Social, political and cultural dimensions of health

Kevin Dew · Anne Scott
Allison Kirkman

Social, Political
and Cultural
Dimensions of
Health


Social, Political and Cultural Dimensions of Health



Kevin Dew  •  Anne Scott  •  Allison Kirkman

Social, Political and Cultural
Dimensions of Health


Kevin Dew
Victoria University of Wellington
Wellington, New Zealand

Anne Scott
University of Canterbury
Christchurch, Canterbury, New Zealand

Allison Kirkman
Victoria University of Wellington
Wellington, New Zealand

ISBN 978-3-319-31506-5     ISBN 978-3-319-31508-9  (eBook)
DOI 10.1007/978-3-319-31508-9
Library of Congress Control Number: 2016939258
© Springer International Publishing Switzerland 2016
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Acknowledgments

We are very grateful for the excellent feedback we received on all chapters from
Bronwyn Polaschek. Her attention to detail and nuance brought greater clarity to the
material presented in this book. Kevin Dew would also like to thank Josh Barton for
providing very useful feedback on many of the chapters. Special thanks to Hendrikje
Tuerlings and Esther Otten from Springer for their support.

v

Contents

1Introduction..............................................................................................1

1.1What You  Will Encounter.............................................................4
References..................................................................................................6
2Health Consumers and the Clinical Encounter....................................7

2.1Introduction...................................................................................7

2.2The Sick Role...............................................................................8

2.3Medical Dominance and the Clinical Encounter..........................10

2.4The Changing Medical Encounter................................................11

2.5New Models for the Clinical Encounter.......................................13

2.6
Case Study – Complementary and Alternative Medicine (CAM)
in the Medical Encounter..............................................................15

2.7Self-Government and New Technologies.....................................18

2.8Conclusion....................................................................................19
References..................................................................................................19
3Material Conditions and Health Inequalities........................................ 23

3.1Introduction...................................................................................23

3.2Material Conditions, Social Systems and Health.........................24

3.3Case Study – Zambia and AIDS...................................................26

3.4Unequal Societies and Health.......................................................27

3.5Life Course...................................................................................31

3.6Conclusion....................................................................................32
References..................................................................................................33
4Gender and Ethnicity in Health............................................................. 35

4.1Introduction...................................................................................35

4.2Ethnicity........................................................................................36

4.3Case Study – The Ongoing Impact of Discrimination
in the United States.......................................................................38

4.4Gender...........................................................................................40

4.5Interpersonal Impacts on Health Inequalities...............................42
vii


viii

Contents



4.6Conclusion....................................................................................44
References..................................................................................................45
5The Health of Indigenous Communities................................................ 49

5.1Introduction...................................................................................49

5.2The Colonized Experience............................................................50

5.3Control and the State....................................................................52

5.4Health Disparities.........................................................................54

5.5Case Study – Indigenous Life in Australia...................................55

5.6Maintaining Disparities................................................................57

5.7Evolving Health Initiatives...........................................................59

5.8Conclusion....................................................................................62
References..................................................................................................62
6Institutions of Health Care...................................................................... 65

6.1Introduction...................................................................................65

6.2Hospitals.......................................................................................66

6.3In the  Community.........................................................................69

6.4Case Study – Caring for the Elderly in China..............................71

6.5The Price and Cost of Health Services.........................................72

6.6Evidence-Based Medicine and Protocols.....................................74

6.7Rationing Debates.........................................................................75

6.8Accountability...............................................................................76

6.9Conclusion....................................................................................77
References..................................................................................................78
7 Health Care Work and Everyday Health Work.................................... 81

7.1Introduction...................................................................................81

7.2Medical Dominance and Professionalization...............................82

7.3Gendered Division of Healthcare.................................................84

7.4The Blurring of Jurisdictions........................................................85

7.5Case Study – Maternity Health Care Work..................................88

7.6Everyday Health Work..................................................................90

7.7Conclusion....................................................................................91
References..................................................................................................92

8Medicalization and Contested Illnesses.................................................95

8.1Introduction...................................................................................95

8.2The Concept of Medicalization....................................................97

8.3Contested Illnesses and the Changing
Face of Medicalization.................................................................98

8.4Case Study – Gulf War Related Illnesses.....................................100

8.5Biomedicalization.........................................................................102

8.6From Disease to Enhancement.....................................................105

8.7Conclusion....................................................................................107
References..................................................................................................108


Contents

ix

9Pharmaceuticals.......................................................................................111

9.1Introduction...................................................................................111

9.2The Rise of the Pharmaceutical Industry......................................112

9.3Expanding the Market...................................................................113

9.4Determining Safety and Benefit....................................................113

9.5Marketing and Drug Safety..........................................................115

9.6Conduct of Trials and Risk Proliferation......................................117

9.7Medical Journals and Selective Publication.................................118

9.8Undermining Research.................................................................119

9.9Case Study – Underreporting of Adverse Reactions....................120

9.10Conclusion....................................................................................122
References..................................................................................................123
10Disability and Chronic Illness.................................................................127

