David Armstrong. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
At the end of the eighteenth century a new explanatory model of illness emerged in Parisian hospitals (Ackerknecht 1967). This new model replaced the constantly shifting symptoms of humoral medicine with the novel idea that illness was a product of a specific localized pathological lesion within the body. The contemporary emergence of the clinical examination and autopsy with which to identify the lesion, and the hospital in which to capture it, represented the practical and institutional manifestations of the perception of illness. Over the subsequent two centuries this framework was extended and developed, culminating in the elaborate and sophisticated biomedical view of health and illness that exists today. The new model of disease and illness provided what must count as the most successful theory of health and illness, spreading over the last two centuries to become the major formal explanatory framework for illness in all countries of the world. As Foucault observed, for two centuries this theory has provided ‘the dark, but firm web of our experience’ (Foucault 1963).
The phenomenal success of the biomedical theory of illness has constituted the essential backdrop for social theorizing about health and illness. The pathological lesion has provided the critical context in which—and sometimes against which—social theorizing has developed. This chapter will therefore map social theorizing about health and illness in its relation to this overarching explanatory framework of pathological medicine. This chapter examines this relationship in five of its principal forms, which also happen to follow a rough historical progression.
First, there is the position of almost total acceptance of the biomedical model that leaves a limited role for social theorizing. At best, social theory can offer conceptual support for the medical enterprise, attempting to provide a theoretical underpinning for wayward patient behaviour, for some of the social precursors of the biological lesion, and for some of its social consequences. The second form of the relationship is less subservient, seeking out an independent role for the social sciences, yet still failing to offer any fundamental challenge to the suzerainty of biomedicine. Nevertheless, in areas such as life events, labelling theory, and patient experience, social theorizing develops an understanding of illness that lies largely outside the dominant biomedical paradigm. The third type of relationship is one of challenge as social theorizing engages with some of the outward trappings of biomedicine such as the power of the profession, its increasing medicalization of the population, and the social values often encoded in seemingly neutral medical/scientific knowledge. Fourth, there comes the point when social theorizing questions the cognitive basis of biomedicine itself, a perspective that is underpinned by viewing biomedicine as historically and culturally located, as simply one way—albeit a very successful way—of modelling illness. Finally, reflecting the postmodern turn in late twentieth-century thought, the chapter offers a brief glimpse of a reflexive world in which social theorizing about illness becomes itself the object of social theorizing.
Inevitably, through space restrictions and the limitations of authorship, this chapter is not a comprehensive or total review of all social theorizing. Rather, it attempts to offer a map or framework for understanding the various forms of social theorizing that have emerged over the last few decades.
Social Theorizing about Health-Related Phenomena Complementary to Biomedical Science
The cornerstone of the biomedical model is the belief that illness can be reduced to a pathological lesion, such as an inflammation or a cancer, within the confines of the body. This lesion has deleterious effects on neighbouring tissues, causing disruption to biological systems, negative experiences for the patient (most commonly pain), and sometimes the possibility of death.
The goal of clinical practice has therefore been the identification and treatment of the lesion. Because the lesion is held to have an effect on a patient’s perceptions and experiences, these latter could be reported to the doctor (through taking the medical ‘history’) and interpreted as symptoms of the underlying lesion. Different diseases produced different patterns of symptoms so that the nature of the lesion could often be inferred from these patient reports. However, this inferential task was considerably aided by additional evidence about the lesion gained from identifying the biological disturbances caused by the lesion that were not directly accessible to patient experience. This other evidence came in the form of the signs of disease elicited by the physician during the clinical examination. (While in recent decades the latter search has been considerably augmented by the development of clinical investigations that, in effect, extend the doctor’s senses.) Having identified the disease type, the physician could then initiate treatment that was focussed on removing the lesion and its potential dangers or, if that was not possible, ameliorating its negative effects in some way.
An additional component of the medical model, that was partially developed at first but subsequently enhanced its success and prestige, was the construction of an aetiological framework for disease that identified the precursors and causes of the underlying lesion. Importantly, these causal factors were mainly construed as biological in nature, perhaps the most famous being the germ theory of disease.
Given the extent and success of the biomedical model of disease, social science found itself constrained, at least in the early years, to working in its formidable shadow. The ‘social’ could only be introduced to the extent that it impinged in some way on the paradigm of biomedicine outlined above. In effect, the first contribution of social science to medicine, and the first opportunity for social theorizing, lay in offering complementary and supportive explanatory models for biomedicine. This contribution can be traced through three core elements of biomedicine, namely the process of identifying illness, assessment of the consequences of illness, and the discovery of the causes of illness.
