The Social Construction of Illness

The second tradition in the sociology of illness is less concerned with the distribution of illness by race, class, and gender, and more concerned with the social meanings attached to illness. It is more concerned with the roles of provider and patient, and with what these roles say about the distribution of power and authority in society. The social epidemiological tradition is involved in the analysis of large data sets (such as national samples) to determine statistical correlations between health status and social traits such as gender, class, and race. The social-constructionist approach is more likely to involve firsthand observation of behavior in a limited number of settings. These observations of behavior provide a basis for drawing conclusions about the nature of healthcare more generally. Favored themes in the social-constructionist approach include the management of uncertainty, the difficulties of lay-professional communication, and the use and misuse of professional authority.

THE SICK ROLE. Sociological speculation about the nature of the doctor-patient relationship begins with Talcott Parsons's discussion of the "sick role" (1951). Although Parsons's unique insight is so commonplace today that we do not appreciate its originality, he was among the first to focus on the doctor-patient dyad as a role relationship with a set of reciprocal rights, duties, and obligations.

Parsons begins with a discussion of the basic social situation in which patients and physicians find themselves. Patients are: (1) not to blame for their condition, (2) powerless, and (3) technically incompetent. Physicians' existential position is one beset with uncertainty about what ails the patient and how best to treat it. In addition, they are unable to cure many of the ills of patients, and there are difficulties with access to both patients' bodies and the intimate details of their lives.

Each role consists of four interlocking imperatives that grow out of the social assumptions made about each actor. The sick patient is granted a temporary exemption from normal social responsibilities. In exchange for this exemption, the patient must seek technically competent help, must be motivated to get well, and must comply with treatment regimens. The passivity of the patient stems from what has been called the "power asymmetry," which Parsons says characterizes the relation of doctor and patient. The only positive action Parsons ascribes to the patient is to seek help. By making this a role obligation, Parsons ignores the complexities of help-seeking behaviors. Such complexities include the recognition of a condition as illness, of the cultural and economic barriers to access, and of the nature of lay networks. In addition, with his stricture on technically competent help, Parsons invalidates any and all alternatives to allopathic medicine.

Physicians, according to Parsons, occupy roles whose demands are dictated by their existential situation. First, physicians achieve their roles by mastering basic areas of knowledge. Some physicians are smarter than others, and some know more, but all have completed the same core medical curriculum. Parsons calls this "universal achievement." Second, physicians limit their ministrations to areas of competence. They are expert in areas of health and illness, and their advice is limited to these areas. Parsons identifies this as "functional specificity." The limits of functional specificity have widened as the links between lifestyle, stress, and illness have been documented. Nonetheless, there are limits. Physicians maintain an attitude of affective neutrality. Renee Fox and Harold Lief identify this as "detached concern." Physicians are involved with the problems of their patients, but not so involved as to interfere with rational decision-making. Finally, physicians act from a stance that

Parsons identifies as "collective neutrality." The physician is not guided by self-interest or the profit motive. Rather, physicians' actions are guided by altruism, by what will restore health, whatever the sacrifice or cost to the physician, patient, or collectivity.

Parsons's analysis describes normative patterns rather than empirical occurrences. His physicians live in a world in which they share values with patients and always act in the best interests of the patient. They also act as agents of social control. The physician provides legitimate excuses from work, directs treatment, and controls access to healing resources. Tension may arise because the interests of the social system and of the patient may not coincide.

THE SOCIAL CONSTRUCTION OF ILLNESS. Parsons's "sick role" is the first sociological theory to recognize that the experience of illness is determined by social factors. Many sociologists accept Parsons's basic insights but differ with him on how the experience of illness is shaped by values and beliefs that are implicit, tacit, unexamined, and variable across cultural groupings. Conflict theorists, for example, emphasize that society is made up of competing groups with different values, rather than, as Parsons argued, cooperating groups with shared values (Freidson). For these sociologists, the physician's role as a fiduciary whose actions express the interests of patients is disputed; the physician is seen instead as a moral entrepreneur who cloaks self-interest or the interests of his or her social class in a neutral scientific language.

Conflict, or labeling, theorists share with Parsons the understanding that physicians act as agents of social control but they differ about who benefits from these gatekeeping activities and what the consequences of these activities are. For Parsons, the physician's actions certifying illness serve the entire society by promoting an environment in which the individual designated as sick can later return to productive social and economic roles. There are no long-term consequences to the labeling of individuals.

Labeling theorists contend that labeling is used by the dominant classes to protect their interests, suppress the less fortunate, and reinforce established hierarchies (Becker; Freidson). Casting an individual in the sick role stigmatizes him or her and spoils life chances (Goffman; Scheff). Susan Sontag has argued that the vocabulary of illness leads those who are sick to blame themselves. Those who are vulnerable to labeling engage in a variety of social strategies to avoid it. Peter Conrad and Joseph Schneider have described how those with epilepsy, for example, attempt to stay "in the closet" with their condition rather than suffer the discrimination that attends candor.

Much of the work of labeling theorists depends on the contention that the locus of social control in the modern state has shifted. Conrad and Schneider observe that explanations of deviance now rely on "madness" instead of "badness." The dominant agents of social control are no longer clergy, but physicians. Social problems become medicalized, and the targets of therapeutic activity are more likely than not to be the socially disadvantaged. Jane Mercer, for example, found that the label mentally retarded was significantly more likely to be applied to members of minority populations.

In labeling theory a key variable of interest is social power. Labels are used to depress the social chances of the disadvantaged are also manipulated to aid the powerful. New categories of pathology emerge that create opportunities for healthcare professionals who use newly discovered syndromes to expand their power, while the social and structural conditions that generate problems remain, or become, invisible. For example, Stephen Pfohl views the discovery of the "battered-child syndrome" as a boon to pediatric radiologists and other pediatric professionals. The beating of children is not new, however, but its treatment as a medical problem is novel. Entire diagnostic classification systems may be viewed this way. Joel Kovel has criticized the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III; now replaced by the DSM-IV), the official diagnostic system of mental health professionals, for hiding social and political meanings in apparently neutral language. The purpose of the DSM, in this view, is to enable the psychiatric profession to control the institutions of mental health.

Individuals may actively seek some labels and avoid others. Tsunetsugu Munkata points out that in Japan the label neurasthenia is widely adopted to avoid the stigmatizing term schizophrenia, while Peter Conrad has shown how both parents and school professionals embrace the label of hyperkinesis to describe unruly children. Parents accepted the label because it absolved them of blame for their children's conditions; school officials accepted the term because it offered an individual-level explanation for restive behavior, allowing them to overlook deficiencies in school organization. Many illness designations signify entities whose precise, objective markers of disease are unclear. Sufferers, however, seek the legitimation of the disease label. Suffering is a powerful determinant of self-labeling, as the proper label serves to excuse and explain behavior that would otherwise be unacceptable. The early labeling theorists concentrated on labeling as a top-down phenomenon, stressing the repressive features of labels while ignoring the benefits some labels conferred.

The fact that the powerful resist—as well as discover, create, or construct—disease classification should also not be overlooked. Phil Brown and Edward Mikkelsen describe how the inherently conservative bias of epidemiological methods that depend on population-based measures retarded the identification of an environmentally generated cancer cluster in Woburn, Massachusetts. In another case, scientific medicine and organized mining interests retarded the recognition of "black lung" as an occupational disease (Smith). Both cases illustrate how the alliance of organized science with corporate interests can burden and delay successful efforts to discover or construct disease or the cause of disease.

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