10.1Introduction...................................................................................127

10.2Biographies of Chronic Illness.....................................................128

10.3The Social Production of Chronic Illness.....................................131

10.4Stigma...........................................................................................132

10.5The Social Model of Disability.....................................................135

10.6Case Study – Disability in India: Interweaving
Legislative, Economic and Cultural Change................................137

10.7Conclusion....................................................................................139
References..................................................................................................140
11Aging, Dying and Death..........................................................................145

11.1Introduction...................................................................................145

11.2The Social Context of Dying and Death.......................................146

11.3The Denial of Death and Sequestration Theses............................147

11.4Awareness Contexts and Dying....................................................149

11.5The Rise of the Hospice and Palliative Care Movement..............150

11.6Dealing with Dying and Death.....................................................152

11.7The Funeral Industry.....................................................................153

11.8Case Study – Funeral Director Work............................................154

11.9The Disposal of the Body Following Death.................................156

11.10Conclusion....................................................................................158
References..................................................................................................158
12Sexuality, Sexual Behavior and Gender.................................................161

12.1Introduction...................................................................................161

12.2Understanding Sexual Preference.................................................163

12.3Early Explanations: Biological and Psychological Causes..........164

12.4From Interactionism to Social Constructionist Approaches.........165

12.5Queer Theories..............................................................................166

12.6Case Study – Sexuality, Health and HIV/AIDS...........................167

12.7Control of Female Sexuality.........................................................168


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Contents



12.8Sexuality and Aging......................................................................170
12.9Conclusion....................................................................................171
References..................................................................................................172


13Mental Health...........................................................................................175

13.1Introduction...................................................................................175

13.2Deinstitutionalization....................................................................176

13.3The Development of Biological Psychiatry..................................179

13.4Development of the New Psychotropics.......................................181

13.5DSM-III and the Increasing Stability of ‘Mental Disorder’.........182

13.6Case Study – Biological Psychiatry as ‘Cultural Colonialism’
in Argentina..................................................................................183

13.7Psychologizing Everyday Life......................................................185

13.8Diagnostic Inflation......................................................................187

13.9Human Rights and Citizenship for Users
and Survivors of Psychiatry..........................................................189

13.10Peer Support..................................................................................192

13.11Conclusion....................................................................................193
References..................................................................................................194
14Technology and  Health............................................................................199

14.1Introduction...................................................................................199

14.2Representing Objectivity Through Magnetic
Resonance Imaging (MRI)...........................................................201

14.3Genetic Testing and Screening.....................................................202

14.4Somatic Individuality....................................................................203

14.5Transnational Reproductive Markets............................................206

14.6Case Study – Gestational Surrogacy in India...............................208

14.7‘Empowerment’ Through Health Apps.........................................209

14.8Conclusion....................................................................................211
References..................................................................................................212
15Promoting Public Health.........................................................................215

15.1Introduction...................................................................................215

15.2Public Health Foundations............................................................216

15.3Health, the State and the Market...................................................218

15.4The Culture of Public Health........................................................220

15.5Popular Epidemiology..................................................................221

15.6Health Promotion and Empowerment..........................................223

15.7Case Study – Tobacco Control......................................................226

15.8Conclusion....................................................................................229
References..................................................................................................229
16Health and the Mass Media....................................................................233

16.1Introduction...................................................................................233

16.2The Media and Globalization.......................................................234

Contents










xi

16.3The Media and Health – Shaping Views
About Health and Health Services................................................235
16.4Women’s Magazines and Health...................................................236
16.5Men’s Sexuality and Health..........................................................237
16.6Case Study – The Media, Metaphors
and Alzheimer’s Disease...............................................................238
16.7Fictional Medicine: The Portrayal of Doctors
and Nurses in Television...............................................................241
16.8Conclusion....................................................................................242
References..................................................................................................243

17Concluding Comments............................................................................245


Chapter 1

Introduction

Abstract This book attempts to give some structure and focus to the fascinating
range of health related phenomena. The aim of the book is to help us understand the
current state of health and health care. Sociology places the experience of health and
the way health services are delivered in a wider, social context. This contextualization provides an enhanced understanding of why things are as they are. We can also
think of some of the consequences of things being this way. With a better grasp of
the social context, we can also think about how things could be different.
Keywords Medical sociology • Sociological imagination

