Sociology and Medicine

Selected Essays by P.M. Strong

Anne Murcott

• Publisher: Routledge
• Year: 2017
• eBook ISBN:
  9781351148825
• Topic: Sciences sociales
• Subtopic: Sociologie

Doctors and patients, inter-professional rivalries, how sociologists might tackle the study of vital topics in health - all these are enduring themes in sociology and medicine. These are also the long-running intellectual preoccupations of Philip M. Strong's twenty-year contribution to the field - one which he did much to shape. Posthumously gathered together for the first time in this volume, are twelve of his major essays, many of which are difficult to find or have been out of print for some years. Grouped by theme, this important reference allows the reader to trace the development of Strong's thought over his career as well as the more general development of medical sociology as a whole.

Part 1
Doctors, Patients and Encounters

Chapter 1
Aren’t Children Wonderful? – A Study of the Allocation of Identity in Development Assessment¹

Introduction

Freidson has argued that organisations ‘create’ handicap, for it is their officials who define the parameters of normality and deviance (Freidson 1972). This is not a particularly novel notion as much of the recent literature on deviance has been concerned to examine the activities of agents of social control in defining, creating and sustaining deviant identities (Lemert 1967; Rubington & Weinberg 1968). However, since Freidson’s attempt to import this organising perspective into the field of medical sociology, there seems to have been little empirical work which uses such an approach to look at the ways in which doctors create deviance or neutralise the processes leading to the creation of a deviant identity. Further, that work which has been done has concerned itself with the processing of adults (Scott 1970; Goffman 1961a) whereas many handicapping conditions can be ‘picked up’ at birth or shortly after. The study of the process of official stigmatisation in children is particularly important as there has been increasing concern within the medical professions to identify all handicaps at the earliest possible age. The introduction of early detection systems such as population screening, at-risk registers and the elaboration of medical criteria for intensive follow-up of a target population has meant that young children are increasingly subject to systematic inspection for anticipated or unanticipated deviations from medical versions of childhood normality. There are many versions of clinical normality, usually based on statistically compiled attributes of normal childhood development.² The application of these tests of developmental normality to a population of children is an attempt to differentiate ‘normal’ children from deviant ones and their application at an early age hastens the process of converting primary deviation into secondary deviation with the attendant elaboration of deviant careers for children found to be abnormal (Lemert 1967; Rock 1973).

One important difference between these procedures and those used to uncover other forms of deviance such as delinquency is that handicaps are not assumed by officials to be a form of motivated deviation. Whereas in much judicial work the reconstruction of motivation is a central problem for agents (Emerson 1969), with this type of medical deviance voluntaristic formulations are never invoked. In general, then, deviation is seen as outwith individuals’ control (Lorber, 1972). This is not to say that others may not seek to establish such a motivational framework. Indeed, the parents of handicapped children may seek to put the onus for the deviation within the will of the child or even themselves, but such accounts are not honoured. Motivational issues have one other relevance here. One possible effect of such testing is to call into question the motivation and competence of the parents. When a child is compared with an ‘ideal type’ there is always the possibility that discrepancies between the particular child’s development and the ideal type can be explained in terms of the quality of the family. Therefore, there is considerable pressure on parents to have their child accepted as normal and thereby get their own normality confirmed.

Thus, where a child is screened over time there are four problems to which doctors have to address themselves in a routine fashion. Firstly, screening is bound to throw up a number of cases where there is some doubt whether the child is biologically and intellectually capable of becoming a properly constituted adult. The clinical indicators may not be of sufficient magnitude to establish once and for all that the child is handicapped (Davis 1963). Consequently, the doctors are often concerned to delay the pronouncement of handicap for fear that the child may eventually turn out to be normal. In these cases the doctors block the possibility of secondary deviation until there is no doubt that the child is handicapped. Of course, doctors were also concerned about the converse, definitively pronouncing children normal who might later turn out to be abnormal. Secondly, doctors have to pay attention to the indeterminate status that the act of testing confers on the child. They either have to normalise the child’s identity immediately or find ways in which the indeterminacy can be maintained until they are certain of normality or abnormality. Thirdly, the doctors have in some cases to convert the parents to accepting the correctness of a clinical version of the child’s abnormality and to preparing a familial context in which the child’s deviation is accepted in a correct manner. Fourthly, the normal stance of the doctor is to deal with presented illness episodes rather than with preventative medicine. But, while for illness episodes the identities of doctor and patient are assumed readily by both interactants, with such medical activities as screening these assumptions are more difficult to sustain, particularly if it turns out that there is little wrong with the child under inspection. In these circumstances it is difficult for the young child to assume the identity of patient and difficult for the parents to present it as such. The doctor therefore has to find a mode of handling the encounter which gives due weight to the child’s identity as normal. We argue that this is done through recourse to the normal adult manner in which children are discussed in our culture, rather than through an inappropriate clinical vocabulary.