The identification of illness relied partly on patients’ accounts of their experience and partly on the doctor successfully eliciting the signs of illness. However, this clinical activity depended on the patient choosing to visit the doctor: the process of deciding to visit the doctor therefore became an early focus for social science enquiry.
The problem of patients not presenting themselves to health services first emerged with the failure of many people to respond to invitations to take part in population immunization programmes. For example, the Sabin and the Salk vaccines provided what appeared to be an effective and safe technique for guarding against poliomyelitis, yet many parents did not take up the invitation to bring their children for this simple procedure. An earlier age might have explained this behaviour in terms of fecklessness or ignorance, but the preventive medicine of the 1950s turned to psychosocial explanations. The major theory to emerge from this work was the Health Belief Model which, with various revisions, is still called upon to explain health-related behaviour (Rosenstock 1965). Essentially the Health Belief Model claimed that various measurable facets of an individual, such as their level of concern, motivation, and previous experiences, could be used to explain and predict behaviour with regard to preventing ill health. Later models such as the Theory of Reasoned Action (Fishbein 1967), the Theory of Planned Behaviour (Ajzen 1985), and the Health Action Process (Schwarzer 1992), developed and clarified these ideas but remained faithful to the original objective of identifying the intrapsychic factors that determined individual behaviour.
The Health Belief Model was primarily a psychological model of human behaviour and related mainly to preventive activities, but evidence began to accumulate of a parallel problem. To be sure, many people failed to use available preventive services, but of far greater consequence—and apparently even more inexplicable—many patients chose not to seek medical attention when ill (Koos 1954). The search for the reasons why patients chose not to take their symptoms to the doctor ushered in a major body of investigations around the problem of what became known as ‘illness behaviour’ (Mechanic, 1962; Mechanic and Volkart 1960).
Initial concerns focused on patients who failed to use services despite needing preventive measures or attention for their illnesses. However, this soon spread to embrace all patient behaviour, including those patients who attended with apparently trivial complaints. Theories to explain behaviour were relatively low level, often taken from a social psychological background with an emphasis on the ‘triggers’ and impediments to seeking medical attention (Zola 1973). Above all, however, these theories of patients’ behaviour relied on the appearance of the symptom as the defining moment from which the process started. As such, the symptom was viewed as a biological fact in exactly the same conceptual form as used by medicine, a biological pointer to the underlying lesion. Certainly it was believed that there could be psychological as well as organic symptoms, but all related to an underside, an illness that the trained medical practitioner could infer. Later, with the realization that all symptoms were percepts, the way would be open to reconstruct the process of going to see the doctor and to locate its origins in patients’ more fundamental experiences and cognitions.
If patients did not respond appropriately to their symptoms, then their behaviour intruded upon the smooth operation of clinical practice; but medicine also expected patients to report their symptoms accurately and take clear note of medical explanation and advice. Early psychological studies of the consultation therefore addressed the mechanics of the interaction and of whether information had been accurately relayed and acted upon (Ley 1988). Limits to patient memory and advice on how doctors could more effectively provide patients with information were of great concern, as was the apparently related ‘problem’ of noncompliance with medical advice. In retrospect, the underlying model of human functioning reflected a very mechanistic one.
The understanding of what has since become known as help-seeking behaviour has remained a thread running through social theorizing over the last four or five decades. From its origins as an adjunct to the biomedical process, it has become a substantive area in its own right. However, perhaps ironically, the topic has tended to move outside the purview of social theorizing as health psychologists searching for the intrapsychic factors that drive behaviour have taken it up with more alacrity. Help-seeking behaviour has also proved of interest in more policy and utilization studies that now recognize that health service use is not simply a product of illness severity. More recent theorizing about risk and risk-related behaviour may yet revive this area of work within mainstream medical sociology.
Social Factors in the Cause of Illness
Perhaps the longest relationship between social science and medicine has been the joint project to explore the role of social factors in the aetiology of disease. The traditional medical model was largely concerned with identifying the immediate biophysical insults that caused disease, but it could raise no objection to an analysis for investigating the social distribution of those same factors. Indeed, attention to the distribution of aetiological factors had been a central concern of nineteenth- and twentieth-century epidemiologists, so it might be better to describe this area of social science as ‘social epidemiology.’ This reflects not only its reliance on traditional epidemiological methods, but also the rather empirical and atheoretical nature of the enquiry in that there was little need to go beyond identification of the population ‘pattern’: the medical model provided the subsequent implications. In this sense, much of the interwar epidemiological work and analyses of mortality statistics might be termed social science, although its theoretical sophistication was very limited.