The hallway doors in a hospice are closed and the all clear is given so the body of a
recently deceased resident can be removed. People diagnosed with dementia may
avoid revealing the diagnosis. Medical textbooks include information about the
natural history of syphilis based on unethical research. Few of the adverse drug
reactions that occur are reported. Decisions in health care consultations about
‘appropriate’ diets are made in a split second. Preventive health measures provided
to Gulf War veterans are perceived as the cause of debilitating health problems. The
United Nations General Assembly adopts the Convention on the Rights of Persons
with Disabilities. In Argentina anti-depressants have been advertised by local drug
companies as a balance to the distressing effects of globalization.
Such a truly diverse range of events, actors and phenomena are developed in
cases studies in this book, and there are many more. In parts of Australia indigenous
Australians were banned from public swimming pools for fear that they would
spread sexually transmitted diseases. Public health arguments have influenced the
decriminalization of sex work in some countries like New Zealand. Privatization
and restructuring programmes mean that in Chile obstetricians undertake high rates
of caesarean sections, and that in Zambia the impact of AIDS has been more devastating. In parts of Asia trade liberalization has coincided with a 10 % increase in
tobacco consumption. In India surrogacy clinics have been established where young
women can earn up to five times the annual household income by giving birth to a

child for a commissioning couple. In China laws have been enacted that require
children to visit their parents frequently.
These are examples of the research material that can be canvassed in sociological
approaches to health, illness and wellbeing. From the everyday encounter to
© Springer International Publishing Switzerland 2016
K. Dew et al., Social, Political and Cultural Dimensions of Health,
DOI 10.1007/978-3-319-31508-9_1

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1

Introduction

international conventions, from the detailed observation of what happens in a consultation to the historical development of the health professional, these are all topics
of interest for the curious sociologist.
With such a huge range of material of sociological interest, how are we to make
sense of it? The theoretical orientations and research tools of sociology can equip us
with the means to comprehend these diverse topics and phenomena. In the examples
above we can consider a range of important concepts and issues that are the material
of sociological analysis. We can observe the everyday impact of processes like stigmatization, medicalization, discrimination, health care decision-making, the production of health inequalities and the construction of medical knowledge. The
impacts on health of economic change and intergenerational relationships and the
cultural shaping of social practices, like those surrounding death, can be considered.
The range of institutions that impact upon health can be studied, from the international, like the United Nations, to those we regularly encounter, like the primary
care practice and to those we experience every day, like the family. Permeating these
processes, relationships and institutions are issues of class, gender, ethnicity, age
and disability. On top of this, we can consider not only outcomes that are planned

for but also the unintended consequences of social interaction.
This book attempts to give some structure and focus to the fascinating range of
health related phenomena. The aim of the book is to help us understand the current
state of health and health care. Sociology places the experience of health and the
way health services are delivered in a wider, social context. This contextualization
provides an enhanced understanding of why things are as they are. We can also
think of some of the consequences of things being this way. With a better grasp of
the social context, we can also think about how things could be different.
The power of sociological analysis is in its potential to reveal the deep layers of
negotiation, compromise, and interests that cover and surround health care practices. Sociology is a richly theoretical discipline that over the last 150 years has
developed and refined a range of concepts and models that can be informative,
insightful, and revealing (Collyer 2015). There are a variety of perspectives in sociology, and the dialogue and debate that occur between them further enriches the
field of sociological inquiry. But the core task of all sociologies is the systematic
and theoretically informed analysis of patterns of social interaction.
Historically the discipline of sociology emerged at a time of great social change
in western society. It was the era of political and social upheaval during the industrial transformation of Western Europe – and intellectuals sought to make sense of
these turbulent events and their impact on established social institutions, like the
family, the church and the state. Out of this social, economic, and political turmoil
emerged a discipline that sought to enquire into the workings of society itself. This
became the discipline we now call sociology.
The major questions that early sociologists asked included: What holds societies
together? What is the basis of social conflict? What is the role of the state in determining social action? What are the roles and functions of social institutions, such as
the family, the professions, religion, science, and how are these institutions changing? In what ways are societies stratified? How important is this stratification in


1

Introduction

3

determining our life chances (Bilton et al. 2002)? These broad questions are still
fundamentally important in sociology,
Sociology is therefore primarily concerned with social interaction between
groups and individuals in the modern world. The sociologist is interested in the way
our lives are shaped by the social world – and that means considering the historical,
cultural, economic, political and institutional forces that shape our lives. As such,
sociology is centrally concerned with the major issues of our day. The breadth and
depth of sociological analysis makes it relevant to a great variety of institutional
settings and professional and academic disciplines.
Sociology leads us to question assumptions about the benefits and disadvantages
of particular technologies, social trends and forms of social organization. Does new
biotechnology, for example, lead to more or less control in our personal lives, or for
the nation-state, or in the capabilities of transnational corporations? How do changes
in the way science and medicine are practised affect other social institutions – families, communities, political and religious institutions? If people feel helpless and
fearful in the face of the dramatic developments in science and medicine, can we
really develop new means of social and political participation to overcome these
feelings?
A focus for some sociologists is the impact that social structures have on the
attitudes and behaviors of individuals. Social structures are often summarised in the
shorthand of class, gender and ethnicity, but also include language, culture and
social institutions such as the family, medicine, the media and the state. The positions that we hold – either by birth or achievement – have a major impact on our life
chances, our state of health, and our interactions with health services. We are all
individuals but the sort of individuals we are is as much the product of the society
we live in as it is of our own unique thoughts and actions. In addition, our own perceptions and actions can influence the behaviors of others and even the shape of
broader societal structures.
The sub-discipline of medical sociology or sociology of health and illness has
developed since the 1950s. Medical sociology has explored a vast range of issues.
At a very broad level medical sociologists have analysed the links between industrialisation and disease (Doyal and Pennell 1979). Another ongoing area of interest
from the beginnings of medical sociology has been the rise to social status and

