Systems Theory and the Sociology of Health and Illness

Observing Healthcare

Morten Knudsen, Werner Vogd, Morten Knudsen, Werner Vogd

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317637592
• Edition: 1
• Topic: Scienze sociali
• Subtopic: Studi sullo sviluppo globale

Modern societies and organizations are characterized by multiple kinds of observations, systems, or rationalities, rather than singular identities and clear hierarchies. This holds true for healthcare where we find a range of different perspectives – from medicine to education, from science to law, from religion to politics – brought together in different types of arrangements. This innovative volume explores how this polycontexturality plays out in the healthcare arena.

Drawing on systems theory, and Luhmann's theory of social systems as communicative systems in particular, the contributors investigate how things – drugs, for example – and bodies are observed and constructed in different ways under polycontextural conditions. They explore how the different types of communication and observation are brought into workable arrangements – without becoming identical or reconciled – and discuss how health care organizations observe their own polycontexturality.

Providing an analysis of healthcare structures that is up to speed with the complexity of healthcare today, this book shows how society and its organizations simultaneously manage contexts that do not fit together. It is an important work for those with an interest in health and illness, social theory, Niklas Luhmann, organizations and systems theory from a range of backgrounds including sociology, health studies, political science and management.

Part I

Polycontextural constructions

1 Drugs in modern society

Analysing polycontextural things under the condition of functional differentiation

Anna Henkel

The endeavour of this chapter is to offer a way for analysing drugs in modern society. The importance of drugs is, on the one hand, obvious: they produce measurable effects, they create costs for the health-insurance companies, and they probably share significantly in the esteem the medical profession has enjoyed for the past two thousand years. On the other hand, there is a problem: in view of the historical development of what is deemed a drug as well as the evolution of corresponding medical and natural scientific theories, ‘drugs’ can hardly be considered a consistent category. So what are drugs? This issue is further complicated by the fact that sociology does not usually pay much attention to the analysis of seemingly non-social objects such as ‘drugs’ or the relationship between society and the construction of things.

Despite the neglect of issues in sociological thinking, I will show that drugs are not simply neutral objects with given qualities but do stand in a certain relationship to medical action and communication. Furthermore, I will show how this relationship changes between the social constitution of drugs and communication with regard to medical treatment as society is transformed. Reviewing the history of pharmaceuticals, it becomes obvious that almost everything was seen as a drug at one time: from cabbage in the old Roman Empire and the fat of people hanged in the Middle Ages to certain fungi in modern society (penicillin). Given this variety, it seems worthwhile to correlate society and the distinct issues it dealt with, and, at the same time, we might learn something about this society if we take its things into consideration.

In the first two sections, this chapter provides a concept of society and a concept of drugs as starting points for the analysis that follows. These starting points are detailed in the following three sections, on the relationship between society and drugs, on current discussions on placebos and functional foods, and the relationship between drugs and organisation. The last section offers some perspectives on the importance of analysing things for the theory of society.

Conceptualise society: functional differentiation and polycontexturality

A main idea of this chapter is that what constitutes drugs changes with the evolution of society. Because we aim to obtain a clearer understanding of drugs in modern society, it is important to first get a notion of modern society. This section briefly describes the concept of modern society as a functionally differentiated society. Polycontexturality is shown to be a specific consequence from functional differentiation.

A main characteristic of modern society is its particular type of differentiation. Despite the existence of other striking characteristics, such as Weber’s idea of rationalisation or the modern idea of a knowledge society, different sociological approaches can at least agree to describe modern society as a differentiated society. This description is important in Weber’s value–spheres (1920/1988: 244 ff.) as well as in Mead’s consideration of a functional differentiation of human society through language (1967: 244, 288 ff., 326 ff.) or in perspectives of action theory (Schimank 2007) and is equally reflected in systems–theory concepts (Luhmann 1999).