Even so, historically there was a theoretical framework for the understanding of the distribution of biophysical threats, namely the Marxist, that was revived in the 1960s (Doyal 1979; Navarro 1976). In the nineteenth century, Engels observed the close relationship between the distribution of poverty and the distribution of illness, and his observations were placed in a powerful explanatory framework by his collaborator Marx. Of course, in the world of biomedicine there was little need for Marxism. It was clear that the distribution of biophysical threats was paralleled by that of poverty and deprivation, but there was little interest in whether it was due to exploitation of the working class or an inevitable part of human progress. In effect, biomedicine continued to control the conceptual and research agenda in that the central problem to be explained remained the link between the noxious agent and the pathological lesion; all else was an epi-phenomenon. If this can be construed as a struggle between the theory of Marx and the theory of biomedicine, there really was no contest. Marxism was to make more of an immediate critical impact on the organization and delivery of health services rather than on understanding the nature of health and illness.
Although it was sociology that claimed jurisdiction over mapping the social distribution of (biophysical) aetiological factors, some of the most significant developments in this area have come, perhaps ironically, from within medicine. On the one hand, the ‘McKeown thesis,’ which argued that health gains over the last two centuries could largely be explained by improving social conditions (McKeown 1979), and the foetal origins hypothesis, mostly associated with Barker (Barker 1992), which claimed it was early environmental conditions that determined later adult morbidity and mortality, have been very influential in both medical and social science in understanding the relationship between social environment and disease.
Although an overt Marxist theoretical framework might have had problems in asserting its claims against biomedicine, a more implicit and empiricist approach in the form of health inequalities research has proved a strong and fruitful line of enquiry. Inequalities in health status have remained a major feature of Western societies, despite increasing standards of living and health-care investment. A number of theories have emerged to explain these differences, ranging from the quasi-Marxist materialist explanation to a more cultural framework. A wealth of studies have tried to test and tease out the exact mechanisms through which deprivation in its many forms gets translated into compromised health status (Blane et al. 1996). There has also been a claim that the extent of the range of material inequality in any society predicts health status irrespective of the actual standard of living (Wilkinson 1996). Explaining this observation offers yet another challenge for social theorizing.
Social Consequences of Illness
For biomedicine, the consequences of disease were expressed in the biological disruption that it caused, and in as much as this might also affect the wider integrity of the patient, it remained a central focus. However, illness also marked a social status beyond the pathological lesion, and this too had implications for patients.
The classic account of the additional psychosocial impact of the lesion was developed by Parsons in his famous essay on the sick role (Parsons 1951). In effect, not only did the lesion damage the biological integrity of the patient, but it also compromised the patient’s social status. Later, critics of Parsons—and there were many—rejected this narrow formulation of the sick role. Its assumptions of consensus and harmony have become less popular as an explanatory framework in sociological theory. Equally, it would seem that the sick role as described by Parsons ignored the plight of many patients with chronic illnesses who were unable to benefit from or fulfil one or more of its characteristics.
Nevertheless, for all its faults, the sick role still forms one of the conceptual building blocks of medical social science (and its theoretical ramifications have remained a topic of interest ever since (Gerhardt 1989)). The historical significance of Parsons’ concept was that it recast the doctor/patient relationship from a therapeutic encounter to an engagement of wider ‘social control’ mechanisms. Illness was a deviant status, and without appropriate control mechanisms over patient behaviour and motivation there was a potential risk to social stability. Parsons also represented the main route through which psychoanalytic theory made its small impression on social theorizing. Parsons himself was influenced by psychoanalysis, and this perspective, as later commentators pointed out, was embedded in his notion of the sick role. Accordingly, the few attempts to bring the unconscious into medical sociology have been through rehabilitation of Parsons’ original insights. Even so, the wealth of psychoanalytic perspectives remains largely marginal to the sociological enterprise (Figlio 1987; Lupton 1997).
The idea of the patient as a social actor corresponded well with the empirical problem of patients’ behaviour that had been discovered in the early medico-social surveys. The notion of the sick role gave a conceptual basis for thinking about the apparent vagaries of patients’ response to symptoms and medical intervention. The other themes in Parsons’ original essay, namely the doctor’s responsibilities in the medical encounter, were less well cited, although they too represented a novel theoretical line of enquiry which was further developed in ensuing decades in terms of the role of the medical profession in society.
Social Theorizing about Health-Related Phenomena Ignored or Overlooked by Biomedical Science
Biomedicine defines health and illness largely in terms of biologically based diseases. This means that causes, manifestations, and consequences of disease are expressed in biological terms. This perspective also treats the ill person, often by default, as a biological object. However, social theorizing identified and addressed the other more psychosocial dimensions of the ill person. The discovery of illness behaviour and the idiosyncrasies of patient behaviour in the consultation began to open up the possibility that the patient was more than an inefficient recording instrument for the underlying pathological lesion.