power of the medical profession, and subsequent challenges to that power (Gabe
et al. 1994). From these analyses have arisen fundamental questions about the role
of medicine in contemporary society, such as whether the medical profession and
the health care system help overcome social inequalities, or whether they reinforce
them (Wilkinson 1996). There has been increasing interest in the ways in which the
allied and alternative health professions have been constrained and shaped by their
relationship to the established medical profession (Dew 2003; Willis 1983). At
another level there has been a focus on the ways in which health professionals communicate with their clientele, and how that limits or fosters interaction (Heritage
and Maynard 2006). Sociologists have also become interested in lay experiences of
health and illness, and the strategies lay people adopt (Calnan 1987). This has been
intensified by the realisation that most healing take place in contexts quite removed


4

1

Introduction

from any formal contact with the established health professions (Dew et al. 2014;
Nettleton 2004).
Our relationship to health and health services is formed by the social and historical period in which we live. Taking a sociological perspective means to take a
step back from our personal interpretations of the world and to look at the social
influences that shape our lives and shape our ways of interacting with others.
By becoming more sensitive to the wider universe of social activity we obtain a
richer awareness of ourselves and of others. By using what has been called the
sociological imagination (Mills 1959) we will come to see the familiar as something
curious, fascinating and different. The sociological imagination allows us to better
make the links between personal issues and social issues. Our life experiences are
anchored in our time in history, our place in culture and our social situation. Our

responses to the world, and our chances in it, are socially structured by such things
as the social class we are born into, the gender roles of our time and the ethnicity we
are assigned, and all the opportunities and obstacles that come with them.
The sociological perspective assists us to examine our own assumptions and to
relate our own experiences to broader social and cultural concerns. Not only does
this enhance our capacities to be self-critical; it also better enables us to examine the
assumptions of other groups in society, and to consider the consequences of social
action, both intended and unintended. This is an issue of prime importance in the
area of health and health care because social interventions in health have life affecting consequences. By examining both our own assumptions – conscious or unconscious – and those that lie behind current social arrangements of health care, we will
be in a better position to ask that question central to the sociological imagination –
how could it be otherwise (Willis 1994: 4)?

1.1

What You Will Encounter

In this book we first explore an aspect of health care common to the experiences of
most people, the clinical encounter. Chapter 2 outlines the historical changes and
continuities in the clinical encounter. The current pressures transforming the clinical encounter and the relationship between health care professionals and the users
of health services is explored. The following three chapters delve into a range of
aspects of health inequality and the structural conditions of health care. Chapter 3
discusses the material underpinnings of health that impact upon everyone and the
social gradient linking health outcomes to material and social conditions. Chapter 4
outlines the differences in sickness experiences and life expectancies by ethnicity
and gender. Chapter 5 covers the experiences of a variety of indigenous communities with a particular focus on settler societies, such as the United States, Canada,
Australia and New Zealand, where indigenous communities have poorer health outcomes than settler groups. Taken together these chapters bring to the fore the social
shaping of health inequalities based in generic or near universal processes like globalization, colonialism, capitalism and patriarchy.


1.1

What You Will Encounter

5

The next two chapters focus on the spaces and the people who deliver health
care. Chapter 6 notes the constantly changing nature of the institutions of health
care focusing on the hospital and primary care sectors. The current trends standardizing the delivery of health care practices are considered. Chapter 7 outlines major
sociological positions on health professional work, its gendered nature and political
shaping, but also the health work undertaken outside of the purview of the health
system.
The following two chapters, on medicalization and pharmaceuticals, look at
shifting trends and the role of commercial enterprise in shaping health experiences.
Chapter 8 interrogates the many drivers of medicalization and the particular shape
it is taking in the twenty-first century. Chapter 9 focuses on pharmaceuticals highlighting the complex interplay between therapeutic goals, industry concerns, scientific legitimacy and interactional dilemmas in medical consultations. Chapters 10
and 11 shift attention more intensively to the experience of morbidity and mortality.
Chapter 10, on disability and chronic illness, draws on the medical sociology literature with a focus on the meanings that individuals and members of their families
make of illness, incapacity and bodily uncertainty. It also discusses disability studies literature with a focus on forms of social oppression. Chapter 11 positions death
and dying as social events that tell us much about social life and interaction in
society.
Chapter 12 examines issues around sexuality and health. It looks at ways in
which the health system and the legal system have a control function in that they
define what is normal and abnormal, what is healthy and unhealthy. How we understand sexuality and gender influences such important health influencing practices
such as sex education, responses to sex work, dealing with sexually transmitted
diseases and our expectations of sexual preferences and behaviors. Important trends
within the broad area of mental health, the influence of mental health consumer
movements, the shift to biologistic understandings of mental illness, and the increasing psychologization of everyday life are described in Chap. 13. Chapter 14 argues
that changes in technology and changes in the broader social world are co-constituted
and technologies lead to pressures and changes in attitudes, practices and values,
changing the social landscape and affecting the delivery of health care.

