The Sociology of Healthcare

Alan Clarke

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317864523
• Edition: 2
• Topic: Medicine
• Subtopic: Health Care Delivery

The Sociology of Healthcare, Second Edition explores the impact of current social changes on health, illness and healthcare, and provides an overview of the fundamental concerns in these areas. This new edition features a brand new chapter entitled End of Life which will help health and social care workers to respond with confidence to one of the most difficult and challenging areas of care. The End of Life chapter includes information on changing attitudes to death, theories of death and dying, and palliative care. All chapters have been thoroughly updated to address diversity issues such as gender, ethnicity and disability. In addition, expanded and updated chapters include Childhood and Adolescence and Health Inequalities.

The text is further enhanced through the use of case studies that relate theory to professional practice, and discussion questions to aid understanding. Links to websites direct the reader to further information on health, social wellbeing and government policies. This book is essential reading for all students of healthcare including nursing, medicine, midwifery and health studies and for those studying healthcare as part of sociology, social care and social policy degrees.

In an age when health policy follows an individualist model of personal responsibility this book by Alan Clarke demonstrates with a vast array of evidence, just how much there is such a thing as society. An excellent overall book. Dr. Stephen Cowden, Senior Lecturer in Social Work, Coventry University

Chapter 1

An introduction to the sociology of health and illness

Chapter outline

• The biomedical model: an introduction and critique
• What is sociology?
• Sociological perspectives
  – Structural functionalism
  – Conflict perspective
  – Interpretive perspectives
  – Feminist perspectives
  – Social constructionism
• Summary
• Questions for discussion
• Further reading

The biomedical model: an introduction and critique

The dominant disease model is biomedical, with molecular biology as its basic scientific discipline. The biomedical model assumes diseases to be a deviation from the norm of measurable variables, without accounting for the social, psychological and behavioural dimensions of illness.

(Decker, 2005, p. 600)

Health, illness and disease not only are biological and psychological conditions but can also be viewed as social states. It is this social dimension that is at the very heart of the sociological study of health and illness. While sociologists acknowledge the importance of biological factors in the aetiology of illness, they are particularly conscious of the pervasive effects of social factors. There is a general perception of health and illness as social products. In other words, people’s experiences of health and the incidence of disease are seen as being influenced by the social, economic and cultural characteristics of the society in which they live. As described in Chapter 2, lay definitions of health, illness and disease are embedded in wider socio-cultural contexts and as such are influenced by prevailing social norms and values. These definitions vary across time and place. This also applies in the case of formal medical knowledge, treatment and practice. As will be discussed later in this chapter, some theorists maintain that medical knowledge is subject to the influence of social processes and is not simply the outcome of the objective analysis of scientific ‘facts’ about the human body and how it works. According to this view, medical knowledge is, in a sense, socially created, the implication being that disease categories are not simply the product of a rigorous scientific analysis of biomedical facts but need to be understood as the creation of a particular set of social, historical and political circumstances.

In order to explore the contention that health, illness and disease are social products, it is perhaps best at the outset to clarify what actually serves to distinguish the Western medical or biomedical model from what has been described as a ‘social’ (Morgan et al., 1985) or ‘sociological’ (Turner, 1987) model of medicine. In general, not only has it been observed that the biomedical model forms a contrast to the social model but, as Nettleton notes, ‘Many of the central concerns of the sociology of health and illness have emerged as reactions to, and critiques of, this paradigm’ (1995, p. 2).

The biomedical model is the dominant model in contemporary medicine and the medical explanations that it provides are based on a number of basic assumptions about the functioning of the human body and the nature of disease. A central distinguishing feature of the model is the way in which it assumes the existence of a dichotomy between mind and body in the conceptualisation of disease. This is referred to as ‘mind–body dualism’. The causal agent of illness is identified as being located within the body; hence emphasis is placed on the organic appearances of disease. The body, as the physical site of disease, is the object of treatment and is studied in isolation. Illness itself is perceived as a breakdown in the biochemical or neurophysiological functioning of the body, which essentially means that the relevance of social and psychological factors is overlooked or ignored. It is this expressed belief in the exclusive nature of biomedical explanations of illness and disease that leaves the medical model open to the charge of physical reductionism (Freund and McGuire, 1991, p. 6).

A second assumption characteristic of the medical model, referred to as the ‘doctrine of specific aetiology’ (Dubos, 1995), is that a specific disease always has a specific cause. As Hart notes, ‘This doctrine has been the most influential force in medical research for over a century. It implies that the way to understand disease is to create it in the laboratory and that the ingredients for explanation are found through minute observation of its bio-chemical appearances. In other words, it proposes that the symptoms of disease tell their own story’ (1985, pp. 534–5). The idea of specific aetiology emanates from the nineteenth century, when germ theory emerged to account for the causation of infectious diseases. According to this explanation, illness occurs as a result of the human body being invaded by disease-laden micro-organisms, viruses or other causative agents. The different agents produce specific pathological manifestations. The task facing curative medicine is to identify and eradicate the various causal agents and restore the individual body to a healthy, disease-free state.