Two strands in social science represented this reconstruction of the patient. First, the external aetiological factors that medicine had conceptualized in terms of biological hazards (and social epidemiology had shown to be socially patterned) began to be perceived as themselves psychosocial in nature. Second, the impact of illness was extended beyond the individualized status of the sick role to the wider social identity of the patient. These two theoretical innovations involved a reconceptualization of the form of identity embedded in patienthood, from the limited well-behaved patient entering the sick role to the holistic experiencing person engaging with chronic illness.
Although the observation that biological hazards were socially distributed was not a central part of the medical model, the analysis of social patterning did not pose a challenge in that the aetiological factors remained essentially biological in nature. However, the components of an alternative aetiological framework already existed in the very heart of social theory. Earlier in the twentieth century, Durkheim analysed suicide rates to show that they were closely related to degrees of social integration and regulation (Durkheim 1952). Examining contemporary suicide statistics in tables of three variables, Durkheim developed a primitive form of multivariate analysis to show that suicide rates varied in different European societies in a manner that fitted his theory, and that the rate was indeed lower amongst ‘integrated’ groups such as the married and Catholics.
The idea that social integration could affect the rate of suicide was taken further with postwar community studies of mental illness. If social disintegration could affect suicide then why not mental illnesses in general (Leighton et al. 1963)? At first social integration was operationalized in terms of respondents’ reports of the health of their community. Later the measure became a more individualized one involving on the one hand the disruptive stimulus of a negative life event, and on the other the protective integration afforded by social support (Dohrenwend and Dohrenwend 1981). Following Durkheim’s original insights, research has since attempted to establish whether social support, or lack of it, had a direct effect on health or acted as a buffer against negative experiences such as life events (Berkman and Syme 1979; Henderson 1980). Antonovsky (1979) provided a further theoretical development of these notions in his concept of sense of coherence that represents a more individualized version of social integrity.
In summary, the collaborative work between social epidemiologists and medical sociologists continued to explore the relationship between social factors and illness. Some of this research was directed at uncovering the links between various facets of lifestyle and their health correlates (Blaxter 1990), particularly as this integrated with the needs of the growing health promotion and illness strategies of the 1970s and 1980s, but another strand of research began to emphasize the importance of psychosocial factors. Psychologists had already reported on the effects of stress on health but, despite the initial promise, stress was proving remarkably difficult to define consistently across many studies. Life events, however, provided a more clearly defined personal ‘insult’ that could be operationalized more easily. Observations of bereavement reactions had shown the powerful immediate effects of a negative life event, and work was pursued to explore the role of life events in psychiatric illness, particularly depression, but also in organic illness (Brown and Harris 1978).
The overall result of these studies of psychosocial threats has been the creation of a conceptual field in which psychology, sociology, and clinical practice intersect. While largely accepting the biomedical definition of illness/disease, these studies have continued to assert the importance of the psychosocial environment against the more biological factors to be found in traditional models of disease aetiology.
Parsons’ notion of the sick role had shown that illness was expressed in social status as well as in biological disruption, and just as the work on aetiology had extended into a more psychosocial realm, the understanding of the social impact of illness was later enhanced. The labelling theory provided the important bridge between social aetiology and social pathology.
Labelling theory was developed in the 1960s as an explanation of why social reaction to a person could have important effects for that person (Becker 1963; Lemert 1967), but perhaps its most famous expression was in the work of Goffman. Drawing upon symbolic interactionism (Rose 1962), Goffman focussed on the everyday interactions between social actors. In later writing he was more explicit about his theoretical grounding (of frame analysis), but his texts on stigma and asylums are important statements in their own right that were to inform much later conceptualization of the impact of illness on patients (Goffman 1961, 1963). Labelling, particularly as inspired by Goffman, has proved important in the field of disability, allowing the psychosocial problems experienced by the mentally and physically impaired—mainly brought about through the reactions of others—to be identified and better understood (Higgins 1980; Scott 1969). Indeed, the WHO was sufficiently convinced of the importance of this perspective and introduced a now well-accepted classification of impairment, disability, and handicap. Impairment was classified as the patient’s biological deficit, disability was the degree to which function was affected, and handicap the extent of social problems, mostly brought about through labelling or the fear of labelling (WHO 1980; Wood 1975).
There has been subsequent theoretical development of the labelling/stigma model. For example, the distinction between felt and enacted stigma has been a particularly useful one (Scambler and Hopkins 1986), but the theoretical insights of this approach have been more remarkable for becoming a taken-for-granted framework for understanding reactions to illness. This meant that the patient became more than a passive repository for the pathological lesion. During the 1970s, this latent sentient creature awoke further as social scientists began to recognize and measure cognitions and experiences.
