Medicine, Health and Society

Hannah Bradby

• Publisher: SAGE Publications Ltd
• Year: 2012
• ISBN:
  9781446292334
• Edition: 1
• Topic: Sozialwissenschaften
• Subtopic: Soziologie

Sharp, bold and engaging, this book provides a contemporary account of why medical sociology matters in our modern society.

Combining theoretical and empirical perspectives, and applying the pragmatic demands of policy, this timely book explores society?s response to key issues such as race, gender and identity to explain the relationship between sociology, medicine and medical sociology.

Each chapter includes an authoritative introduction to pertinent areas of debate, a clear summary of key issues and themes and dedicated bibliography.

Chapters include:

• social theory and medical sociology

• health inequalities

• bodies, pain and suffering

• personal, local and global.

Brimming with fresh interpretations and critical insights this book will contribute to illuminating the practical realities of medical sociology.

This exciting text will be of interest to students of sociology of health and illness, medical sociology, and sociology of the body.

Hannah Bradby has a visiting fellowship at the Department of Primary Care and Health Sciences, King?s College London. She is monograph series editor for the journal Sociology of Health and Illness and co-edits the multi-disciplinary journal Ethnicity and Health.

1

INTRODUCING THE SOCIOLOGY OF MEDICINE, HEALTH AND SOCIETY

In the face of scientific medicine’s failure to offer a technique to regulate nature, we remain confronted with the inevitability of sickness, ageing, suffering and death. The democratic welfare state, which offered such hope of health for the masses, has failed to eradicate inequalities and deliver universal social justice in a national setting, and inequity in social life appears inevitable. Sociology retains a conviction that suffering in all its complexity should be kept at the heart of human society’s common concerns (Fassin and Reechtman, 2009: 153). However, the means of moving beyond just witnessing or representing the suffering of others, and yet remaining in sociological territory, sometimes seems elusive (Bradby and Hundt, 2010). While globalization and new mobilities are key to our social futures, the networked nature of trans-global suffering has proven difficult to research. Healthcare systems are organized on a national basis and constitute an important part of the imagined or actual bond between the state and the citizen. The prospects for theoretically complex, methodologically robust research addressing questions that breach national boundaries and disciplinary norms seem poor at a time when global economic recession is severely limiting the funds available for speculative and sociological research.

Auguste Comte’s suggestion that sociology constitutes the ‘Queen of the Sciences’ (Comte, 1896) because it includes and integrates all the other sciences and relates their findings into a cohesive science of human society remains an aspirational potential. However, this depends on an ability to encompass methods and material that stretch from the aesthetics of suffering to the influence of corporations on global health, without being distracted by disciplinary politics.

This book surveys the main areas covered by the sociology of health, illness and medicine in order to assess the ongoing significance and likely future direction of the field. The main research problems that are addressed through the course of the book can be described as follows:

 

1. Inequalities in rates of morbidity and mortality along various dimensions of stratification, particularly socio-economic class, gender and ethnic group;
2. The embodied aspects of experiencing illness, disability and pain and the ways that the body as a cultural object problematizes biomedical models of the body;
3. The organization of healthcare in a national welfare system in which the interests of capital, patients and professionals are all operating in mutual and contradictory ways.

 

Sociological theory as a means of analysing the social relations of health, illness and medicine is important to the field’s disciplinary claims. Chapter 2 sketches out theoretical developments from Talcott Parsons’ functionalism and its early role in defining the focus of medical sociology, through the development of conflict theory, interactionism and phenomenology, to the ideas of post-modernity and post-structuralism. While studies of health, illness and medicine often have implicit rather than explicit theoretical models, social theory remains a distinguishing feature when surveying the field of health studies. The implicit nature of many theoretical concepts is apparent in the body of work on health inequalities, discussed in Chapter 3. The undeniable social injustice of mortality and morbidity rates being structured by socio-economic class has meant that theoretical interrogations of the problem have been less common than studies mapping the inequalities and interventions aimed at reducing them. The relationship between socio-economic stratification and mortality levels has been well documented in British and some other European states and comparative analysis has offered clues as to the mechanisms underlying the inequalities. The issue of global disparities in mortality rates points up the centrality of gender as a social variable and shows the necessity of its consideration in conjunction with socio-economic classifications.

Chapter 4 traces the development of feminist questions about the social relations of health and illness. While the days when gender was invisible in sociological research are long gone, there are still ways in which gendered ideology renders women’s illness invisible or, paradoxically in some cases, hyper-visible. For instance, women’s rates of heart disease remain under-counted due to cultural assumptions about the interpretation of their symptoms, and yet with respect to, for instance, children’s health, women are highly visible in that mothers’ responsibility for the health of their offspring is presumed. The emergence of a field known as men’s health offers interesting parallels to the development of feminist approaches to women’s health in terms of identifying the vulnerabilities of a group defined by sex and/or gender. The limits of feminism, in terms of accounting for men’s health and for global, gendered health problems, point to other dimensions of stratification. Chapter 5 gives an account of how ethnicity and racism have developed as part of the public health agenda in the USA and the UK, and the limitations that have emerged from everyday and scientific conceptions of difference and diversity. Studying the stratification of health outcomes by class, gender and ethnicity has been central to the development of a social model of health – a multi-disciplinary process in which sociology has played a key role – and which has presented a sustained challenge to a reductionist view of health as an absence of disease.