In portraying disease as the consequence of the malfunctioning of the human body, the medical model adopts a mechanical metaphor as an explanatory device. The body of the sick person is likened to a malfunctioning machine in need of repair. As Freund and McGuire assert, ‘Modern medicine has not only retained the metaphor of the machine but also extended it by developing specializations along the lines of machine parts, emphasizing individual systems or organs to the exclusion of the totality of the body’ (1991, p. 227). In other words, individual parts of the body can be subjected to treatment without the rest of the body being affected. The doctor is cast in the role of a ‘body mechanic’ (Hart, 1985, p. 532) working to restore normal functioning to an organism’s biochemical system.

The biomedical model is at the heart of modern scientific medicine. Despite having undergone some changes in the light of advances in medical knowledge following the introduction of new medical technologies, many of the fundamental assumptions on which the model is based still find support today. Down the years the medical model, with its emphasis on scientific investigation and explanation, has come to displace or profoundly influence culturally derived belief systems surrounding health, illness and disease. In this regard it has been noted that

The historical fact we have to face is that in modern Western society biomedicine not only has provided a basis for the scientific study of disease, it has also become our own culturally specific perspective about disease, that is, our folk model. Indeed the biomedical model is now the dominant folk model of disease in the Western world.

(Engel, 1977, p. 130)

For Engel, the medical model has not only become a ‘cultural imperative’ but also acquired the status of dogma.

The traditional medical model has been the subject of much critical attention. This has come not only from supporters of alternative medical therapies that challenge orthodox biomedical practice, and social scientists engaged in the study of the organisation and delivery of medical care, but also from critiques of the biomedical approach that have emerged from within the medical profession itself. In essence, the stance taken by the various critics can be broadly labelled as essentially either ‘pragmatic’ or ‘fundamental’ in nature (Morgan et al., 1985, p. 14). Those who take a pragmatic approach accept in principle the biomedical model of disease but consider that, on the whole, the medical model falls short of providing a full account of the aetiology of disease. In particular, it is claimed that too much emphasis is placed on biochemical processes and insufficient consideration given to the causal significance of social and psychological factors. In marked contrast, critics who adopt a fundamental position challenge the basic assumptions and definitions characteristic of the medical model. For them, medical concepts of disease are not viewed as simply the natural outcome of the application of objective methods of scientific discovery to the study of the human body; there is an important social dimension to the creation of medical knowledge that must not be overlooked. As will be discussed later in this chapter, critics who subscribe to the idea that medical knowledge is socially constructed see medicine as a form of social practice and the application of medical labels to physical and mental conditions as the product of social processes.

Despite its dominance the biomedical model does have a number of limitations, particularly when it comes to explaining the role of medicine in improving the health of the population and accounting for the social distribution of health and illness. Firstly, historical research questions the validity of the biomedical model by suggesting that the contribution of medical intervention to the decline in mortality rates from the mid-nineteenth century through to the early decades of the twentieth century has been overstated. For example, McKeown (1976) illustrates how the death rate from respiratory tuberculosis showed a substantial decline well before the introduction of effective medical treatment in the form of antibiotics and the BCG vaccination. Furthermore, with reference to infectious diseases in general, he maintains that improvements in nutrition and hygiene were primarily responsible for the observed decline in mortality from around the middle of the nineteenth century.

Secondly, as a result of its inherent biological determinism, the medical model does not address the relationship between social conditions, such as material deprivation, and poor health. As Nettleton observes, ‘The sociology of health and illness has repeatedly demonstrated that health and disease are socially patterned’ (1995, pp. 5–6). Variations in mortality and morbidity rates between different socio-economic groups cannot be explained by reference to biological factors alone. As described in Chapter 4, lifestyle and material circumstances are important and these can vary according to non-biological factors such as social class position, ethnic status and gender.

A further shortcoming of the medical model stems from the assumption that there is a clear distinction between the mind and the body. As noted above, this mind–body dualism ensures that an instrumentalist approach is adopted towards the human body. In concentrating on the body as a discrete physical entity the medical model focuses on treating the disease as opposed to the whole person. Adopting an exclusively biomedical framework effectively results in social and psychological factors being ignored. As an alternative to the biomedical model, Engel advocates a ‘biopsychosocial model which includes the patient as well as the illness’ (1977, p. 133). He stresses the importance of taking the social context in which the patient lives into account. This is not only because psycho-social factors have a role in disease causation but also because, although biochemical abnormalities determine the form a disease takes, it is social and psychological factors that largely determine whether a person suffering from a biochemical dysfunction seeks medical help and adopts the sick role. The importance of structural and cultural elements in the formulation of lay people’s definitions of health and illness and the significance of the concept of the sick role in explaining patients’ illness behaviour are explored in Chapter 2.