Cognitions and Experiences
Research on illness behaviour, which had been such a potent force for defining a disciplinary space for medical sociology, began to run out of steam in the 1970s. The problem was a theoretical one. Understanding patients’ responses to symptoms had failed to develop a coherent theory that would allow fruitful predictions; the result was a series of largely empirical studies offering at best a descriptive epidemiology of symptom prevalence. This framework was revolutionized by studies using an ethnographic/anthropological approach that argued that theorizing had to start from the patients’ understanding of the symptom’s meaning (Herzlich 1973; Kleinman 1980). This meant that health-related behaviour could be linked to patient’s cognitions or lay explanatory models of illness. For example, biomedicine explained an upper respiratory tract infection in terms of a virus, whereas most lay people seem to have ideas about draughts, wet hair, cold feet, etc, together with appropriate ‘folk’ remedies (Helman 1978). It thus became possible to begin to explain the 50 per cent of patients who failed to comply with medical instructions in terms of a failure of the doctor to identify the real underlying problem. Sociologists could then advise doctors that part of the consultation should be spent eliciting and dealing with the patient’s ‘lay theories’ (Tuckett et al. 1985).
The second aspect of patient functioning that, in parallel, became a focus for sociological work was patient experience. Rather than seeing illness as something patients ‘had’ or reacted to (especially in terms of help-seeking behaviour), it could be viewed as something patients experienced. There followed a great number of studies that explored patients’ experiences of a variety of illnesses, particularly in the ways that patients ‘made sense’ of illness-related events (Anderson and Bury 1988; Fitzpatrick et al. 1984; Scambler and Hopkins 1986).
Ironically, while the emphasis on cognitions and experience represented an initial challenge to medicine, it was not long before these same themes began to find their way into medical practice. In this case it was medicine living in the shadow of social science rather than the other way round. Understanding the patients’ view and experience of illness remains an important force in changing, even humanizing, clinical practice, and just as the old biomedical paradigm studied the clinical manifestations of the disease, modern social science writes a parallel text on the experiential manifestations of illness. However, this is largely empirical work, usually based on qualitative methods, and theoretical development has been limited.
In 1977, Engel advanced the notion of a biopsychosocial model of illness that combined the various elements of the classical biomedical model with the new researches of social scientists (Engel 1977). Despite its name, his model did not give equal priority to the different dimensions (how could it?), but offered the biomedical prime place. In effect, it can be seen as an attempt to consolidate social theorizing into biomedicine. Yet, despite frequent appeals for a biopsychosocial approach, social science had already begun to move beyond the cognitive constraints of biomedicine. Patients’ explanatory models posed an alternative understanding of the nature of illness; true, it was ‘lay’ rather than professional, ‘folk’ rather than scientific, but in effect it mapped out the ground for later battles. Biomedicine no longer had a monopoly of theories of illness.
Social Theorizing in Opposition to Medical Science
Writing in 1957, Straus made what has now become a classic observation: there was both a sociology in medicine and a sociology of medicine (Straus 1957). Sociology in medicine was concerned with offering support for the medical enterprise, in effect, a continuation of biomedical theory or an addendum to it. Certainly it seemed much more orientated towards the patient’s perspective than traditional medical practice, but it was still essentially concerned with the improvement of health services and the further amelioration of illness and disease. The sociology of medicine promised much more, but against the overwhelming dominance of the biomedical model of illness progress was slow. Indeed, initial skirmishes were not directed against the medical citadel-at the time it seemed largely impregnable—but against the way that medicine was practised. If medical knowledge was unassailable, then the medical profession and the organization of health-care delivery offered a more tempting target.
Echoing Carr-Saunders and Wilson’s 1933 classic interwar treatise on the medical profession (Carr-Saunders and Wilson 1933) and following Durkheim’s supportive stance towards professional and guild groups (Durkheim 1933), social theorists at first saw the profession and its work as a form of ideal social organization. This view certainly informed Parsons’ view and the place he reserved for the medical practitioner in his functionalist account of the doctor-patient relationship. Here was a group of people drawn together by a commitment to the welfare of the public and sharing a common expertise: these two characteristics, namely a service ideal and an esoteric knowledge base, were the basis of any profession in society (Goode 1960). Questions then arose about exactly which occupational groups could be defined as professions and, for those aspiring to professional status, the steps that might be taken to achieve it (Wilensky 1964). However, it was medicine that remained the archetypal profession against which all other claims had to be compared during the 1950s and indeed for most of the 1960s.
From the Parsonian perspective, the medical profession had been seen as an important mechanism in the maintenance of social stability, but there was an alternative account of the profession’s role in society that was less benign. This alternative view held that doctors existed because they had successfully wielded power in the marketplace to seize a virtual monopoly of control over health-care provision (Berlant 1975; Parry and Parry 1976). This enabled the profession’s past ‘altruistic’ acts, particularly those around licensing and registration, to be seen as less intended to ‘protect the public’ and more to squeeze out competition.
