialized medicine in the American context was regarded as a political threat to the fundamental values of individualism (Porter 1997). In terms of social Darwinism, the survival of the fittest was the only safe guide to public policy.
Medical paradigms, which operate on the basis of a religious belief system and from an individualistic perspective, would include the ascetic practices of monastic religious orders, where diet and abstinence were thought to be simultaneously beneficial to soul and body. Illness was linked to the fundamentally evil nature of fallen man in creation, but human beings were exhorted to strive against evil through a ‘government of the body’ (Turner 1992). Such medico-religious paradigms can also assume more collectivist forms. Taboos attempt to regulate human behaviour in the interests of society as a whole, because individuals who disregard ritualistic prohibitions bring misfortune and disease upon the whole tribe. Shamanistic medical rituals are illustrations of this sacred and collectivist orientation.
This chapter proposes that in Western societies there has been a long historical trend, starting with the scientific revolution in the late sixteenth and early seventeenth centuries, away from collectivist/sacred conceptions towards individualistic/profane perspectives, which simultaneously charts the rise of scientific professional medicine. However, this dominant paradigm is constantly challenged by both collectivist/secular social medicine and by alternative medical paradigms that draw upon various religious legacies. At the level of both the individual and society, various paradigms can exist simultaneously. For example, it is not uncommon to find that a person dying of cancer may seek out both chemotherapy and exorcism in a desperate attempt to find a cure.
Primitive Medical Systems
In primitive societies, disease is symbolic of the relationships between the sacred and the profane world. Diagnosis and healing are both undertaken within a sacred context. According to Emile Durkheim in The Elementary Forms of the Religious Life (1954), the belief systems of primitive society were based on a profound dichotomy between the everyday world of practical utilitarian activities and the sacred world, which is organized around religious phenomena that are set apart and forbidden. Human illness and disease provide a bridge between these two worlds because sacred values are revealed to humans via the extraordinary states of consciousness, which are associated with disease. Hence, according to Henry E. Sigerist (1951: 127)
‘the primitive does not distinguish between medicine, magic and religion. To him they are one, a set of practices intended to protect him against evil forces. Spirits inhabit the objects of his environment. The ghosts of the dead are hovering over the village. The transcendental world is real to him, and he partakes in it when he dreams and his soul leaves the body temporarily and has intercourse with the spirits.’
While Sigerist’s summary of the anthropological perspective is still valuable, there are real limitations to this account. First, as Sigerist himself acknowledged, even in so-called primitive society there was, alongside the religious belief system, a realm of practical medical practices based on experience and experiment. For example, in Egyptian medicine, while there was a strong dimension of religious cosmology, there was also an ‘empirical-rational medicine,’ which had been revealed by research in 1922 by James H. Breasted of the so-called ‘Papyrus Edwin Smith.’ These documents show, among other things, that Egyptian court physicians relied on elementary diagnostic and prescriptive practices that were grounded in observations, case studies, and pragmatic responses to illness through the use of herbs, diets, rest, and other mundane approaches. It suggests that, while religious belief systems were important, physicians did not confuse religious meaning with mundane medical interventions.
Similar conclusions can be drawn from the extensive anthropological debate about magic, religion, and science. For example, Bronislaw Malinowski (1948) argued on the basis of his fieldwork that Trobriand Islanders systematically distinguish between magic, which attempts to regulate the environment through ritual, and religion, which is an expression of belief. When Trobriand fishermen were involved in outer lagoon fishing—which was considered dangerous—they regularly resorted to magic. In primitive societies, magic functions to give some structure and predictability to uncertain and dangerous contexts. Religion, by contrast, is the cultural vehicle for general social values. Similar conclusions might be drawn from the work of E. Evans-Pritchard (1937), whose field-work showed that in primitive cultures human beings believe they are surrounded by threats. These dangers are often the products of social conflicts and tensions, wherein accusations of witchcraft, for example, indicate interpersonal conflicts. Divination, which is important in explaining illness, has the important social function of allocating blame and responsibility. Thus, ‘disease categories’ function in a context of social uncertainty as explanations of misfortunate.
In Western philosophy, we often look back to Greek civilization as the cradle not only of democratic institutions, but also of natural science and rational inquiry. Certainly, Greek traditions have come to play a major role in shaping medical ethics and practice. The notion of the Hippocratic Oath itself has been fundamental to the evolution of professionalism in medical etiquette and practice. While the Greek tradition contained a mixture of rational scientific and religious perspectives and practices, generally speaking, Greek medicine represents a secular orientation to health and illness because health was seen as a consequence of natural causes. The humoral theory of disease, which survived into the modern period, was derived from the secular traditions of Hippocrates, Empedocles, and Galen. The world was conceived in terms of four basic elements (fire, water, air, and earth), four qualities (hot, cold, dry, and damp), four humours (blood, phlegm, yellow bile, and black bile), and four personality types (sanguine, phlegmatic, choleric, and melancholic). In this humoral theory, the body could be imagined as a hydraulic system in which illness represented a lack of balance (Turner 1996). For instance, melancholia was a consequence of an excess of black bile. Greek therapeutics consisted of bloodletting, diet, exercise, and bed rest, which were designed to restore the equilibrium of the system. In the Greek system, the reproductive processes that involved a sexual act were compared to a convulsion or fermentation; sex involved heating up the organism (Foucault 1986). These notions of balance also reflected the basic premise of Aristotle’s ethics in which ‘the good life’ was one that avoided the excesses of both hedonism and asceticism. In these medical regimes, diet played an especially important role. The word ‘diaita’ indicated a way of life, a regimentation or regime, or a government. Medical prescriptions for good living covered a variety of activities, including leisure, nutrition, lifestyle, and sexuality. These regimes were based on secular assumptions about medicine and the role of the physicians, who attempted to distinguish themselves from popular medicine, which included leech craft and magic. For example, the Hippocratic treatise on The Sacred Disease argued that epilepsy was not brought about by sacred causes, but could be understood within the naturalistic framework of the four humours.
