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Chapter 1

Ways of Thinking Sociologically about Health, Illness, and Medicine

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Chapter Overview

· •There are many different approaches to research and analysis in the field of sociology.

· •In this book we have divided these into six different theoretical perspectives: (1) structural-functional, (2) conflict, (3) interpretive/social constructionist, (4) feminist, (5) critical race theory, and (6) post-structuralism.

· •Each perspective involves a fundamentally different paradigm or way of seeing the important issues in health and medical sociology as well as some distinct methodological strategies.

· •Structural functionalism, based initially on the work of Émile Durkheim, sees society as a system of interlocking and functional parts.

· •Conflict theories, from the work of Karl Marx, are concerned about the documentation and elimination of injustices, particularly those based on economic inequities.

· •Interpretive or social constructivist sociologies, based initially on the writing of Max Weber, see sociology as the study of social action insofar as it is socially meaningful.

· •Feminist theories are more recent, dating from the latter part of the last century. Gender, as distinct from sex, was the original core concept for critical analysis. The work of Canadian sociologist Dorothy Smith is used to exemplify feminism.

· •Studies based on critical race theory have much in common with critical feminist studies in that they focus on structural problems within society and its institutions. The work of a Canadian, George Sefa Dei, is used to illustrate anti-racist theories.

· •The post-structuralist focus on how power produces effects through reflexive and circulating discourses is based initially on the work of Michel Foucault.

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Introduction

Almost all of us have been sick at some time in our lives. When do we acknowledge that we are sick? Is it when we stay in bed for a day or two? Is it perhaps when we feel a pain or have a fever but use over-the-counter medicines purchased from the drugstore and go on with the day as planned? Or perhaps we may not truly claim sickness unless we go to the doctor to find a name for the unusual way we feel. All of us experience illness in a social context. We recognize it because we have developed a vocabulary that allows us to think and talk about it with others in our immediate circle or in the larger social world. We learn what to do about it as we interact with friends and families, at times with the formal medical system, and with our society through television, newspapers, magazines, and various social media and online websites.

Health and illness are socially patterned. Are you aware of the relationship between ethnicity and sickle-cell anemia? Sickle-cell anemia is more common among people of African or Mediterranean background. Did you know that unemployment is often followed by ill health? Most types of morbidity and mortality are inversely related to income. That is, it is statistically correct to say that the lower the income, the higher the rates of sickness, disability, and death. What are the health consequences of the global spread of  neo-liberalism ? In many ways and in many places the gap between the rich and the poor has increased within individual countries. Increased inequality has limited progress towards better health and health care. The early and dramatic spread of HIV/AIDS among some of the poorest workers and their families in Africa is a case in point. It happened in part because male workers frequently had to travel away from their homes and families for an extended period of time in order to make a living. During time away they engaged in sex with strangers, including sex workers. When they went home they unknowingly spread the disease to family and friends. The experiences or meanings of symptoms are constructed differently in various societies, classes, and cultures. Socio-psychological factors are linked to various diagnoses. These are the sorts of issues discussed in the sociology of health and illness. The sociology of health and illness seeks to describe and explain some of the social causes and consequences of illness, disease, disability, and death; to show the ways lay people and medical professionals construct their own distinct categories of disease and illness; and to describe the identities and experiences associated with illness and wellness.  Table 1.1  lists examples of relevant topics.

Table 1.1Examples of Topics within the Sociology of Medicine and of Health and Illness

Sociology of Medicine

Sociology of Health and Illness

Medicalization and biomedicalization The organization of the Canadian medical care system in the context of medicalization and biomedicalization The profession of medicine (and auxiliary and competing health-care professionals) Alternative health-care providers The financing of medical care The medico-industrial complex Class, racism, and sexism and the organization and provision of medical care The health-promotion and prevention industries Medical care around the globe The development and perpetuation of medical discourse and ideology

The construction and distribution of disease and death in the context of medicalization and biomedicalization Disease and death in socio-historical context Socio-demographic explanations for disease and death Class, patriarchy, racism, and sexism as explanations for disease and death Socio-psychological explanations for disease and death Experiencing and talking about disease and death Ways people construct or label certain signs as symptoms of disease Environmental conditions and health, occupational health, safety issues, and health consequences Health and illness around the globe