Chapter 15 discusses important social and political dimensions of public health.
It notes public health’s capacity to challenge and temper the activities of other
spheres, such as the state and business, but also its tendency to disempower citizens
as well. Finally, Chap. 16, on health and the media identifies ways in which the
media shapes perceptions about health and health services which in turn influences
our expectations and hopes.
A goal of this book is to facilitate the reader to see things differently and have an
enriched analysis of health care in contemporary society. It provides an up-to-date
discussion of key concepts and debates in the sociology of health. The concluding
chapter underscores ways in which a sociological analysis deepens our understandings of health and health care and the ways in which it may do so into the future.


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Introduction

References
Bilton, T., et al. (2002). Introductory sociology (4th ed.). Basingstoke: Palgrave.
Calnan, M. (1987). Health and illness: The lay perspective. London: Tavistock.
Collyer, F. (Ed.). (2015). The Palgrave handbook of social theory in health, illness, and medicine.
Basingstoke: Palgrave.
Dew, K. (2003). Borderland practices: Regulating alternative therapies in New Zealand. Dunedin:
University of Otago Press.
Dew, K., Chamberlain, K., Hodgetts, D., Norris, P., Radley, A., & Gabe, J. (2014). Home as a
hybrid centre of medication practice. Sociology of Health & Illness, 36, 28–43.
Doyal, L., & Pennell, I. (1979). The political economy of health. London: Pluto Press.
Gabe, J., Kelleher, D., & Williams, G. (Eds.). (1994). Challenging medicine. London: Routledge.
Heritage, J., & Maynard, D. (Eds.). (2006). Communication in medical care: Interaction between

primary care physicians and patients. Cambridge: Cambridge University Press.
Mills, C. W. (1959). The sociological imagination. New York: Oxford University Press.
Nettleton, S. (2004). The emergence of e-scaped medicine? Sociology, 38, 661–679.
Wilkinson, R. (1996). Unhealthy societies: The afflictions of inequality. London: Routledge.
Willis, E. (1983). Medical dominance: The division of labour in Australian health care. Sydney:
George Allen & Unwin.
Willis, E. (1994). Illness and social relations: Issues in the sociology of health care. St Leonards:
Allen & Unwin.


Chapter 2

Health Consumers and the Clinical Encounter

Abstract The relationship between the health professional and the patient, or
health consumer, and the clinical encounter where this relationship develops, are
central to the experience of health care for most people. This chapter explores the
history of these roles and the clinical encounter itself, from notions of the sick role
and the paternalistic medical encounter, through to twenty-first century models of
the active health consumer, and new models of the clinical encounter. A case study
of the treatment of complementary medicine in the clinical encounter through conversation analysis is developed. The chapter concludes that although transformation
has occurred to the roles of health consumers, who are now expected to co-produce
their own good health, and health professionals, whose social status has declined in
the contemporary context, nevertheless the entrenched culture of the clinical
encounter may continue to act as a hindrance to substantive change.
Keywords Medical encounter • Sick role • Consumerism • Doctor-patient relationship • Shared decision-making • Interactional submission • Complementary medicine • Health information • Telemedicine

2.1

Introduction

The relationship between health professionals and their patients – or ‘health consumers’ as they are rather controversially now known – is central to the experience
of health care for most people, and also to the nature of health work. The clinical
encounter has been important within sociological research and theorising; some
discussion of it goes back to the earliest days of sociology. Harriet Martineau’s Life
in the Sick Room of 1844 (Martineau 1845), probably the first sociology of health
and illness text in the English language, looked centrally at this topic. However,
theorising about the doctor patient relationship really took off in 1951 when Talcott
Parsons published an account of ‘the sick role’ in his major functionalist work, The
Social System (1951). Parsons’ account galvanized both positive and negative reactions, as we shall see, and it speaks to a wide variety of contemporary issues, from
trust in the medical encounter, to consumerism in healthcare, uncertainty within
medical practice, and the rise of the ‘expert patient’ (Williams 2005).
© Springer International Publishing Switzerland 2016
K. Dew et al., Social, Political and Cultural Dimensions of Health,
DOI 10.1007/978-3-319-31508-9_2

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Health Consumers and the Clinical Encounter

In this chapter, we will suggest that the medical encounter between patient and
practitioner is changing; over the past half century, it has become less paternalistic
and more participatory. Patients are now expected to be actively responsible for
their own health care, and the concept of the ‘health consumer’ encapsulates a new
understanding of the role that recipients of healthcare should have. However, there

are also some surprising continuities in the nature of the clinical encounter, and in a
case study looking at one medical interaction we will demonstrate the subtle ways
in which these can work. We will conclude by looking at the way that, through new
technologies and a “care transition” (Bury and Taylor 2008: 201), the relationship
between healthcare providers and health consumers is continuing to transform.