Greek medical tradition also revealed the tension between an individualistic and a collectivist approach. In his Mirage of Health, Rene Dubos (1959) recalls the struggle between Hygeia and Asclepius. The former was associated with the virtues of a rational life in a pleasant and healthy environment. In Rome she was known as Salus, or general well-being, from which we derive notions such as ‘salubrious’ and ‘salutary.’ Asclepius, the first physician, by contrast did not teach wisdom as a response to illness, but found therapies in the study of plants and herbs. As the mythology of these figures evolved, Asclepius eventually appears as a self-confident young god in the company of two maidens-Hygeia from whom we derive the notion of hygiene, and Panakeia from whom we derive the concept of panacea. From these gods, a division in medicine developed that I define in terms of a collectivist (hygienic) approach and an individualistic (Asclepian) perspective. Hygeia points towards a communal and preventive approach that identifies a rational lifestyle in a salubrious environment, whereas Asclepius promotes an interventionist medicine that restores health by directly treating the ailments of an individual.
Medicine and the World Religions
While the Greek legacy of Galen (129-99 AD), Hippocrates, and Aristotle shaped medieval practice and laid the foundations for contemporary secular medicine, this Greek legacy often came to the West via the medium of Judeo-Christian beliefs. Islamic medicine was also an important conduit for this tradition, and Islamic science contributed significantly to optics and chemistry. In the Abrahamic faiths, there was often a tension between their Greek legacy and the prophetic monotheism of the Old Testament. Thus, early Christianity was a hellenizing force whose language was Greek, but whose basic notions of man and God were Hebraic (O’Leary 1949). These tensions were also present in Christian responses to health and illness.
This Judeo-Christian legacy was deeply ambiguous with respect to the importance and role of secular medicine. Pauline theology was based on an assumption about the punishment of the flesh. These attitudes were particularly prominent in the early Church’s attitudes towards women and sexuality, where marriage was at best regarded as a necessary evil against the corrupting presence of sexual desire. We must also keep in mind that the early Church expected and hoped for the end of the world in a ideological system that predicted the Second Coming of Christ as an end to human suffering and sinfulness. Given the anticipation of the end of human history, there was no strong motivation to invest in human health and happiness, which were merely illusory chimera. As the anticipation of the Second Coming largely disappeared in the official position of the Roman Church, there emerged a clear division between lay people who lived in the world (and experienced its sinfulness) and those (monks and priests) who devoted their lives to God and His works. Hence, lay people married to reproduce, while religious people ‘married’ Jesus in order to obtain grace. This division of labour created a system of exchange whereby the charisma of grace, which was stored up in the Church and handed on to the religious, was transferred to the (sinful) laity through such means as baptism, communion, and confession. There developed, therefore, a metaphorical parallel between health and grace, in which the healing grace of the body of Christ, for example, was transferred to the people through the Eucharistic feast. This metaphorical exchange of gifts ‘traded’ on an etymological similarity between salvation and solus (salutation and health). Christianity came to adopt a model in which the religious were responsible for both the health of the body and the salvation of the soul of its Flock.
The ascetic doctrines of Christianity treated the body as a means of human education through suffering. Disease and discomfort are inevitable in this world because the body, as the vessel of the soul, is corrupted by the Fall from Grace in the story of Adam’s disobedience. However, through this suffering human beings can come, through humility and pain, to a better understanding of God and themselves. The lives of the saints revealed this ambiguity towards the sinfulness of human embodiment (Turner 1997a). Disease is a corruption that indicates the sinfulness of human kind, but also creates the occasions of insight and knowledge. However, since God is the author of nature, He must also ‘send’ disease into the world. Disease had a characteristically ambiguous status. It could simultaneously indicate charismatic status through divine election and indicate the sinfulness of the victim. These contradictions are summarized in Christian theology under the notion of theodicy, which is any attempt to explain and justify God as a merciful and all-powerful being, who both loves and punishes human beings.
This ambiguity was characteristic of the Church’s response to plague and plague control. While the spread of plague was a sign of human sinfulness, religious institutions had an obligation to care for the sick and the poor. Christian houses for plague victims and leprosaria expressed this religious obligation through acts of charity. Medieval religious houses provided an institutional model of care from which evolved a secular means of poor relief and medical support. The word ‘hospital’ derives from the Latin adjective ‘hospitalis,’ relating to ‘hospites’ (guests). Early religious houses were ‘hospices’ (spitals) for pilgrims, and eventually evolved into hospitals in the modern sense. Between 1066 and 1550, 700 spitals were created in Britain, and spitals for leprosy emerged around 1078 as so-called ‘lazar houses.’ Leprosy declined after 1315 partly because of the Black Death (1346-50), which produced a profound crisis of theodicy in the West.