Some work has been done on how social actors explain or neutralise their deviation (Emerson 1969; Scott & Lyman 1968; Sykes & Matza 1957). Little has been done on how agents themselves go about neutralising doubt about the status of potential deviants. We propose to concentrate on one aspect of this process, the use of neutralising techniques in different medical settings. In particular we shall be concerned to examine the ways in which doctors make recourse to everyday modes of talk about children as a means of neutralising doubts about a child’s identity. Since doctors in our culture are typically granted the right and duty to underwrite the identity of young children, their rights to formulate and enforce a particular working consensus were normally validated by the parents in the encounters we observed (Goffman 1961b). We are only concerned with this working consensus in these encounters and thus only with parents’ overt worries or the worries doctors treated them as having. There are good reasons why mothers would accept such formulation in public. For a mother to display distance from the normal rhetoric in which children are discussed in our culture would be to formulate themselves as indifferent or peculiar mothers. They may have such doubts or they may find the doctor’s remarks gushing and overstated, but they do not seem able to voice such feelings within medical encounters.

Some General Procedures for Formulating Children as Normal

A central means used by doctors to establish a child’s normality was to talk about it in the everyday manner appropriate to normally constituted children, to appeal to relevant adult assumptions about what children are like rather than face the task of explaining the clinical version of childhood with which they operated. Besides, even if this were done it might still not convince. Essential normality cannot be demonstrated by a doctor merely ticking off a child’s accomplishments on some standardised check-list, although such work is a routine part of assessment, but must be directly addressed and established by the entire manner in which the child is treated. The doctor has to demonstrate a correspondence between the clinical version of normal childhood and the everyday version. To treat the occasion solely in a clinical fashion would not be to establish the child’s normality in the everyday world.

Children are treated as a separate class of human actor lacking adult legal and interactional status and requiring in one’s interaction with them special interactional skills (Strong & Davis 1976, reprinted as Chapter 2 in this volume). Their nature requires special adult treatment and correspondingly adult maltreatment of children is more heavily sanctioned than other adult crime, e.g. the attitudes and penalties surrounding the battering or sexual molestation of young children (McCaghy 1963). Their special features are treated as requiring special institutional arrangements. Thus, as regards medical treatment there are normally separate children’s wards and ‘ideally’ a separate children’s hospital. Perhaps associated with children’s lack of competences, adults typically seem to deny the relevance in interaction with children of many of the normal criteria for treating others. Thus, in a study of the intensive care unit of an American hospital which contained both adult and child patients, it was noted:

It appears that in the minds of the nurses children are not perceived as being black or white, rich or poor, male or female, they are just children. (Coombs & Goldman 1973).

Despite this categorisation of children as a separate class of being, adults generally seem to find their actions readily interpretable and have recourse to the normal model of attributing motives and feelings that they use with fellow-adults. Thus, during the examination of young children the doctors commonly engaged in overt role-taking, imputing a host of intentions and emotions to the child: ‘He doesn’t seem to like that’, ‘He’s more interested in this’, and so on. In doing so they formulated the child as someone whose actions were readily understandable in terms of everyday schemes, i.e. as someone who was essentially normal. At the same time, since they are separate there were other features of their behaviour which were formulated by doctors as routinely uninterpretable, as seemingly odd – ‘You never know why they do it’ – but nothing to worry about since all babies did it.

The qualities involved in being ‘just children’ seem somewhat ambiguous. On the one hand children are viewed as potential adults, with the capacity to achieve many things. Thus, the developmental assessment of young children consists in part of their certification as biologically and intellectually capable of becoming a properly constituted person. This provides doctors with a routine method of reassurance, for references to a normal future adulthood can be read as a firm statement about a child’s present normality. Typical references were:

(1)Doctor: He has the feet of a footballer …. Ha-ha.