Perhaps the most significant break with the old sociology of the professions—which was said to have simply accepted the profession’s own definition of itself—was Freidson’s claim that the medical profession’s status was a product of political action in the widest sense (Freidson 1970). This thesis ushered in a series of new studies that ‘exposed’ the self-seeking aggrandisement of the profession. The backdrop for most of these studies was the realization that the medical profession had managed to pull off an amazing feat. By the mid-twentieth century the medical profession was extremely powerful but, unlike other commanding institutions of organized labour, the population had been largely persuaded that the profession’s power was in the public interest. The roots of this achievement clearly went back to the nineteenth century, so sociologists turned to historiographical sources, many of them secondary, to support their explanations of how medicine had succeeded. Most of these analyses focused on the marketplace. Medicine had succeeded in cornering the market for health care and it had demonstrated skilful Occupational closure’ through which new recruits did so under the auspices of the profession and, at the same time, unqualified healers were driven out of business (Larson 1977).
The sociological exposure of the doctors’ professionalizing tactics proved useful for understanding the ascendancy of the medical profession, but it has been argued more recently that the power of the profession may be in decline as clinical autonomy is restricted by third-party payers and medico-legal concerns. An alternative literature on deprofessionalization has therefore emerged that tries to set professions within the wider health division of labour and health-care systems (Hang 1988). These new studies have yet to achieve the theoretical coherence of the earlier professionalization literature, but nevertheless properly situate health work within a wider occupational context.
The argument that the growth of biomedicine under the tutelage of the medical profession might have negative consequences also resonated with further developments in relating the notion of ‘social control,’ as laid out in Parsons’ model of the doctor-patient relationship, to ‘modern medicine.’ Far from control being exercised for patient welfare and wider social well-being, medicine seemed to be extending its interest and involvement into the minutiae of social life. Not only were considerable medical resources available for the ill, but even the healthy were being persuaded that they were still ‘at risk’ and could usefully follow medical advice. The net effect was the increasing ‘medicalization’ of everyday life (Zola 1972) and of deviance (Conrad and Schneider 1980). Medicine was seen to be replacing the role of the church and the law in policing the boundary between normal and abnormal. At its mildest, ‘experts’ took responsibility away from people, thereby rendering them more docile; at its most extreme, people were being controlled and manipulated by a subtle and potentially dangerous force.
The thesis that society was becoming medicalized allowed a strong indictment of the way medical knowledge was used. Perhaps Illich’s charge in his book Medical Nemesis that ‘The medical establishment has become a major threat to health’ represented an extreme but oft-cited illustration of this position (Mich 1975: 11), but this critique was essentially about how medical care was delivered. There was little comment on the ‘validity’ of so-called scientific biomedicine. This more fundamental analysis of medicine emerged in a series of studies that emphasized less the political/economic ascendancy of medicine and more its cognitive triumph. Nevertheless, the medicalization thesis has proved an important consideration in understanding the ever-increasing demands for more health-care provision.
In 1972, Johnson published a short monograph entitled Professions and Power in which he described three historical phases of professional organization, namely, patronage, collegiate, and mediated (Johnson 1972). The basis for this division was his quasi-Marxist analysis of the relationship between professions as producers (of a service) and their clients as consumers. In any transaction between producers and consumers there is always an irreducible element of uncertainty, or indeterminacy as he called it, that both sides struggle to control. In the eighteenth century, patients largely controlled this indeterminacy because they tended to hold a higher social and economic position. Thus, the medical profession was organized under a system of patronage. During the nineteenth century, the medical profession seized control of the indeterminacy contained in medical knowledge as their work shifted to the new hospitals and their clients were drawn increasingly from lower social and economic strata. This allowed medicine to organize itself along self-governing collegiate lines. During the twentieth century, governments and other third parties (particularly insurance companies) have become more and more involved with the funding of health care; these agencies have begun to claim the right to control the indeterminacy factor by monitoring and influencing what doctors actually do in clinical situations. This represents the third phase of professional organization, namely third-party mediation. According to a study by Starr of the medical profession in the United States, over the last 200 years this process may have almost reached the point where medicine has lost its former preeminence as an autonomous self-governing body able to define the nature of illness, and he asks what should be done about it (Starr 1982).
For Johnson, the key to professional organization was control over knowledge. Four years later his colleague Jewson extended this analysis by examining the form of the knowledge itself under these different regimes of professional organization (Jewson 1976). Medical knowledge had long seemed inviolable to sociological investigation; after all, it was highly technical and came under the trusteeship of ‘science’ as a form of ‘privileged’ knowledge. However, the exclusivity and epistemological superiority of scientific knowledge was itself under siege from the sociology of science, and the way was soon open for sociologists to invade the citadel of medicine.