Christian asceticism and the institutions of charity were both responses to this profound theological condemnation of the human body as flesh and as the conduit of evil into the soul (Turner 1991). Because the Fall of Man was often blamed on the weakness of Eve, Christian theology was basically patriarchal, and its negative view of women was reinforced by the legacy of Greek philosophy and medicine. For example, Aristotle had noted that women may occasionally achieve orgasm, but their fluids were not seminal. The womb was simply a vehicle within which male sperm produced another human being. For Aristotle, there was a parallel between female blood in menstruation and male sperm in orgasm, but a woman was essentially a sterile man and her organs were merely a pale and inverted form of male organs. Greek medical manuals, which the Fathers of the Church inherited, were written to assist male fertilization and, by implication, control women’s bodies. Christian patriarchy can be regarded as a continuation of the attitude of classical authors to women and reproduction in which Christianity contributed a more potent and far reaching doctrine of sinfulness (Rousselle 1988). The mortification of the flesh by the female religious became a form of ‘holy anorexia’ by which the saints could paradoxically accept the patriarchal authority of the Church and assert their own spirituality (Bell 1985).
As the Roman Church became established as part of the dominant political institutions of the medieval period, sin became both regulated and commercialized by the practice of confession and indulgences. Both sinfulness and illness were treated within this network of monetary exchanges, whereby sinful lay people bought a salvation in the next world and health in this world. It was this commercialization of the sacred that was challenged by Luther and Calvin. The Reformation retained a conception of the total depravity of man and took away the conventional means of grace (baptism, eucharist, and confession) by which that sinfulness had been managed. The consequences of this emphasis on the individual, the authority of the written word, and the criticism of conventional religion produced both uncertainty and individualism, which contributed to the rise of the seventeenth-century scientific revolution and the erosion of medieval visions of disease and depravity.
Empirical Rationalism and the Growth of Experimental Medicine
In sociology, we are familiar with the argument (Weber 1930) that the ascetic and individualistic ethic of the Calvinistic sects had an ‘elective affinity’ with the emergent culture of competitive capitalism. Alongside the growth of rational capitalism in the seventeenth century, there was an elective affinity among the philosophy of Rene Descartes (1596-1650), Isaac Newton (1643-1727), and the growth of empirical and rational medicine. The growth of experimental medicine was founded on the rationalism of Descartes and Newton through the work of the physician Herman Boerhaave (1668-1738). Just as early capitalism assumed an individualistic and ascetic orientation, so the medical revolution of the seventeenth century assumed an individualistic, rational, and experimental ethos. There was an important convergence in values and practice between the religious Reformation and the scientific Renaissance.
Descartes created the basis of modern experimental rationalism by attempting, through a thought experiment, to exclude religious and irrational dimensions from philosophy. His rationalism attempted to find a point of certainty that was beyond further doubt. His solution was the famous individualist slogan, ‘A think, therefore I am.’ The force of this claim is to give a primacy to cognitive rationalism over emotions and feelings, but it also gives a focus to individual truths. Furthermore, it sets the foundation for the separation of mind and body, which has been characteristic of Western thought from the seventeenth century. Descartes was not entirely successful in establishing his own brand of rationalist philosophy in the universities, being replaced by an empirical philosophy that was probabilist, mechanical, and Newtonian. By the end of the seventeenth century, rationalist medicine was neo-Newtonian. However, Cartesian rationalism as a system remained a profoundly influential doctrine. Cartesian secularism became a potent aspect of medical belief. It required a simple and complete separation between mind and body. Indeed in Cartesianism, body is merely extension. However, Cartesian materialism was highly compatible with a mechanistic and materialist vision of reality.
Cartesian rationalism was combined with Newtonian physics in the quest for a mathematical system to express the laws that governed the processes of the human body. Physicians sought to create a medical system that would have the same elegance and simplicity as the Newtonian laws of gravity. In the seventeenth century, physicians such as Archibald Pitcairne (1652-1713) were part of a scientific network stretching from Edinburgh through Oxford to Leiden. This scientific network wanted to provide medical theory with mathematical precision (Guerrini 1989). This theory was referred to as ‘principiia medicinae theoreticae mathematicae’; its influence was considerable. Newtonian ideas became influential in the work of George Cheyne (1671-1743), whose publications on diet had considerable influence on the eighteenth-century London elite (Turner 1992). Cheyne offered medical advice to the London coffeehouse set who, like Cheyne, were victims of obesity. The principal causes of melancholy were connected with excessive consumption of food, drink, and tobacco.