(2)Doctor: They say it’s the sign of a good athlete …. Ha-ha.

(3)Doctor: (to mother of twins, one male, one female).

Doctor: And does she drink from a cup?

Mother: Aye, she holds it like this.

Doctor: Does he?

Mother: Yes, they both use the baby ones.

Doctor: Oh, yes, I wouldn’t expect them to be drinking from a tankard yet.

Mother: No …. Ha-ha.

One variation of this appeal to the future was for the doctor to characterise what the child was doing at present in adult terms, terms which plainly did not literally characterise the present performance. Thus:

(1) A one-year-old child babbled to a doctor who responded – ‘That’s a nice story you’re telling me.’

(2) A six-month-old baby was struggling when the doctor tried to lift her to a sitting position, and the doctor commented – ‘Hey, you want to dance! … Ha-ha’

Although this reference to the future would seem an important way in which one could demonstrate a child’s normality, in practice it seemed to be much less used than either of the others, perhaps because of its slight unreality. When it was used it was always in a joking fashion, as if it was somewhat absurd to characterise a day-old baby as a footballer or to picture one-year-old twins drinking from tankards.

Children’s essential nature as wonderful

We have noted a variety of features of ‘children’ to which doctors made appeal, their separate nature, their intelligibility and their potential adulthood. This does not, however, exhaust the list. The feature which doctors’ stressed above all was the pleasure which all adults, and they in particular, felt in regarding the bearers of such characteristics, and it is the appeal to this pleasure which forms the main theme of this paper. Children as a class are commonly seen as wonderful. All children it would seem can be described as ‘wonderful’, ‘gorgeous’ and a source of ‘joy’. In contrast, we feel that to apply such epithets to all adults seems a strange claim to make. ‘Aren’t adults wonderful’ seems an odd statement. Even when such claims are made about particular adults, then good grounds must be provided or be available, grounds normally resting on action statements or occasionally on aesthetic criteria. However, this would not seem to be the case for children. Their very existence would seem to constitute sufficient grounds. Of course, being wonderful was not the only quality ascribed to children. It was also recognised that they could and would routinely constitute a source of trouble and anxiety for parents. Both of these features are illustrated in the following excerpt:

Doctor: Apart from her food are there any problems?

Mother: Well, there’s her sleeping.

Doctor: Well, what, doesn’t she sleep?

Mother: (firmly) … Well, she does now because she gets something to make her sleep.

Doctor produces her stethoscope, grins and waves it about. She dangles it in front of the child then comments to researcher ‘Isn’t it marvellous having a baby like this?’ … Researcher smiles, mother smiles at researcher.

Doctor: But it’s not always marvellous. What’s this about her not sleeping?

We may note, however, that quite often in clinics the problems that children created were glossed by both parents and doctors by the use of hyperbole, thus sustaining the theme that really they were wonderful and things were O.K. Children were commonly described by both doctors and parents as a ‘handful’, a ‘wild thing’, a ‘terror’, or a ‘monster’. Such remarks were often addressed to the child itself – ‘You’re a wild thing, aren’t you?’ – and said with a smile both to it and to the other adults present calling forth appropriate smiles for them also. Thus, even the trouble they caused was wonderful.

The sources of this wonder seem to lie both in the child’s relationship to the adult world and in its own unique qualities. Children seemed to be held to be wonderful for what they were in themselves – they had a special quality of beauty. They also lived in a special world of play and laughter, a world which adults might enter too in a child’s company.

Interviewer: People at the children’s hospital seem to think that it makes the hospital a happier place having children around.

Doctor: Oh, yes, much better, much better than adult wards. The wards at the infirmary are grim places. There’s no comparison …

Interviewer: Certainly the local authority clinics I’ve attended seem incredibly cheerful kinds of places.

Doctor: Oh, I think so, because children are spontaneously happy if they get the chance.

But children also seemed to...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Preface
• Acknowledgements
• Part 1: Doctors, Patients and Encounters
• Part 2: Professional Place, Occupational Boundary
• Part 3: Models, Methods and Methodologies
• A Bibliography of the Work of Philip M. Strong
• References
• Index