Sociological Theory and Medical Sociology

Graham Scambler

• Publisher: Routledge
• Year: 2022
• Topic: Social Sciences
• eBook ISBN:
  9781000577594
• Subtopic: Diseases & Allergies
• Index: Social Sciences

Originally published in 1987, this book builds bridges between medical sociology and mainstream theory. It does so by demonstrating in new and important ways how selected theories of major thinkers like Marx, Durkheim, Weber, Freud, Parsons, Goffman, Foucault, Habermas and Offe stand to inform, and in turn be informed by the often highly focused and empirical studies of health, disease and health care found in contemporary medical sociology. The topics covered include doctor-patient interaction and the formation of health policy.

1 The value of labour-power and health

David Blane

Introduction

Marxism has always been concerned with some of the phenomena which are now seen as the subject matter of medical sociology. Engels, for example, described the effect of environmental factors on workers’ health (Engels 1845), and Marx drew attention to the consequences of overwork by comparing the health of workers in industries covered by the Factory Acts with those in industries not protected in this way (Marx 1867). While these early ‘founding fathers’ concentrated on the effects of living standards on health, later contributors from within the Marxist tradition have also examined the provision of medical services. Tudor Hart (1971), for example, has analysed the effects of private medicine on the distribution of medical care, and Robson has examined the effects of the drug industry (1972) and professions (1977) on the NHS. Finally, some medical sociologists such as Navarro (e.g. 1978) and Doyal (e.g. 1979) are at present working within an explicitly Marxist framework.

However, it is not the intention of this chapter to review further these contributions to medical sociology. Instead an attempt will be made to explore the way in which Marxist theory and medical sociology can contribute to one another, by examining an obvious area of overlap between these two schools of thought.

McKeown’s thesis (McKeown and Lowe 1966; McKeown 1976; McKeown 1979), that rising living standards have been primarily responsible for the fall in British mortality rates, has had a profound influence on medical sociology. In his treatment of this issue, however, ‘rising living standards’ appears as an atheoretical and taken-for-granted concept. In Marx’s analysis of capitalism, in contrast, this concept, in the guise of the value of labour-power, appears as one factor in a fully developed theoretical scheme. This chapter proposes to examine the issue from both points of view. Starting with an examination of Marx’s analysis of the value of labour-power and, then, the ‘McKeown Thesis’, it goes on to focus upon the period 1870-1914, and ends by re-examining both Marx’s and McKeown’s contributions in the light of events during this period.

The value of labour-power

The status of the producer is central to Marxism. Thus the defining characteristic of capitalism is not the search for profit nor factory production, but the existence of labourers who are ‘doubly free’. ‘free’, first, of the means of production; that is dispossessed of the means needed to produce the necessities of life, and hence forced to sell their labour in order to buy these necessities. Second, ‘free’ to dispose of their labour; in the sense of being citizens under formal democracy, who have the right to make a contract with any other citizen. The former ‘freedom’ resulted from the enclosures, which deprived peasants of their land; the latter from the growth of ‘civil society’ which abolished the feudal law tying peasants to their lords’ lands. Only under these historically specific political and economic conditions did labour, or more precisely labour-power, become a commodity and the producer become a proletarian or worker who must sell his or her labour-power in order to live. Capitalism is thus a system of ‘generalized commodity production’, in which the commodity form has been extended to include the labourer’s ability to work.

In general, the value, or more accurately the exchange value, of a commodity is established by the labour-time which is normally necessary for its production at any particular stage in the development of the productive forces. In the early volumes of Capital Marx argued that commodities are exchanged on the quantitative basis of equal labour-times, and although he amended this initial formulation in the third volume, when dealing with the transformation of value into prices, it remains the case that exchange values are the basis upon which commodity prices are formed.

The value of labour-power is established in the same way as that of any other commodity; that is by the labour-time necessary for its production. As labour-power, or the ability to work, cannot be separated from the existence of the labourer, the value of labour-power equals the value of those commodities necessary for the worker’s existence. Marx analysed this value in terms of three components. First, the value of the means of subsistence necessary to maintain the worker as a labouring individual. Second, as the labourer is mortal but capital requires a continuous supply of labour-power, the value of the commodities necessary to raise the worker’s replacements. Third, the value of the commodities necessary to support the worker during the training which is appropriate to any particular type of work within the division of labour. Each of these three components will now be considered in more detail.

Subsistence

Marx was emphatic that the first of these components was neither a fixed value nor tied to a physiological minimum:

the number and extent of his [i.e. the labourer’s] so-called wants, as also the modes of satisfying them, are themselves the product of historical development, and depend therefore to a great extent on the degree of civilisation of a country, more particularly on the condition under which, and consequently on the habits and degree of comfort in which, the class of free labourers has been formed. In contradistinction therefore to the case of other commodities, there enters into the determination of the value of labour-power a historical and moral element.

(Capital 1: 171)

Similarly, and following from this, while the minimum limit may be formed by the value of those means of subsistence which are physically indispensable, ‘If the price of labour-power falls to this minimum, it falls below its value, since under such circumstances it can be maintained and developed only in a crippled state. But the value of every commodity is determined by the labour-time requisite to turn it out so as to be of normal quality’ (1: 173).