The iatromathematicians of the period reduced God to a clockmaker who was in a general way responsible for the functioning of the Newtonian universe, but who did not intervene through revelation into the lives of human beings. There was little space here for a compassionate saviour on the cross. William Harvey (1578-1657) had discovered the principles of the circulation of the blood, validating the doctrine of circulation on Aristotelian and teleolo-gical grounds. His De Circulatione of 1649 gave further authority to this view of the human body as a mechanical pump whose flows and tides could be measured mathematically by exact calculation. The machine might need a soul to start the motor, but there was little room for a reflexive mind in this mechanical universe. We should not exaggerate the secular dimension of medical practice in the seventeenth century. Medical interventions were still typically set within a broader moral and religious framework. In prescribing a dietary regime in order to control the machine, Cheyne was following a long line of Christian physicians who sought to regulate the soul through a diet of the body. His views on a disciplined life to control the nerves appealed to the leader of Methodism John Wesley who, in his Primitive Physick of 1752, provided a methodistical version of the medical regime. In addition, the moral significance of the seventeenth-century anatomy lesson should not be underestimated. Comparative anatomy had always raised questions of conscience because it was either thought to spy on God’s secret principles of the universe, or it was thought to be a vain and pointless quest for ultimate causes. From a Christian point of view, if the body is merely flesh, can the anatomical inquiry reveal anything of God’s purpose? Anatomy had, as a result, remained a conservative area of medical science, where it continued to be dominated by, for example, Galen’s text On the Conduct of Anatomy. Anatomy had begun to change radically with the work of Andreas Vesalius (1514-64) who, through experimentation on human beings, broke away from the scholastic conformity to the Galenic tradition.
In the seventeenth century the anatomy lesson continued to function as a moral lesson. In the work of anatomists such as Andreas Laurentius (1558-1609), the anatomy section encouraged the observer to ‘know thyself’ and to embrace the feeling that ‘there, but for the grace of God, go I.’ These sentiments are well illustrated in the famous painting by Rembrandt in The Anatomy Lesson of Dr Tulp of 1632, which shows Dr Nicolaas Tulp in the Waaggebouw over the sectioned body of the criminal Aris Kint. The light and shadow employ the realism of Caravaggio, but the picture has many iconic features pointing to Christian truths about the frailty and finitude of man. For example, behind the figure of Tulp there is in the wall a Christian symbol of the shell. The anatomy lesson continued to be part of a moral discourse about sinfulness and judgement within the new framework of scientific experiment, which stood at the core of the seventeenth-century scientific revolution.
Mental Health and the Panoptic Gaze
In this chapter I am primarily concerned with concepts of physical health, but it is important to touch briefly on the issue of mental health. Contemporary sociological analysis of medical systems has been profoundly influenced by the work of Michel Foucault (1926-84), who contributed to the study of madness, French post-revolutionary medicine, the medical responses to sexual deviance, and the history of Christian attitudes to health and illness. Foucault’s work on systems of knowledge follows the tradition of Gastón Bachelard and George Canguilhem who, among other things, demonstrated that scientific revolutions often take the form of a violent break with the past (an ‘epistemological rupture’), and that science was best understood in its practice rather than in its claims, which were typically inconsistent with, or not supported by, its practical applications. Both propositions tend to be critical of whiggish views of history as an evolutionary progress.
Foucault (1971) identified a break in the middle of the seventeenth century when large numbers of people were confined in detention in such places as the General Hospital in Paris. Because the definition of madness was broad and vague, detention functioned as a way of imposing government or regulations on the poor, needy, and incompetent. ‘Madness’ is a regulatory discourse for the management of large populations. A second break occurred in the eighteenth century when ‘madness,’ as an indefinite concept, began to give way to modern notions of ‘mental illness.’ Whereas madness as in the notion of ‘folie’ or foolishness in Shakespeare’s King Lear was historically associated with divine insight and creativity, mental illness became a technical discourse that overtly attempts to distance itself from more traditional notions of possession, violence, and creativity. In ‘folie,’ reason and madness could communicate, but the modern notion of insanity has domesticated and neutralized the old forces of jest and foolishness. This new conception of mental illness required a new setting, and Foucault traced the evolution of psychiatry alongside the institutional growth of the modern asylum, which applied the principles of panoptic surveillance in Benthamite utilitarianism to the management of the mentally sick (Foucault 1977).
The point of Foucault’s history of the categories of mental health was in fact to criticize the dominant ideology of psychiatry, which analyzed the history of its own profession as the triumph of reason over witchcraft. Foucault noted that, like medieval responses to witchcraft, psychiatry involved various forms of ‘governmentality’ to regulate individuals whose behaviour was in various ways ‘deviant.’ Foucault’s approach directed attention to the function of concepts of disease and illness as components of a larger system of social regulation. Although his approach was very different in its assumptions and methods, there is some similarity between Foucault and, for example, Thomas Szasz (1961, 1970), who questioned the role of psychiatry in eroding individual and human rights. For Szasz, the differences between the liberal West and the communist East had been exaggerated because in both societies medical practices such as electroconvulsive therapy could be used to control political dissidents. The importance of writers like Foucault and Szasz in the social sciences of medicine raises fundamental questions about the alleged neutrality and reliability of scientific method and concepts in the management of human affairs because the medicalization of deviance often removed the right of an individual to rational debate. The attempt to treat homosexuality as a mental disease is a classic illustration.
The Nineteenth Century: The Struggle with Infection
Although the nineteenth century is seen in official histories of medicine as the great triumph of the scientific revolution, it also disguised a profound struggle between individualistic allopathic medicine and social medicine. At the core of this debate was on the one hand, the great success in scientific responses to infection through such techniques as vaccination, and on the other, the great social needs of the urban population and the growth in social science responses through the development of town planning. It is the classic illustration in the historical conflict between human suffering and illness as the effects of environmental pollution and social degradation versus an individualistic medical response to the disease entities. These differences are particularly important in the historical analysis of such epidemics as tuberculosis (Szreter 1988). Were the major improvements in health a consequence of medical intervention to control disease through vaccination, or were the improvements in health a function of rising standards of living? The nineteenth century produced monumental social investigations on the conditions of the poor, which continue to influence social responses to health and illness.