Not only is the body isolated from the person in the medical model but, as described above, it is also depicted as a highly complex biochemical ‘machine’ whose constituent parts can malfunction or break down. The use of the machine metaphor encourages an interventionist view of medical practice in which doctors are seen to use their expert knowledge and technical skill to diagnose the fault and repair the malfunctioning body part. It is perhaps not difficult to appreciate how a machine metaphor can flourish in the world of modern medicine, especially when the scientific model of medicine extols the virtues of clinical detachment and stresses the importance of the need for medical practitioners to function objectively without emotional involvement. Advances in medical technology and the increasing use of highly sophisticated diagnostic and monitoring equipment and devices also create an atmosphere in which the scientific mode of thinking predominates. It is the application of scientific methods and ideas to the practice of medicine that ‘encourages the passivity of the patient, for the scientist knows; the patient, not being a scientist, does not know’ (Stacey, 1988, pp. 173–4). How this specialist knowledge produces an imbalance of power in the doctor–patient relationship and subsequently leads to the patient being assigned a passive role in the treatment process is addressed in Chapter 9.

All this is not to deny that biomedical science has had a significant impact on the success of clinical medicine in improving health and relieving suffering. However, as outlined above, the main challenge to the dominance of the medical model is directed at the limitations imposed by its conceptual framework. As summarised by Nettleton, ‘The body is isolated from the person, the social and material causes of disease are neglected, and the subjective interpretations and meanings of health and illness are deemed irrelevant’ (1995, p. 3).

At a conceptual level, Turner illustrates how ‘The sociological model of illness takes a critical and opposed position on the biochemical model of disease’ (1987, p. 9). It does this by questioning the very assumptions on which the medical model is founded. Firstly, it rejects the notion of the existence of a clear dichotomy between the mind and the body. Secondly, it challenges the reductionist tendency in the medical model by arguing against the idea that illness can be ultimately reduced to disordered bodily functioning. According to the sociological model of illness it is overly simplistic to think of a disease as having one single cause. Many explanations of specific diseases are multi-causal, describing how physical and biological causes interact with social and environmental factors. Finally, a sociological approach holds that the patient needs to be considered as a ‘whole person’. Illness can only be fully understood by taking account of the wider social and cultural context in which physical and mental conditions are observed, diagnosed and treated. As Turner asserts, ‘The sociological perspective encourages medical professionals to approach the person and not the patient as the focus of an enquiry into illness’ (1987, p. 9, emphasis added). In order to appreciate the potential contribution a sociological focus can make to our understanding of health, illness and healthcare practice we need to know more about the general nature of sociology and its subject matter.

What is sociology?

… sociologists try to understand the world in terms of the relationships between people’s choices … and the structures that constrain and create the decisions and opportunities available to them. Thus, sociology grounds the study of any particular issue in the empirical world, but moves beyond simple reportage. It examines and explains the regularities and differences that are evident in society … [and] offers the potential for a more nuanced and sophisticated understanding of the social world and our own life and others’ lives.

(Smith and Natalier, 2004, p. 2)

Sociology is a social science discipline that takes a distinct approach to investigating society. According to Stacey, sociology ‘constitutes a body of knowledge about societies and social relations within them and takes as its subject matter all areas of the social’ (1991, p. 13). As a consequence of this focus on ‘the social’ all aspects of human life are open to sociological investigation. It is the study of social behaviour that is at the very centre of the sociological enterprise. Explanations of behaviour based solely on individual biological factors or psychological processes often only provide us with a partial understanding of why individuals behave the way they do. From the point of view of the sociologist, human beings are essentially social animals and therefore a full understanding of human behaviour cannot be achieved without taking into account aspects of the social setting in which the behaviour occurs. As Lee and Newby assert, ‘Sociologists have … repeatedly rejected the possibility of the totally isolated, non-social individual’ (1983, p. 17). As a field of enquiry, sociology explores the human processes of social interaction through studying the relationship between individuals, groups and social institutions.

Given its subject matter, one often hears sociology referred to as the ‘science of society’. This is a claim that has produced considerable controversy. However, before any such claim to scientific status can be properly evaluated we need to know on what basis the claim is made. In other words, it is important that we understand what it is about a discipline that justifies it being labelled a science. We can begin by considering some of the characteristic features of the natural sciences, such as chemistry and physics. Here systematic observation, sometimes under experimental conditions, produces evidence of general regularities in the natural world. In this way a body of scientific knowledge is constructed, the principal aim being to identify cause and effect relationships in order to explain why particular events occur. This leads to the formulation of scientific theories to describe and explain causal relationships. The whole process is a cumulative one, whereby scientific theories build on one another, with the newer theories amending and extending the older ones.

The fundamental features of the discipline of sociology are such that any claim to scientific status based on the model of the natural sciences is problematic. As Giddens observes, ‘Studying human beings … is different from observing events in the physical world, and neith...