Luhmann observes modern society primarily as a functionally differentiated society. His notion of functional differentiation implies that communication is no longer primarily oriented as a social hierarchy but follows self–referential selection criteria of meaning contexts (i.e. codes of functional systems). Law is not what a God defines as law but what, according to the criteria of the legal system, can be seen as lawful instead of unlawful. The same is true for science, economics, religion and several further value–spheres. Luhmann examined such specificities of functional differentiation. I will therefore simply provide a synthesis: in a theory that defines the social as self–referential communication, modern society is mainly characterised by its functional systems in the sense of self–referential contexts of meaning.

There are, of course, a lot of consequences from this perspective on society. For the purposes of this chapter I would like to draw attention only to one of them: the polycontexturality of perspectives that evolves with functional differentiation. Under the condition of functional differentiation, each functional system develops its own specific construction of a topic. As a result, there is not only one perspective on a certain topic but a number of different but equally valuable perspectives.

Take unforeseen side effects of drugs as an example. From the perspective of science, the possibility of side effects is not a risk but a fact constitutive for how science is operating; it is the idea of science to produce new facts, until now anything is seen as potentially harbouring an undisclosed issue. This at first neutral situation becomes a risk from the medical point of view: a medical treatment might shift from making someone healthy to making them sick – and this is a risk because it (as scientific progress) is outside the medical system. For the political system, the scientific fact of possible side effects, and the medical risk of causing illness, can mean the risk of political scandal. The side effects of drugs were not a part of the political discourse for a very long time. Even the Thalidomide scandal in the 1950s, a drug that caused severe birth defects, had almost no political repercussions at all. Only a second scandal involving a dietary product shortly afterwards transformed side effects into a political issue. Finally, from an economic point of view, the risk of side effects means a drop in profits. The same issue, possible unforeseen side effects of drugs, thus produces very different risks depending on the context.

In a functionally differentiated society, the terminology of polycontexturality in the aftermath of Gotthardt Günther can be applied regarding this specific relation of observation. The concept of polycontexturality in the first step refers to the level of society. It points to the fact that topics and situations can be reconstructed from different contexts of viewpoints, with consequences such as a competition of interpretational offers or mutual self-irritation or such interpretive self-irritation of these different communicational logics (Vogd 2010). The idea of polycontexturality is at the same time a logical and empirical hypothesis on society. The logical hypothesis states that a two-valued logic must be replaced by a three-valued logic so as to adequately account for the phenomenon of self-reference and its implied dimension of time. The empirical hypothesis states that society creates polycontextural relations of observation when it moves into a state of functional differentiation. Despite the fact that communication generally is thought of as recursive, polycontexturality remains the specific perspective of observation of a functionally differentiated society.

Conceptualise drugs: the drug as structural identity

In the first section we gained a starting point for the analysis of drugs in modern society by discussing the notion of modern society: modern society can be observed as functionally differentiated, with the consequence of polycontexturality regarding important issues of society. Before we can start our core analysis of drugs in modern society, we now, as a second starting point, have to develop a concept of drugs consistent with our notion of modern society. Obviously, an ontological understanding of drugs is not compatible with the notion of polycontexturality. I will argue that it is useful to conceptualise drugs as structural identities that are characterised by the (potentially changing) expectations attached to them.

A new sociology of medical treatment would not be complete if it did not take drugs into account. Since Hippocrates, medical treatment with the means of drugs is one of the three medical pillars, next to dietary and surgical means (Schmitz 1998; Schulze 2002). No small part of the reputation of the first medical practitioners is due not to the surgical and artisanal aptitude of their knowledge about a balanced way of living (the word ‘diet’ comes from the Greek word for way of living), but their reputation is due to the rational medical application of pharmaceuticals (in Greek the word for medical potions) which before then only priests could provide. Drug treatment has become the predominant means of healing, which proved functionally equivalent to other ways of medical treatment, including surgical measures (Friedrich et al. 1977; Rosenbrock and Gerlinger 2006).