Throughout Europe, there were major social attempts to control illness through the political manipulation of urban conditions to improve hygiene. For example, in The Netherlands the Hygienists were a group of medical practitioners who, between 1840 and 1890, embraced the view that the health of the nation was determined by public health (Houwaart 1991). The Hygienists rejected attempts to centralize public health at the level of the state and supported some devolution of health care. The movement illustrates the fact that medical and political reform tend to go together because the Hygienists were very much a product of the 1848 liberal revolutions, which were characteristic of Germany and France. In their medical views, they rejected the contagionistic assumptions and traditional methods of describing diseases by their external aspects, which characterized early nineteenth-century epidemiology. These concepts were focused on ontology. For the Hygienists, diseases were not entities that flourish and die following environmental changes, but were caused by anatomical and physiological relations in the body. By their standardization of disease classification, they were able to collect more effective statistical evidence on morbidity and mortality. After 1850, they came to accept the Bodentheorie (ground or soil theory) of Max von Pettenkofer (1818-1901), the professor of hygiene, who claimed that epidemics were caused by soil pollution. His reputation was based on his analysis of the south German cholera epidemic of 1854. The cholera germ was a product of the soil, not the human intestine, and von Pettenkofer offered a technical solution, namely a reconstruction of urban water systems in order to regulate water levels. The Bodentheorie was well suited to the political culture of postrevolutionary Europe because it implied a technical, rather than a political, response to epidemics.
This illustration of public health in the nineteenth-century Netherlands has to be located within the broader context of the debate about contagion. The notion that disease was passed from one person to another by infective organisms by contagion can be traced back to responses to pestilence in early societies. The author of Leviticus recognized that leprosy and gonorrhea were transmitted by contagion and had therefore to be quarantined—a name derived from quarantina or the 40-day period of isolation required of people entering Italian ports who were thought to be infected by disease. The alternative view of epidemics was that they are caused by atmospheric influence or ‘epidemic miasma.’ Epidemics are caused by bad air; mal aria. Although the notion of miasma has long been discredited, it pointed to the role of poor living conditions and lack of hygiene as a cause or condition of illness. However, miasma as a theory was destroyed in the nineteenth century by the discovery of the living organisms that produced many diseases. The theory of contagion by infective organisms also led, after much professional resistance, to the conclusion that disease was spread by doctors from one patient to another. The work of Ignaz Semmelweis, from the General Hospital in Vienna, in the 1860s on puerperal fever was significant in the development of hygienic practices in the treatment of pregnant women. Through observation, Simmelweis came to the conclusion that infection (in this case puerperal fever) was spread by his own students from dead infective material. Cleanliness and hand washing in a solution of chloride of lime reduced mortality rates by more than 6 per cent. The scientific principles behind these practical procedures were eventually supplied by Joseph Lister, for example, building on the tradition of Louis Pasteur and Robert Koch. These advances made possible a much safer environment for the practice of surgery and contributed to the containment of infections following hospitalization (Youngson 1979). Despite the resistance of the medical profession to the scientific discoveries of Semmelweis and Lister, the advances in medical science made possible the growth of the medical profession as a ‘learned profession’ driven by the cutting-edge of science. It also contributed to the ‘mirage of health’ as a Utopia of modern consciousness.
The Twentieth Century: The Rise of the Medical Faculty
The twentieth century has been the context for radical changes in medicine. In these changes, one cannot separate transformations of the concepts of health and illness from the development of the role of professional medicine. Medical power and social knowledge are necessarily combined, and therefore the transformation of the university curriculum indicates shifting balances in authority between different professional groups and institutions. The reform of the medical curriculum is an important guide to these changes. The triumph of allopathic, individualist, and secular medicine over social or environmental medicine is symbolized by the publication of the Flexner Report on Medical Education in the United States and Canada in 1910. Abraham Flexner argued that scientific medicine required an intensive and protracted university-based training in the fundamental natural science curriculum. The immediate implication was that only students from the upper classes could achieve the lengthy university training necessary for professional entry into medical roles (Berliner 1984). The report had the consequence of limiting the flow of black students, women, and the working class into the medical faculty, and the recruitment of these groups into the profession showed no sign of revival in North America until after 1970 (Mumford 1983).
The Flexner Report recognized and authorized the social dominance of a research-oriented scientific medicine in which the biological sciences, along with laboratory training, provide the foundation of medical understanding. It also involved the triumph of allopathic over complementary medicine generally, and homeopathic medicine in particular. Medicine was increasingly specialized in terms of its knowledge base, and there was a division of labour around the separate organs of the body. The new breed of scientific doctors were specialists in the biological functioning of the human body.