Chapter 6 considers another major aspect of sociology’s critique of medical conceptions of health, with an account of the body and embodiment. Considering the body as a cultural object that is socially negotiated shows the ways in which medicine misses crucial aspects of illness and of suffering. Medical models of the body, its constitution in internal organs, its enhancement and capture in technological terms, can all be understood as part of bio-power – the statutory management of bodies through the technology of public health. The subjective and lived experience of pain, disability and the negotiation of medical treatment have had to be approached or recovered by using alternative methods, such as narrative, poetics and visual methods.

Chapter 7 gets to grips with the context in which medicine is practised in terms of professional, statutory and commercial structures and their interplay with patients’ and professionals’ values. The dynamics of the mutual and competing interests of corporation, state and professional bodies have been studied to the extent that sociologists have described the rise (and fall) of the medical profession in specific cultural settings, but it has not proved possible to make more general theses. In the final chapter, we revisit the main research problems that the book has covered and speculate regarding the future directions of the sociology of health and medicine.

As an aid to the reader, the Glossary gives the reader a brief definition of various terms used in the text. Sociology often makes specialized use of words that feature in other professional vocabularies and/or in everyday language, and so some indication of the intended meaning can be helpful. The Glossary is not meant to give finally conclusive, authoritative or definitive statements, but rather to offer indicative definitions to support the discussion in the main text.

REFERENCES

Bradby, H. and Hundt, G. (2010) ‘Introduction’, in H. Bradby and G. Hundt (eds), Global Perspectives on War, Gender and Health. Avebury: Ashgate. pp. 1–17.

Comte, A. (1896) The Positivist Philosophy of Auguste Comte (trans. H. Martineau). London: George Bell & Sons.

Fassin, D. and Reechtman, R. (2009) The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton, NJ: Princeton University Press.

2

SOCIAL THEORY AND THE SOCIOLOGY OF HEALTH AND MEDICINE

INTRODUCTION

Given the broad and eclectic nature of the sociology of health and medicine, any account needs to attend to the substantive research topics as well as the theoretical frameworks that have underpinned or justified the approach to research. As noted in the Prologue, theoretical frameworks derived from sociology (an inherently fragmented discipline [Johnson et al., 1984]) predominate in the sociology of health and medicine. Furthermore, the problem-solving orientation and hybrid disciplinary nature of much research relevant to medical sociology, with its strong empirical tradition, means that a theoretical position is not always explicitly described in published research. Researchers have often taken a very pragmatic approach to theory, picking elements that serve specific purposes. Despite its sometimes implicit and frequently fragmentary nature, social theory is nonetheless a key attribute of the sociology of health and medicine, and seen as distinguishing it from other social science approaches. This chapter sketches out the theoretical developments of the discipline from functionalism to realism, via interactionism, while subsequent chapters concentrate on substantive findings around particular research problems as outlined in Chapter 1.

PARSONS AND FUNCTIONALISM

The obvious place to start a survey of medical sociology is, of course, the beginning. And yet, as indicated in the Prologue, the beginnings of medical sociology are contested and there is dispute as to who were the key figures. Do we start with the mid-nineteenth-century reformers who recognized the statistical link between social position and rates of morbidity and mortality? Do we follow Foucault’s suggestion and tie the origins of sociology to those of modern medicine and the emergence of anatomical, sociological and demographic bodies as objects of interest? Whether or not he is regarded as the founding father, there’s no denying the significance of Talcott Parsons’ work for the subsequent development of medical sociology as a body of research recognized by other disciplines. Parsons offered medical sociology an ‘academic respectability by providing its inaugural theoretical orientation’ in the shape of structural functionalism, calling attention to its potential as an area of sociological inquiry (Cockerham, 2007: 293). Parsons recognized the doctor–patient relationship as a social system built upon Emile Durkheim’s interest in the societal norms, structures and processes which were beyond individuals and whose effect is social cohesion. Durkheim (1858–1917) viewed the fundamental social problem to be the limitlessness of human desires in the face of finite resources. He envisaged the resolution of this problem through the imposition of a framework of expectation that permits only attainable aspirations. When the framework fails to limit people’s desires in line with the means to respond to them, Durkheim (1952 [1897]) termed the resultant discontented normlessness ‘anomie’.