Social Theorizing about Medical Theories
In the English-speaking world at least, it was Freidson’s Profession of Medicine, subtitled ‘a study of the sociology of applied knowledge,’ that initially opened up a more cognitive approach to the study of medicine (Freidson 1970). Freidson tried to show that what medicine had achieved was the legitimate right to define who was ill and who was not, and what was biologically abnormal and what was normal. He also claimed that ‘illness may or may not be based in biological reality, but it is always based in social reality.’ Of course, this claim had resonance in Parsons’ 20-year-old notion of the sick role that defined a social dimension for all illness. The strong implication that it was possible for illness to exist only in social reality, without any biological correlates, was also unexceptional in view of the rhetoric of the 1960s antipsychiatry movement: that was precisely their claim. Psychiatrists had used social judgements and not biological ones to identify/label mental illness (Sedgewick 1973).
However, there was also another more radical implication in Freidson’s statement, namely that perhaps the biological reality of illness was actually irrelevant, and that it was possible to perceive all illnesses as social constructs. Such an argument appears counter-intuitive: illnesses, especially those that result in death, must be fundamentally biological in nature because individuals are fundamentally complex biological machines. On the other hand, perhaps the very claim of the fundamental nature of the physical and biological realms, particularly in its relation to human identity, was part of the problem that needed to be explained. At the very least, the essential medical distinction between normality and pathology could not be predicated in ‘nature,’ but must be dependent on social classification and judgement. This insight radically widened the possibilities for critically evaluating medicine.
During the early postwar years a new branch of sociology emerged that took scientific knowledge as its object of study. At first, it concentrated on identifying those social factors that influenced the timing and appearance of new scientific knowledge, but this approach was then transformed by the publication of Kuhn’s The Structure of Scientific Revolutions in 1962 (Kuhn 1962). Kuhn argued that it was possible for social scientists to examine the internal cognitive structure of scientific knowledge. A decade or so later this insight began to be applied to medical knowledge.
Adopting a Marxist theoretical framework, Jewson examined the ‘social forces of production’ of medical knowledge (Jewson 1976). He suggested that the three phases of professional control, as identified by his colleague Johnson, could be used to explain the form of medical knowledge that emerged. First, under patronage, or bedside medicine, as Jewson referred to it, the patient controlled the relationship so that medical practice was primarily based on the patient’s view as expressed through symptoms. It was therefore the client’s view of the world, based on detailed recounting and classification of symptoms, that was embodied in late eighteenth century medical knowledge.
With the advent of a collegiate system of professional control, a regime of hospital medicine came to dominate. Patient’s views, as expressed through symptoms, were then subordinated to the doctor’s perspective on illness that was informed by pathology. A specific pathological lesion hidden within the body became the locus of illness, not the capricious movement of obscure symptoms. This meant that the patient had to defer to the doctor’s knowledge of the true nature of illness that occurred beyond immediate lay perception. Thus, the relative relationship of activity and passivity between doctor and patient produced a system of medical knowledge in the form of pathological medicine or biomedicine—with its concomitant clinical examinations and autopsies—which, in its turn, reproduced the particular form of the doctor-patient relationship characterized by a subservient patient. According to Jewson, this process was further extended in the late nineteenth and early twentieth centuries by the increasing reliance on laboratory medicine, in which the ‘sick man’ became even further divorced from the immediate reality of his illness.
Jewson’s account of the shifts in medical knowledge described an increasing alienation of the patient from her own illness through the imposition of the medical intermediary. His work thus belongs to that humanist (and at times Marxist) trend in medical sociology which has seen itself struggling for patients’ rights in the face of medical domination. However, in parallel with this exposure of medical knowledge as both the product and producer of alienation, a different theoretical tradition proposed an alternative reading of the nature of medical knowledge. Foucault’s Birth of the Clinic, first published in 1963 (Foucault 1963) (but long in translation and even longer in recognition), also explained the emergence of biomedicine, or the ‘clinic’ as he called it, at the end of the eighteenth century, but here the analysis (coupled with his later writing) portrayed not a negative alienating force but a creative one.
The fundamental difference between the Marxist and Foucautian perspectives lies in their views of the nature and identity of the individual. For Marx, human nature and identity (and presumably the human body) is a historical given. It is different modes of production that imprint themselves on those same bodies/identities and, as with biomedicine, objectify and alienate. For Foucault, however, there is no prior identity or body. Rather the processes of objectification as represented by biomedicine serve to construct the very nature of the body. In this sense, the current anatomical reading of the body is simply one way, neither the first nor the last, of making the body legible.