This scientific corpus of medical knowledge was also associated with the evolution of the medical faculty within the university system as a separate, high cost, research faculty with its own unique authority and eventual dominance over the academic board. Medical faculties were increasingly separate in spatial and academic terms from the rest of the university. This physical separation reinforced the social solidarity of the medical faculty and effectively isolated the medical curriculum from other parts of the university. Specialization and subspecialization intensified the technical aspects of the scientific discourse of medicine, which was later associated with the rapid growth of physiology and pharmacology (Perrin and Perrin 1984). These curriculum changes laid the foundation of the golden age of twentieth-century scientific medicine from 1910 to 1950, in which Flexnerian reforms were dominant in North America and Europe. The growing importance of the general hospital was also associated with the rising social status of medicine. Improvements in hygiene, sanitation, and nursing resulted in declining morbidity rates, thereby making hospitals safe for their middle-class clients. The growth of scientific medicine, the research medical faculty, and the evolution of the hospital were the context for a distinctive period of medical professionalism, where the medical associations controlled entry into the medical occupational cluster (Larson 1977). There were complementary processes of professionalism in dentistry, pharmacy, nursing, and many other paraprofessional groupings. These social changes ushered in the era of the medical-industrial complex (Ehrenreich and Ehrenreich 1970) and fostered a new wave of social criticism directed at the negative consequences of the ‘medicalization’ of society and the growth of iatrogenic illness (Mich 1976).
A variety of medical analysts have argued that since the 1970s there has been a profound transformation of health-care systems associated with a decline in the centrality of professional medicine and its professional autonomy (Starr 1982). The decline of medical dominance has also been associated with the erosion of social security schemes, centralized welfare states, and the commercialization of medical provision. As the insurance companies began to influence debates and policies about health funding, the professional autonomy of doctors became constrained. Governments have also turned to a mixture of preventive medicine, third-sector finance, and public health policies to support self-regulation. These fiscal crises in health care are closely related to the greying of the population. These political and economic changes have focused the attention of medical sociologists on what Foucault called ‘governmentality’ (Turner 1997b).
The Greying of the West
By the second half of the twentieth century, there was a general agreement that the great epoch of infectious disease had come to an end. Medical historians and epidemiologists such as Thomas McKeown (1979) could argue that the infectious scourges of the previous century (tuberculosis, measles, whooping cough, and venereal disease) had virtually disappeared with improvements in housing, water supply, food, and education. McKeown’s thesis, which is not simply confined to the nineteenth century, demonstrated the importance of environmental and social causes in the decline of mortality rates. Tuberculosis was declining steadily from the 1830s before the use of bacillus Calmette-Guerin vaccination and the introduction of drug treatment such as streptomycin in 1944, paraaminosalicylic acid in 1946, and isoniazid in 1952. The drug treatment of TB had a profound impact on mortality rates. Whereas 900 girls died from TB in England and Wales in 1946, only 9 died in 1961. However, these improvements, according to McKeown, were the consequences of socioeconomic improvements that enhanced the general health status of the population.
Social inequality and poverty are now regarded as major determinants of individual health, with major differences in morbidity and mortality among social classes, as demonstrated in Great Britain by the publication of the Black Report (Townsend and Davidson 1982). Social medicine, as a result, has often been closely connected with political radicalism because it has concluded that poverty causes illness, and therefore the remedy has to be sought in social change, if necessary, of a revolutionary character. In Great Britain the new discipline of social medicine was advanced by radicals such as John Ryle, who in 1942 became the first professor of social medicine (Porter 1997). In North America, the debate about the social causes of illness and disease was promoted by medical sociologists such as Howard Waitzkin, who explored the notion of ‘the second sickness’—a disease of the body produced by social injustice (Waitzkin 1983; Waitzkin and Waterman 1974).
As mortality rates declined, the populations of the industrial societies increased because birth rates remained high. Demographic transition was the result. However, as contraceptive devices became more common and there was a new emphasis on the family and motherhood, households sought to control their reproduction and birth rates began to decline. The conventional view is that modernization, in demographic terms, involves an s-shaped curve as societies pass from high death and birth rates to low death and birth rates. One further consequence, in the absence of migration, is the greying of the population and the epidemiological transition as deaths from infectious diseases are replaced by mortality determined by cancer, heart disease, and strokes. As Western societies became more affluent, geriatric illnesses such as diabetes came to dominate the demography of advanced societies. In terms of social knowledge, these changes were accompanied by the rise of social gerontology, which remains an incoherent domain of theory relating to both individual and cohort ageing (Green 1993). The greying of the population has also given rise to a general debate about the impact of age dependency on the capacity of societies to provide care for the elderly. The new social gerontology has begun to chronicle a wide range of new infirmities and misfortunes waiting for human beings who have successfully survived into later life, in particular Alzheimer’s disease, which is present in 20 per cent of the population over age 85.
Although geriatric illness has not enjoyed the same status as heroic medical intervention in acute diseases, there has been considerable interest in a range of degenerative conditions. For example, there has been a medicalization of ‘women’s complaints,’ especially menopause. There has been considerable debate on the existence and consequences of premenstrual tension, the universality of menopause, and the existence of the sexual drive in old age. Some anthropologists have denied that menopause is universal, claiming that maturation for women in many societies, including Japan, is not accompanied by hot flashes, tension, and irritability (Lock 1993). Medical responses to the menopause, such as estrogen replacement therapy, have been equally controversial, with accusations that similar ageing processes in men have been ignored or neglected. Indeed many men’s activist groups argue that, given the political importance of feminism, men’s diseases such as prostate cancer have been neglected. Prostate cancer is the second leading cause of death from cancer for older men in the United States.