When we think that we are sick, what do we do? Some of us treat ourselves with our favourite home remedies such as bed rest, lemon tea, or chicken soup. Some of us seek advice from friends or family members. Some of us visit our general practitioner, a medical specialist, or a pharmacist. A few head off to the emergency room of the nearest hospital. Others seek alternative health care such as homeopathy or acupuncture. When you seek the advice of a doctor, do you think you would receive better medical care from a physician who works in a fee-for-service setting or from one on a salary paid by the state, a corporation, or a clinic? Do practitioners in group practice provide better care than those in practice on their own? Does the Canadian government have adequate drug safety procedures to protect Canadians against another drug disaster such as thalidomide? Why does the universal medical insurance scheme provide guaranteed funds for medical practitioners and pharmaceuticals when in hospital but only limited funds for outpatient pharmaceuticals. Why are complementary and alternative health-care providers excluded from medicare? How does medical care financing vary around the world? Do you think that medicine sometimes is used to fulfill dreams and aspirations or is it simply for treatment of disease? These are some of the questions we ponder in the second half of this text.

The sociology of medicine is the study of the ways the institutionalized medical systems construct what they consider to be illness out of what they recognize as signs and symptoms, and what they constitute as their responses to such “illness” through the treatments they prescribe (see  Table 1.1 ). The medical care system also has to respond, sometimes with diagnoses and particular treatments, to the everyday demands of patients, the bidding of the disease-related support and advocacy groups, pharmaceutical regulations and advertising, the requests of governments and health insurance companies, and the innovations of medical device corporations, among other external forces. Sociology of medicine examines and offers explanations for such issues as  medicalization ,  biomedicalization , the varying types of medical practice and medical  discourses , the ideology and organization of medicine, different ways of financing medical care, the structure and operation of the hospital, the pharmaceutical industry, and the occupational worlds of nurses, doctors, and myriad other health-care workers. It also attempts to explain the relationships among the different types of health care and the role of the medical care system in the context of the culture, the political economy of states, and the globalizing world.

Sociologists study the social world from a variety of perspectives. Depending on their perspective, they focus on some aspects of social life and ignore others, and ask different questions and   use different ways to answer them. Sociologists have approached both the sociology of health and illness and of medicine with different or even contradictory assumptions. At times, different sociologists have described or analyzed an aspect of illness or medicine from such widely differing points of view that they appear to be discussing different phenomena. Among sociologists you will find some agreement, amid a lot of debate, that the various perspectives can be distilled into six distinct paradigms. The present convention is to call these perspectives structural-functional theory, conflict theory, social constructionist/interpretive theory, feminist and anti-racist theories, and post-structuralism. Table 1.2 outlines the principal characteristics of each approach. In this chapter we will begin to learn about the research and writing from each of these theoretical perspectives.