While these passages are ignored at their peril by those who argue that rising living standards are in some way incompatible with Marxism, they still leave important questions unanswered. Most importantly, how is the value of the means of subsistence established, given that it is above the physiological minimum, and how is it increased? All Marx had to say in answer to the former of these questions was ‘in a given country, at a given period, the average quantity of the means of subsistence necessary for the labourer is practically known’ (1: 171), which begs the questions ‘known by whom, and how?’, although the use of the term ‘practically’ suggests that it is an empirical issue which is resolved in practice, perhaps, during wage bargaining between workers and employers. Marx did not deal with the question of how ‘the historical and moral element’ in the labourer’s standard of living is increased, although, in what may be taken as a parallel instance, he showed that ‘the determination of what is a working day presents itself as the result of a struggle, a struggle between collective capital, i.e. the class of capitalists, and collective labour, i.e. the working class’ (1: 235). The problem with this analogy, however, lies in the difference between the length of the working day, which was established by class-wide legislation, and the generally accepted standard of living of labourers, which emerges from myriad local wage negotiations.

In a more polemical treatment of the question of wages Marx seems to imply that this difference is not important:

The maximum of profit is, therefore, limited by the physical minimum of wages and the physical maximum of the working day. It is evident that between the two limits of this maximum rate of profit an immense scale of variations is possible. The fixation of its actual degree is only settled by the continuous struggle between capital and labour, the capitalist constantly tending to reduce wages to their physical minimum, and to extend the working day to its physical maximum, while the working man constantly presses in the opposite direction. The matter resolves itself into a question of the respective powers of the combatants.

(1865: 51-2)

In this work at least, Marx was pessimistic about the workers’ chances of success, concluding that

their struggles for the standard of wages are incidents inseparable from the whole wages system, that in 99 cases out of 100 their efforts at raising wages are only efforts at maintaining the given value of labour, and that the necessity of debating their price with the capitalist is inherent in their condition of having to sell themselves as commodities.

(1865: 54)

He explained this general balance of class forces (‘in its merely economic action capital is the stronger side’) by arguing that capital always has the option of replacing labour with machines: ‘machinery is in constant competition with labour, and can often be only introduced when the price of labour has reached a certain height’ (1865: 53).

Reproduction costs

The second component in the value of labour-power consists of the commodities necessary to raise the next generation of workers.

The labour-power withdrawn from the market by wear and tear and death must be continually replaced by, at the very least, an equal amount of fresh labour-power. Hence the sum of the means of subsistence necessary for the production of labour-power must include the means necessary for the labourer’s substitutes, i.e. his children, in order that this race of peculiar commodity owners may perpetuate its appearance in the market.

(1: 172)

This component is often referred to as ‘reproduction costs’.

Marx was not claiming that all wages included adequate reproduction costs, indeed he explicitly recognized that ‘Individual workers, millions of workers, do not get enough to be able to exist and reproduce themselves’ (1847: 79), but that the continuity of capitalist production demanded that the value of the labour-power of the class as a whole contained these reproduction costs. Anticipating a later discussion, it is also worth noting that he recognized labour-power may be paid below its value, with the difference being made up by the state. For example, ‘the honest English farmers ... depressed the wages of the agricultural labourers even beneath the mere physical minimum, but made up by the Poor Laws the remainder necessary for the physical perpetuation of the race’ (1865: 51).

This aspect of Marx’s analysis of reproduction costs has been subjected to a vigorous critique by socialist feminists. Barrett and McIntosh (1980), for example, have argued that ‘there is one point that is certain: this notion does not serve as an accurate description of the means by which the working class has been supported and reproduced’. In place of a ‘family wage’ (that is a male wage which includes adequate reproduction costs) these authors have stressed that the production of the next generation of workers crucially depends on unpaid female labour within the home and on subsidies from the state.

It is in fact possible to see these two means of subsidizing reproduction costs not as alternatives, but as historical accretions. Hewitt (1958) has described how married female workers during the early nineteenth century, while accepting the obligations of mother and housewife, had begun to develop a way of discharging these obligations through the market, by hiring young girls, old women, and industrially maimed people to nurse, child-care, cook, clean, and wash. The logical development of this system would have involved, among other things, reproduction costs (‘the family component’ of wages) being transferred from the value of male labour-power to that of female workers. Instead of this, as Hewitt documents, moral entrepreneurs, often supported by male workers, launched a veritable propaganda campaign designed to transfer married women from paid employment into unpaid domestic labour. A prominent feature of this campaign was the supposed effect of maternal employment on infant and child health, and, although the effectiveness, in this respect, of professional nursery care and paid maternity leave had already been demonstrated in France, these lessons were ignored in Britain. Whether or not as the result of this campaign, the proportion of married women in paid employment fell throughout the second half of the nineteenth century, and reached an historic low by 1900. As a solution, at least to the problem of poor infant and child health, this form of subsidizing reproduction costs proved a failure, as was shown by the unchanging infant mortality rate up to 1900 and by the high rate of rejects among a...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Notes on contributors
• Introduction
• 1 The value of labour-power and health
• 2 Durkheim and social realism: an approach to health and illness
• 3 Bodies of knowledge: Foucault and the problem of human anatomy
• 4 The lost subject of medical sociology
• 5 Parsons, role theory, and health interaction
• 6 Goffman, interactionism, and the management of stigma in everyday life
• 7 Habermas and the power of medical expertise
• 8 Rationalism, bureaucracy, and the organization of the health services: Max Weber’s contribution to understanding modern health care systems
• 9 Political science and health policy
• Index