In this way, Foucault’s work can be used to explore the emergence of the current dominant biomedical model that reduces illness to an intracorporal biological lesion. The disciplinary mechanism of power/surveillance, which Foucault contended has pervaded Western society since the end of the eighteenth century, can be used as a method of explaining the emergence of various facets of modern medical practice, particularly the hospital and autopsies and the clinical examination. These techniques were used in the nineteenth century to ‘discover’ the human body, and can be seen in the twentieth century as being used to construct (‘discover’) the human mind and social relations through analysis of patient’s talk and relationships (Armstrong 1983). These techniques further extend surveillance to everyone through the monitoring of ‘risk’ status in total populations (Armstrong 1995; Arney and Bergen 1982). In this sense, the fundamental building blocks of the biomedical model are revealed to be cultural artefacts (Young 1995) and biomedicine, above all else, a social activity.
Taking its cue from the sociology of knowledge, the more recent forms of social theorizing treat biomedical theories as simply another form of knowledge, as a descriptive language for constructing what is held to exist. Becoming a doctor involves internalizing this descriptive language and then imposing it in clinical practice (Atkinson 1981). Because of its privileged status, this biomedical knowledge has therefore come to define and constitute the very nature of health and illness in modern society. In this way, exploration of biomedical theory opens up the possibility of fundamental theorizing about health and illness.
Social Theorizing about Social Theorizing…
Just as biomedical theories construct a reality about which social theorizing can engage, so social theorizing constructs a world that itself can be explored with a more reflexive perspective. There is a limited literature reflecting on theory (Gerhardt 1989; Scambler 1987), but it leaves considerable scope to develop, at a sort of metalevel, theories of theories. For example, the changes in social theorizing outlined in this chapter map not only a shifting conceptual framework for understanding health, illness, and the patient, but also successive reconstructions of those objects. There are several common ‘patterns,’ including the changing reality implied by successive theories of the nature of the patient (and to a lesser extent of the doctor) that have shifted from positions of passivity and objectivity to ones of activity and subjectivity. Surely, social theorizing is not simply a passive activity in this process, monitoring the changes induced by forces beyond itself, but is an integral part of the process through which certain social objects are created. Did the concept of stigma not change the way that the disabled and handicapped were viewed, and in consequence the very experience of being in this social state? Did the emphasis on patient cognitions and experiences of illness not lead to the application of techniques, in research and in the clinic, that helped crystallize these very phenomena? A postmodern twist would suggest that social theory could become the material for further social theory in some virtual (and virtuous?) regression.
This chapter has attempted to provide a map of social theorizing about health and illness. A few conceptual roads have proved to be cul-de-sacs, many have emerged into important highways, and some of the most recent are little more than paths that need further exploration. Nevertheless, social theorizing in this area has proved fertile ground over the last few decades.
Any discussion of social theorizing in health and illness must necessarily draw boundaries around the topic. One such boundary is that which separates social theorizing about health and illness from social theorizing about other worlds, but these are not watertight compartments. Classical theorists such as Marx and Durkheim have been usefully deployed in the area of health and illness to further theoretical work, and some general conceptual schemata such as labelling have passed smoothly across the divide. Particular mention must also be made of the heterogeneous field of feminist theory and feminist writing that has had an important impact on almost all of the theoretical areas described above. In part, it has involved feminist theory simply using the health field as a suitable medium in which to develop and apply theory (Martin, 1987); in part it has been the importation and incorporation of feminist theory into social theorizing about health and illness (Lupton 1994; Stacey 1988).
Movement of theory in the opposite direction has been less noticeable. The reason why is given by the underlying thesis of this chapter: social theorizing has grown in the shadow of biomedicine and for much of its history has been tied to the core assumptions of that paradigm. It is only when it develops theoretical positions that transcend medicine will its creative output become more transferable.
In focussing on the different strands of social theorizing in health and illness, this chapter has perforce ignored the vast number of influential studies that have produced important empirical findings. It has also ignored the complex and fruitful relationship between theory and method. Arguably, the rise of qualitative methodologies over the last two decades has changed the form of social theorizing in that inductive processes rarely lead to high-level theory. Indeed, much of the output from qualitative research can only be described as descriptive, and at best offers only low-level theoretical understanding. This, of itself, would not be a problem if one study could build on the findings of another, but too often the ‘field’ simply produces another set of findings that produce yet another set of grounded concepts. Perhaps this proliferation of (conceptual) narratives is itself simply another component of the postmodern turn described above, but so long as theory remains constantly and deliberately grounded it impedes the development of the sort of social theorizing that is described in this chapter. This would be ironic, as it is theory that has provided in many different ways the facilitative framework that has enabled these empirical studies, both qualitative and quantitative, to become possible.