2.2

The Sick Role

For Talcott Parsons (1958: 176) health is “the state of optimum capacity of an individual for the effective performance of the roles and tasks for which he [sic] has
been socialized”. Therefore illness is an incapacity of an individual to effectively
perform social roles. From a Parsonian perspective medicine is a key institution in
stabilizing society in that as an institution it operates to limit social influences
related to sickness that can motivate people to avoid fulfilling their social roles.
Parsons argued that in the past the family was the centre of caring for the sick but
the institution of the family in modern society is not equipped to take on that burden.
Sickness has to be taken out of family control as illness may become accepted as an
alternative to fulfilling role obligations. This related to Parsons’ concern that the
non-authoritarian nurturance of the family would have a strong appeal and overcome the motivation to get well (Idler 1979). In addition the nuclear family formation in modern society is not equipped to take the strain on family resources required
to care for the ill (Parsons and Fox 1952). Medicine, then, is an institution of social
stability and control as it facilitates the fulfilment of role obligations. The sick role
provides a functional ability to overcome the motivation to stay sick.
For Parsons (1951), social roles may be stratified, or unequal, but each role is
necessary to the overall functioning of society. The sick role was an example of the
way this process worked; doctors and patients were each said to fulfil a complementary role. These worked together to ensure that illness, which Parsons saw as a type
of deviance, was contained and its impact was reduced as much as possible. There
were a number of components to the doctor’s role, and the sick role for patients also
involved several components (Gerhardt 1987). These were:
1. The sick person is exempted from his or her normal social obligations.

2. He or she is also exempted from responsibility for his or her own state. S/he is
not held responsible for becoming ill.
3. However, s/he must want to become well, and take responsibility to become well
as quickly as possible.


2.2 The Sick Role

9

4. The sick person should seek the help of a qualified physician or other caregiver,
and should cooperate with this person.
The sick role thus serves to prevent a deviant sub-culture of illness forming, by
reintegrating the sick individual back into his or her normal social roles in society
as quickly as possible (Williams 2005: 124).
The doctor’s role within this functionalist approach was to help the sick person
regain their health, by applying a high degree of technical competence, by being
altruistic and collectively orientated, by staying objective and detached, and by
working in a professional manner (Parsons 1951). In return he or she was given
authority over the patient, and the right to examine the patient intimately. Parsons
drew on psychoanalytic theory to think through the implications of the emotional
relationship between doctor and patient which, as Arthur Frank notes (Frank 2004)
can be existentially charged with intimations of death, disability and high levels of
vulnerability. Issues of the sacred are involved which, within this very Western
model, are dealt with by a calculated avoidance. The physician was to maintain a
continuing stance of objectivity and emotional detachment (Williams 2005: 127).
This is of course very culturally specific, as in many cultures the health practitioner’s role is more openly invested with spiritual and emotional significance; it
involves interventions into the sacred (Erickson 2008).
Simon Williams (2005) argues that Parsons prefigures some important debates
regarding consumerist approaches to healthcare, and emotions in the medical

encounter. He suggests that Parsons’ enduring significance has been underestimated. However, the concept of the ‘sick role’ has also been heavily critiqued.
While once very relevant, the concept of the sick role has been argued to now be a
poor fit with contemporary ways of doing health, illness and medicine (Burnham
2012). This is for a number of reasons:
1. Health consumer groups no longer want to be seen as ‘deviant’.
2. Medicine has shifted its focus to healthy people through screening and risk orientated practice.
3. The increase in chronic illness means the sick role is no longer a temporary state.
4. Managed care (or cost control processes put in place by for-profit health maintenance organizations) is leading to commercial and privacy considerations overriding traditional forms of professional autonomy.
5. The doctor-patient relationship is no longer ideally seen as paternalistic.
These reasons relate closely to the historical transformation in twenty-first century healthcare which has been dubbed ‘biomedicalization’ by Adele Clarke and
colleagues (2010), and which is discussed more comprehensively in Chap. 8.
Another critique of Parsons suggested that not all the components of the sick role
were always present in practice. Twaddle found in 1969 that for older, married,
urban men, the four components of the sick role were present in only a minority of
cases. The most contested element of the sick role was exemption from normal
roles; many people carried on with their normal roles, even while sick (Twaddle
1969). Twaddle found in the late 1960s that being released from responsibility for


10

2

Health Consumers and the Clinical Encounter

the illness was the least contested component of the sick role. However, this has
changed. Burnham (2012) and others (Bury and Taylor 2008; LeBesco 2010; Lupton
2013a; Veinot 2010) make the point that with the new emphasis on ‘healthy lifestyles’, responsibility for becoming ill is often placed on the sick person in the
twenty-first century. These arguments point to the fact that the medical encounter is
not static. It is historically changing, and recent transformations in technology,

political ideology, social relations and communications have led to fairly dramatic
changes in the ways that we perform ‘sickness’ within the clinical encounter.