The greying of the population in the United States, where in 1990 more than 12 per cent were over age 65, has resulted in important political conflicts over illness categories. With medicalization there is a tendency to treat ageing as a disease which, with profound medical interventions (cosmetic surgery, hormone replacement therapy, organ transplants, and coronary bypass surgery), can be partially arrested. While the rich and famous have attempted to deny ageing and death, mainstream grey politics have challenged the assumption that immobility, memory loss, and an erosion of libidinal interest are inevitable consequences of ageing (Friedan 1993).
By the 1970s it was assumed that the conquest of disease in Western societies would require the development of drugs that would delay or manage old age. As medical attention moved from acute to chronic diseases, preventive medicine and health education would contribute to the containment of diabetes and heart disease. This complacency was shattered in the 1980s by the emergence of the HIV/AIDS epidemic, which was first reported in 1979-80 and which spread rapidly among the homosexual communities of North America, Europe, and Australia. The epidemic has, and will have, a major economic impact on Third World societies and in those communities (such as Islamic fundamentalist societies) that refuse to recognize the presence of HIV-positive communities in their midst.
The virus is now reported in 130 countries and carried by millions. In North America, it was originally confined to the homosexual communities of the West Coast and New York. In Australia, approximately 80 per cent of new cases are reported in Sydney, the gay capital of the continent. However, the virus spread to heterosexual couples and to hypodermic drug users who failed to observe the necessary etiquette of not sharing needles. The epidemic often gave rise to hostile moral condemnation of gay men, demonstrating once more the intimate connection between medical and moral discourses.
I refer to the HIV/AIDS phenomenon as an ‘epidemic’ partly to indicate its complexity. One does not die of AIDS but from the cluster of conditions (such as pneumonia) to which it gives occasion. AIDS is a medical condition that promotes a spectrum of illnesses and discomforts, so the categorization of AIDS requires other Opportunistic infections. The constellation of signs and symptoms in the context of HIV infection is termed the AIDS-related complex or ARC. In short, AIDS is socially constructed of the multiplicity of illnesses and malignancies that opportunistically flourish within a depleted immune system. Given the complexity of the condition, it is not surprising that a wealth of social metaphors also opportunistically multiplied. Susan Sontag (1989) suggests that AIDS shares with medieval plagues the notion of an invasion, but it is also organized around notions of pollution resulting from personal perversity.
Sexually transmitted diseases have forced society to rethink policies towards infectious disease, but they also demonstrated once more that medical understanding can never be easily separated from moral assumptions about normal behaviour. AIDS has also indicated that the future development of human health will inevitably and inextricably be part of a more general process of cultural globalization. In previous centuries, while plagues and epidemics were spread by migration and trade in the world, diseases were somewhat specific to geographical niches. With the growth of world tourism and trade, the global risk of infectious disease has spread rapidly. Influenza epidemics now spread almost instantaneously. There is widespread anxiety about the development of a variety of new conditions that are difficult to diagnose and to classify, complex in their functions and diffusion, and resistant to rapid or conventional treatments. The list of such conditions includes the eruption of newly discovered diseases such as hantavirus, the migration of diseases to new areas (such as cholera in Latin America), diseases produced by new technologies (such as toxic shock syndrome and Legionnaires’ Disease), and diseases transmitted from animals to humans. These problems have, along with ebola, Marburg virus, Lassa fever, and swine flu, generated a concern for ‘the coming plague’ (Garrett 1995).
These fears have been associated with the perception that we now face a new generation of hazards and risks that arise from the global pollution of the atmosphere and the environment. These global hazards gave rise to a new theory of society in the work of Ulrich Beck (1992), who argued that with modernization we have moved into an uncertain and precarious social condition called the ‘risk society.’ As society becomes more sophisticated, the potential risks from scientific experiment increase, especially where medical innovations are inadequately regulated. Indeed as societies become more deregulated and subject to market discipline, the scale of risks and hazards increases. Many critical commentators claim that the damage from the thalidomide drug, the spread of ‘mad cow disease,’ and the speculation surrounding the causes of Creutzfeldt Jacob’s Disease (CJD) are evidence of the arrival of a risk society where medical interventions and experimentations are increasingly out of control. President Clinton’s attempts to control the spread of cloning is simply further evidence for many that a ‘brave new world’ of secret medical experimentation is already upon us. The globalization of disease, the reproduction of people through new technologies, the degradation of the environment, the spread of cyborgs, and the mechanization of the domestic environment have given rise to speculation about postmodernization of the human body, which would become a hybrid phenomenon, precariously poised between nature, technology, and culture. In postmodern theory, human beings will no longer be metaphorically mechanical; they will, in fact, be mechanized.
Conclusion: The Philosophy of Medical Science
To provide a history of medical concepts is automatically to raise questions about the ontological character of disease states; to indicate that any phenomenon has a history is to imply a relativistic view of reality. In this chapter, I have been concerned to trace, through a heuristic typology of disease concepts, the broad parameters of medical change in Western societies. In so doing, I have taken for granted a range of analytical issues concerning disease. It would be important in a more detailed approach to distinguish carefully among the experiences of sickness, the social behaviour associated with disease, the social roles that people are expected to perform in such circumstances, and the disease categories by which medical science describes a range of physical and mental malfunctions. In this history of concepts of health and illness, I have been primarily concerned with expert systems of knowledge and belief.