Obviously, drugs are an important issue for the sociology of medical treatment. That further begs the question of whether drugs should be treated analytically with regards to a polycontextural perspective. Within social research in general, drugs are an issue that is rarely addressed (for an overview, see Abraham 2008; Henkel 2012). Taking polycontexturality as the research perspective, current approaches to observing drugs become difficult to apply, like a focus on the interests and power especially of the pharmaceutical industry on drug development (Abraham 2010) or a focus on the prescription attitudes of doctors (Lilja 1976). What remains is to use drugs themselves as the relevant reference point, as the tertium comparationis (Vogd 2010: 31) of polycontextural observation and to ask how this approach may contribute to a new sociology of medical treatment.

To make the ‘drug’ itself the tertium comparationis of polycontextural constructions incurs – at least at first – conceptual difficulties. At the core of these difficulties, especially from a perspective of system theory, is the consideration that drugs are things and accordingly cannot be observed as self-referential systems like society or organisation. On the contrary: things appear to be entirely beyond the object of research as defined by systems theory within sociology.¹ This consideration might be the reason why there was no analytical perspective on ‘things’ that developed in the context of systems theory and that empirical studies on ‘things’ are equally a desideratum.² The theoretical reservations with regard to things betrays itself in remarks according to which the research of self-referential systems required a logic of three values, while the research of things might content itself with a logic of two values (Vogd 2010: 46): a thing is, or it is not. The example of the placebos indicates that this distinction is too easy. In this case, the thing is and is not a drug at the same time, depending on the observer.

A dichotomy of self-referential systems of meaning on the one side and two-value based objective things on the other is not compatible with the general starting point of the social as communication. Meaning in this theory is conceptualised as the last horizon (Letzthorizont); non-meaning is not accessible. We therefore cannot make any ‘true’ declaration about a possible observer-independent objectiveness of a being or thing as such. What is accessible for sociological research is only that which under certain social conditions successfully claims to be the true reconstruction of the world ‘outside’ of social meaning. From this perspective, approaches which claim a quasi-social influence of the non-meaningful by its materiality are to be doubted (see, e.g., Hacking 1983; Pickering 1989; Latour 1995). Instead, we are interested in how society constructs the non-meaningful and how the forms of the meaningful and description of the non-meaningful change as society changes. From the perspective of system theory’s notion of society, we can apply as a heuristic hypothesis that the social construction of the non-meaningful and probably even the function of such constructions changes with the evolution to a functionally differentiated, polycontextural society.

Things themselves are not reflexive. But how they really are is not accessible to communication. Accessible is only their communicative reconstruction. In other places I demonstrated that drugs can be analysed sociologically by means of the analytical category of the pharmacon with regard to the semantical and social evolution of the pharmaceutical (Henkel 2011, 2012, 2013). With regard to the new sociology of medical treatment endeavoured in this publication, I apply the research perspective of polycontexturality to the empirical case of the drug.

Accordingly, there are three analytical questions from the general approach which I review here: first, what it means for drugs to be considered as a tertium comparationis; second, which contextures of this tertium comparationis relate to each other; and third, which relation persists regarding a polycontextural organisation. The tertium comparationis of this contribution is the drug in the sense that ‘drug’ as a reference point remains identical, but is embedded in different discursive contexts. How can such a reference point be further understood?

A non-meaningful environment is real for communication in so far as it has been through the double filter of consciousness and communication. This meaningful construction of the non-meaningful is based on attributions of expectations. What remains is the by-no-means-unimportant question of what such expectations are attributed to. Luhmann, in this context, considers things as structural identities, analogous to persons, roles, programmes and values which equally attract expectations and make them durable by themselves persisting as an identity (1984: 424 ff.). In the case of roles, programmes and values, it may remain plausible to understand such identities as communicative structures. But already, when persons are concerned, the body is forced upon the observer as something going beyond communication. This is all the more true in the case of the thing and its material substance. Yet, concerning persons, Luhmann himself explained that in this case the communicative structure provides the reference identity (2005b). In an analogous way, it is true for things: a body or material substrate does not procure the structural identity but rather a communicative structure.

Analogous to the role of the doctor or the value of human ...