2.3

Medical Dominance and the Clinical Encounter

During the twentieth century, the nature of the clinical encounter was critiqued by a
number of sociologists. Eliot Freidson (1970) noted that the doctor patient relationship was not always harmonious; in fact it was necessarily marked by conflict, even
if this conflict was latent. This was due, according to Freidson, to the separate
worlds of layperson and professional; for example, the patient might want more
information than the physician was prepared to offer, and the patient may also want
a mode of management specifically fitted to him or her as an individual, while the
doctor wanted to manage the case in conventional and convenient ways (Freidson
1970: 321–322). This critique of the medical encounter, then, was based on an analysis of the hierarchical and paternalistic social organization of medicine in North
America at that time.
Another well-known critique of the medical encounter (Mishler 1984) drew on
conversation analysis to explore the ways physicians dominated the medical interview through using a question – response – assessment structure to control the turntaking process. Doctors also controlled the content of the interview by initiating
each new topic and by selectively attending only to those parts of a patient’s statements that he or she saw as biomedically relevant. Finally, closed questions were
used to elicit short answers with no extraneous material. Mishler referred to this
dominance of the medical encounter by physicians focusing only on biomedically
relevant details as ‘the voice of medicine’. His analysis noted that patients sometimes attempted to interrupt the flow of the medical interview by bringing in the
personal or social contexts of their problems. He referred to this as ‘the voice of the
lifeworld’ and analysed the way these interruptions led to a struggle for the control
of the clinical encounter (Mishler 1984). Mishler concluded that, generally, physicians rapidly repair such disruptions, regain control of the clinical encounter, and
reassert the voice of medicine (Mishler 1984: 95).
A number of critiques have focused on gender, ethnic and/or social class relations within the clinical encounter. In a classic overview of gender relations and the
medical profession, Barbara Ehrenreich and Deidre English (1973) noted that, in
the nineteenth and early twentieth centuries, middle-class women were expected to
be sick and working-class women to be well, even while they were seen as carrying

contagion. This changed in the mid-to-late twentieth century as psychiatry came to


2.4

The Changing Medical Encounter

11

replace gynaecology as the locus of female pathology. In the 1970s, they concluded
that the medical system had replaced organized religion as a prime source of sexist
ideologies and an enforcer of sick roles (Ehrenreich and English 1973: 83). Twelve
years later, Helen Roberts (1985) published a critique of the clinical encounter making the similar point that the relationship between doctors and their women patients
was a power relationship, and noting some of the ways that dominance was maintained by physicians in the clinical relationship. In the 1990s, Sue Fisher, in a sensitive analysis of one medical consultation, showed how social class and gender
ideologies led to a poor quality medical consultation for a working class woman in
the United States. Within this medical encounter, a great deal of ideological work
was done which continually inscribed the incompetence of the patient and the dominance of the physician (Fisher 1995). A number of studies have looked at ethnic
relations in the clinical encounter (Knowles 1991; Manderson and Allotey 2003; Lo
and Stacey 2008). Health professionals tend to ask less questions of ethnic minority
patients and to provide them with less information (Ong et al. 1995); this can at
times have devastating consequences (Manderson and Allotey 2003). None of these
sets of power relations operate alone: as Lo and Stacey (2008) note, multiple structural forces – gender, ethnicity, immigration status, age, and social class – intersect
within the context of the clinical encounter.

2.4

The Changing Medical Encounter

The medical encounter in the late twentieth century, then, was heavily critiqued as
hierarchical, paternalistic, operating in a way that excluded the lifeworld of the

patient, and laden with power relations rooted in social class, gender, and ethnic
differences. However, a number of social changes came together, at the end of the
twentieth century and the start of the twenty-first century, to lead to a transformation
in the way clinical encounters operate.
The first of these is the generally accepted decline in the social status of physicians (Lupton 1997; Potter and McKinlay 2005). This had several sources. The
growth in use of complementary and alternative medicine (Ernst and Cassileth
1998; Xue et al. 2007; Yamashita et al. 2002) has occurred against a backdrop of
increasing scepticism towards scientific authority (Beck 1992) and the primacy of
biomedicine in health provision (Broom 2002, 2005). Moreover, there has been an
increasing awareness of medical malpractice, fraud, and other forms of violation by
health practitioners (Lupton 1997). In addition, increasing patient expectations of
cure have run up against a growing awareness of the limits of medicine’s curative
powers. Where the physician once carried a mystique and an accompanying
extremely high social status, it has been claimed since the late twentieth century that
doctors are being reduced in status and even deprofessionalized (McKinlay and
Stoeckle 1988; Ritzer and Walczak 1988; Schlesinger 2002). With this decline in
medical status, it has become increasingly acceptable to dialogue with one’s doctor,
or even to challenge him or her.