Talcott Parsons (1902–1979), influenced by Emile Durkheim, Max Weber and others, was interested in the maintenance of value consensus and its translation into a stable social order. Like Durkheim, the role of people’s internalized self-control in maintaining a functional social order, was of particular interest. Parsons was committed to grand theory to unify a social scientific understanding of society’s working under a single framework, which has come to be known as structural functionalism. Parsons’ interests were wide ranging, taking in education, race relations and psychoanalysis, and his high-profile academic career as a faculty member of Harvard University, meant that his work attracted critical comment in his own lifetime, some of which he responded to.

Like Durkheim’s explanations of suicide in terms of social facts, Parsons sought to analyse individual behaviour in the context of large-scale social systems and the link between the two was ‘pattern variables’ which structure any system of interaction. His interest in ill health was in terms of its influence on the wider functioning of society: high levels of illness and low levels of health being dysfunctional for society, preventing people from fulfilling their social roles (Parsons, 1951: 430). A certain level of good health in the population was, in Parsons’ view, a key social resource for the efficient functioning of society, with medicine working to maintain this favourable level of health. The onset of illness was of interest to Parsons because it prevented the fulfilment of social roles, such as paid employment and parental duties, and he also conceptualized disease as motivated in some measure. The motivation to withdraw from social roles and to be cared for as a sick person is, in this model, countered by the medical practitioner. Where a person’s ill health requires a relinquishing of normal social roles, he or she is expected to visit a doctor and this encounter involves a reciprocal set of obligations and privileges. The incapacitated person is offered a niche, termed ‘the sick role’, where usual expectations are lifted and he or she is permitted time off to recover. The sick role offers the privilege of bed rest and the suspension of domestic and employment duties, on condition that professional help is sought out and full cooperation is ceded to the physician. In return, the physician is reciprocally obliged to act in the patient’s best interests and to offer technically competent care in an objective fashion. Writing in the USA, Parsons underlined that the patient’s welfare, rather than personal or commercial gains through the profit motive, must inform the physician’s actions towards the patient (Parsons, 1951: 435). Where doctors achieve the required affect, neutrality and technical competence in the skilful application of medical knowledge to their patients’ problems, they are granted the freedom to behave as autonomous professionals, and have privileged access to patients’ bodies in ways that would be taboo under other circumstances.

Parsons described an ideal type, delineating institutionalized roles of doctor and patient that were reciprocal, consensual and functioned to reduce the social costs of deviant illness behaviour, such as hypochondria and malingering. The doctor’s official sanctioning of a state of illness discourages illegitimate claims to the privileges of the sick role and means that doctors and the medical diagnoses they make regulate access to sickness benefit, sick leave and treatment. Parsons saw the reciprocal obligation on the patient to make an effort to recover as the means whereby people were returned to the performance of their normal social roles as rapidly as possible, thereby reducing the harm done to the social consensus by illness. Blaxter (2004: 94) describes Parsons’ theoretical proposition as: ‘if the function of institutions is to maintain social stability, then these are the rules which are necessarily followed in the case of medicine’.

Parsons’ interest in deviance was part of a wider preoccupation in the sociology of the time. Gerhardt sees the widespread nature of the interest in deviance as a legacy of the Second World War, during which boundaries of ‘normal’ and ‘deviant’ became blurred in civilian, as well as military populations. In the aftermath of the war, it became clear that the roots of Nazi thought which justified the extermination of various ‘deviant’ groups, were far more widespread than had been thought (Gerhardt, 1989: xvii). Gerhardt emphasizes the dual nature of Parsons’ sick role, which encompassed not only the deviancy model focusing on the ‘positive-achievement’ motivated aspects, but also the incapacity model capturing the ‘negative-achievement’ aspects of illness (1989: 15).

CRITICISM OF PARSONS’ IDEALIZED TYPE

As already noted, Parsons is credited with offering a theorized sociological approach to understanding the medical treatment of illness as a social encounter. The sick role has provoked theoretical and empirical further investigation and, as a result, has been much subject to criticism. The idealized typing of doctor and patient roles has attracted criticism for being too simplified to be a useful model of real healthcare encounters. Far from the consensual negotiated doctor–patient encounter of the ideal type, a patient’s entry into the sick role can be a process that is both complex and fraught, and that is mediated by specific features of the illness and of the patient. The severity, the familiarity and the likelihood of recovery from the illness may influence how easily the patient is admitted to the sick role. Parsons’ model envisages the sick role as a temporary one, and whether it is primarily seen as a state of deviancy or of incapacity, there is a presumption that occupancy of the role will be resolved by recovery from illness and a resumption of normal social duties. Of course, this timely relinquishing of the sick role may not happen when the illness is chronic rather than acute. There is an assumption in the model that the nature of the illness brought to the doctor is irrelevant since the professional’s affect neutrality ensures the same treatment for all conditions. However, some conditions are highly stigmatized, to the extent that at certain times doctors have been unwilling to treat, for instance, people with HIV or those who have overdosed with illegal drugs. Thus, features of the patient’s illness or incapacity are relevant to the ease of their entry to the sick role, as too are characteristics of the patient. Stereotyped ideas mean that some types of people find it harder to get their symptoms taken seriou...