A weak program in the sociology of knowledge may simply argue that while lay perceptions of health and illness have a history because they are embedded in everyday understandings of reality, scientific concepts of health and illness may be either true or false, but they are not determined by the cultural context within which they emerge. Medical sociology has often embraced ‘social constructionism’ as a platform for its research. This perspective is said to entail three dimensions. First, the meanings of social reality are not fixed or intrinsic, but are the product of human interaction. The meanings of social reality emerge out of the constant flux of social exchange. Second, these meanings can never be taken for granted because they are constantly contested in everyday interactions. Third, human beings are self-reflexive about these meanings and constantly intervene to discuss and to change them (Levine 1992: 186). Such a perspective has been useful in studying the processes by and through which patients and doctors negotiate the meaning or significance of illness. This perspective also goes on to argue that these meanings of illness at the microsocial level are also conditioned by, and impact upon, the more general macrobelief systems that surround health and illness concepts. At this general level, concepts of health and well-being become inextricably connected to fundamental notions of self-identity (Herzlich and Pierret 1987).
Although from a sociological point of view this constructionist argument is persuasive, it is in many respects a limited view of scientific beliefs. A critic of this orientation might argue that, while lay beliefs and everyday assumptions about health and illness are indeed the products of everyday experiences of being sick, the clinical categories of disease that arise from close scientific inspection and doctors’ observations of symptoms are not socially constructed and do not change significantly over time. One version of this argument would be to claim that some concepts of disease are more socially constructed than others (Turner 1992: 106). What people say or believe about a disease changes over time, but the clinical condition itself is relatively timeless. Thus, Ilza Veith (1981: 222) claims that Hippocrates’ clinical description of mumps could easily be identified and confirmed by a contemporary general practitioner; she argues that ‘what is unchanged is disease. What did change, however, is the way in which disease was looked upon.’ Our understanding of this contrast can be facilitated by Lester King (1982: 149), who suggests a useful distinction between a clinical entity and a disease entity. A clinical entity (from kline or bed) is a configuration or pattern that is observed by a doctor in (a bedside) interaction with a patient. The concept is thus linked to the practice of medicine. A disease entity is ‘knowledge about’ a condition that is produced by doctors’ observations, statistical information, and laboratory tests. As a disease entity becomes scientifically established, it may well radically alter a clinical identity. A textbook of medicine is, in essence, a collection of theories of disease entities. Thus, if we compare Thomas Sydenham’s seventeenth-century description of puerperal fever with Hippocrates’ description, we find a remarkable convergence. What is being described (the clinical condition of the fever) is relatively constant, but the theory behind the description has changed considerably. Theories change over time because they are produced by changes in domain assumptions, reorganization of university curricula, professional competition between scientists, new discoveries from laboratory trials, and so forth.
It is not contradictory, therefore, to hold both that there is a clinical reality (fever or mumps) which is captured in the ‘classic descriptions of disease’ that doctors handed down over the centuries (King 1982:152), and that theories and concepts of health and illness vary considerably over time, being influenced by general social values, fashion, and changing social circumstances. It is in the strong program of the sociology of knowledge and in the social studies of science tradition that one finds research that attempts to demonstrate that these fundamental concepts of science are socially produced. However, clinical entities are also socially produced by the fact that, for example, doctors are trained to recognize the signs and symptoms that announce the presence of fever or mumps. To say that fever is socially produced is not to say that it is a ‘fiction,’ or that it does not exist, or that it could be conjured up by the doctor as a magician pulls a rabbit from a hat. However, the signs and symptoms of fever in a clinical setting are mediated through and by the experiences and training of physicians, and these physicians are the products of specific and local medical cultures.
From a social science perspective, we can summarize the principal issues in contemporary understandings of the concepts of health and illness in the following manner. Regardless of the epistemological difficulties surrounding the notion of disease entities, there is widespread agreement that conceptions of disease have changed radically. It is no longer accepted that there is a universal taxonomy of disease or that medical categories are neutral. The general theories of health and illness that explain the medical condition of humanity are shaped and organized around the dominant ideologies and beliefs of a culture (its domain assumptions). Medical categories are not neutral because they typically carry and house the metaphors of a society by which praise and blame are allocated. In addition, the nineteenth-century search for the specific etiologies of every disease, in which each disease has its own cause, has been abandoned. Disease is now seen to have multiple, interactive causes and therefore no simple single cure is possible or desirable. As we have seen, the AIDS epidemic is a good illustration of this complexity. In this respect, Bachelard, Canguilhem, and Foucault have influenced social science approaches that generally accept some version of the argument that sciences develop through revolutionary paradigm shifts, and that scientific theories are socially constructed.
At the everyday level, social experiences of illness are equally shaped and constructed by cultural assumptions and social relationships. At this level of lay beliefs, there is a continuing tendency to see illness experiences within a moral framework of blame and responsibility, a framework that attempts to help individuals, in a predominantly secular environment, to answer questions about life and death. The growing literature, both lay and professional, on death and dying is one indication of the fact that despite, or because of, the erosion of the authority of traditional religious institutions, rituals, and beliefs, ordinary individuals need to find some meaning for the seemingly trivial nature of the passage from birth to the grave (Nuland 1994).