12

2

Health Consumers and the Clinical Encounter

In a related development, the late twentieth century saw a rise in medical consumerism. This is the tendency to see patients as autonomous rational actors, who
can access healthcare as they would any other commodity in a free market. The
movement to see patients as consumers had its origins in the radical health movements of the late twentieth century: the women’s health movement, the psychiatric
survivors, self-help groups and the community health movements, for example

(Archibald 2007; Bella 2010; Klawiter 2008; Morrison 2005). These movements
emphasized dignity, empowerment, autonomy, access to information and the
patient’s freedom to choose. This theme was picked up within neo-liberal political
ideology in the 1980s and 1990s, as the New Right sought to treat healthcare as a
commodity, and to engineer a shift “from patient-as-supplicant to patient-as-sceptic”
(Stacey et al. 2009: 730). A hegemonic discourse about ‘patient choice’ accompanied the increasing corporatisation of healthcare, the use of quality ratings to bring
about competition between health providers, and in New Zealand and the United
States, the arrival of direct-to-consumer pharmaceutical advertising (Lupton 1997;
Potter and McKinlay 2005; Stacey et al. 2009). An intended aim of these efforts was
to engineer a transformation in the clinical encounter, from the dependence and
paternalistic relationship which had marked the mid-twentieth century, to a relationship in which patients would be autonomous rational actors, exercising free choice,
and doctors would provide a commodified healthcare service to them (Lupton 1997;
Mol 2008; Stacey et al. 2009).
As a number of sociologists have noted, this initiative in medical consumerism
has run aground on the fact that health is not like material commodities; dependence
and trust are necessary to successful healthcare relationships at a time of illness and
distress (Lupton 1997; Mol 2008). It has also come adrift as the metaphor of medical consumerism is replaced by one of corporatization, in which third party payers
such as insurance companies, as well as other third parties like professional bodies
issuing clinical guidelines, have much influence within the clinical encounter (Potter
and McKinlay 2005). We will return to this transformation in the social relations of
medicine later in this chapter.
A third reason the clinical encounter changed was the development of new
sources of health information; these began to bridge the gap between patient and
practitioner. Maren Klawiter (2008) has documented the way the breast cancer
movements of the late twentieth century largely had their origins in the newfound
ability of patients to access information about breast cancer and the treatment
options associated with it, and in changes to standard medical practice that gave
them time for such explorations. Such information was often published by patients’
self-help organizations (Boston Women’s Health Collective 1971; Chamberlin
1977; Klawiter 2008), and came in the form of pamphlets, workshops and books.

With the arrival of the world wide web in the early 1990s, health information
began to appear on the internet (Hardey 1999). The wide diversity of information
available there generated an intense debate about the implications of internet use for
the medical encounter and the status of medical practitioners (Broom 2005; Hardey
1999; Henwood et al. 2003; Nettleton et al. 2005). Early indications suggested that
patients gleaning health information over the internet would challenge biomedical


2.5 New Models for the Clinical Encounter

13

understandings with alternative health and lay health information, reinforcing a
trend towards deprofessionalization within medical practice (Hardey 1999).
However, later empirical studies showed that the clinical encounter generally
transformed in character, rather than being undermined (Broom 2005; Henwood
et al. 2003). The internet converged in nature with older media, with major biomedical organizations owning the websites which came up first in most search engine
searches (Nettleton et al. 2005); patients thus tended to find high quality biomedical
information when searching the internet, rather than information on alternatives or
lay perspectives. Patients generally use health information found on the internet to
support their relationship with their physician, preparing questions to ask him or
her, or learning more about what they have been told in the consultation after it is
over (Broom 2005; Nettleton et al. 2005). Many patients engage in “interactional
submission” (Stacey et al. 2009: 735) with their doctors; even if they have information which challenges what they are being told in the consultation, they do not say
anything about it in that setting (Chiu 2011; Henwood et al. 2003; Stacey et al.
2009). In this way, patients perform as expected for ‘active’ patients, and physicians
have noted that, with internet using patients, a physician-patient partnership can be
established, treatment compliance can improve, and these clients are less likely to
blame the physician if things go wrong (Broom 2005). Some physicians do not like
the changes in the medical encounter being created by the use of the internet, however, and with these doctors, “demanding encounters” can be created by patients

challenging medical authority or demanding specific treatments with information
they have gleaned from the internet (Broom 2005; Stacey et al. 2009: 729).
There are thus a number of reasons why the medical encounter has been changing. In addition to the changing status of physicians, the growth in medical consumerism, and the availability of new forms of health information, the growth in chronic
illness has played a role. By the turn of the century, infectious diseases accounted
for less than 5 % of the mortality rate in the United States, whereas just three major
chronic diseases accounted for 55 % of the mortality rate (Potter and McKinlay
2005: 470). With long-lasting conditions in which the patient develops extensive
experiential expertise, the doctor-patient relationship can become less hierarchical,
and more of a partnership. Finally, there has been a discernible shift since the 1970s
towards incorporating patient values, perceptions and preferences into what has
become known as ‘patient-centered medicine’ (Thompson 2007). All of this has
meant that the paternalistic approach to medical relationships that was so heavily
critiqued by late twentieth century sociologists has begun to be supplanted by new
approaches to, and models of, the clinical encounter.

2.5

New Models for the Clinical Encounter

In the twenty-first century, a continuum of different models for the clinical encounter have replaced the universally paternalist model which existed in the mid-to-late
twentieth century. There are four such approaches which are commonly discussed