Table 1.2The Six Central Sociological Perspectives

	Structural Functionalism	Conflict Theory	Interpretive/Social Constructionist Theory	Feminist Theory	Critical Race Theory	Post-Structuralism
Exemplar	Émile Durkheim	Karl Marx	Max Weber	Dorothy Smith	George Sefa Dei	Michel Foucault
Model of subject matter	Society is a social system of interlocking and interrelated parts of institutions.	Society is a system of classes.	Society is composed of selves who make their social lives meaningful through interaction.	To truly understand society, we must be keenly aware of inequity, social organization, structure, power, and knowledge from women’s perspective.	Understanding how racism affects inequity, social organization, and power is necessary to understanding society.	There is no single reality; we need to interrogate key social concerns through fundamental concepts: biopower, medical gaze, power/knowledge, governmentality, and technologies of the self/subjectivities.
Model of the subject matter in process	Institutions perform (dys)functions that are both manifest and latent in the interest of the (dis)continuation of the social system in equilibrium.	Power groups with contradictory purposes, based on their relationship to the basic economic structures.	Selves create reality anew from situation to situation in interaction with others.	Selves and identities are tied to the relations of ruling. Feminist and anti-racist research has change as one of its goals. They emphasize critical analysis and transformation of patriarchal and racist social system.		Circulating discourses infuse everyday practices through power/knowledge, governmentality, technologies of the self, and subjectivities.
Ways of doing sociological analysis	System explainable and predictable through a series of “if x … then y” causal statements; x and y are social facts.	Power groups are understandable from a committed stance examining the conflicts in historical context.	Selves’ world views and symbols arise out of interaction and are made understandable through process of interpretive, empathetic understanding—verstehen.	All methods of data collection may be used but a collaborative approach (between researcher and subjects of research) is advocated. Triangulation is suggested. Language is gender appropriate.	All methods of data collection may be used but a collaborative approach (between researcher and subjects of research) is advocated. Triangulation is suggested. Language is anti-racist.	Research is archaeological, genealogical, and historical discourse analysis as well as contemporary discourse analysis.
Objectivity/subjectivity	Necessary to be objective and to study the social world objectively.	Value-committed perspective necessary.	Acknowledgement of the inevitability of contextual reflexivity of knower and known.	Focuses on and begins with the experience of women. Impossible to be objective. Therefore important to clarify standpoint and acknowledge reflexivity.	Focuses on and begins with the experience of racialized people along with other marginalized identities. Impossible to be objective. Therefore important to clarify standpoint and acknowledge reflexivity.	Objectivity is not possible because of the irreducible connection between power/knowledge.
Image of human nature	Human beings believe, think/feel, and do as the result of external constraining forces.	Human beings are alienated from self, others, and meaningful work, and need the liberation that would come from revolutionary change.	Human beings continually construct reality as they interact with others in their social worlds.	Differences by racialization, class, gender/power, sexual orientation, dis/ability limit generalization.	Differences by racialization, class, gender/power, sexual orientation, dis/ability limit generalization.	Subjectivity is continually recreated and resisted through technologies of the self-infused with power/knowledge.

Structural Functionalism

Structural functionalism  dominated North American sociology for many years. It had been the reigning paradigm, the “normal” science of the discipline (Kuhn, 1962). Many sociological studies published in North America have adopted this perspective. The American field of the sociology of medicine was founded on it (see, for instance, the major journal in health sociology in the United States, the Journal of Health and Social Behavior, as well as publications and research in the fields of mainstream public health and  epidemiology , for continuing examples of the dominance of this perspective). Auguste Comte (1798–1857), who first gave the name of “sociology” to the science of society, thought that sociology’s goal was to better society so that it might become orderly and progressive. He might be called the godfather of sociology. Émile Durkheim (1858–1917) provided both the theoretical and methodological models for structural functionalism. Durkheim defined sociology as a science of social facts. Social facts, he said, were to be treated and studied as if they were real, external to individuals, and yet capable of constraining and directing human behaviour and thought. The subject matter of sociology was these social facts and their impact on human behaviour. Constrained by the external world, human beings, in Durkheim’s view, were predictable and controllable through the power of social facts that exist as norms in their own right, aside from their manifestations in individuals.

Sociology in the Durkheimian tradition is often called structural functionalism. It assumes that the proper level of study for the sociologist is the system. The social system is composed of parts, institutions that function to maintain order. Just as the organs in the human body are inextricably tied to one another and function as interrelated components, so, too, do the parts or the institutions of society—the family, the economy, the polity, and the educational, welfare, justice, military, and medical care systems. All of these institutions operate interdependently to keep the society functioning. The goal of maintaining a good working order in society motivates theorizing and research in this sociological perspective.

Structural-functional theory is associated with positivist methodologies. Positivists view sociology as a science in the same way that physicists view physics as a science. Positivists assume that social scientists should and can remain objective and value-free while observing, recording, and measuring external social facts and their impacts on people. Just as the natural sciences seek universally true, causal explanations of relationships in the natural world, so do positivist sociologists in the social world. As well, since positivists believe that social facts are to be treated as real and external, they tend to rely on data that are assumed to be objective, collected from interviews and questionnaires, administered to individuals in survey research, and analyzed and organized to reflect the probability of the occurrence of particular behaviours among a certain aggregate of individuals.

Five principles distinguish structural functionalism from the other perspectives. They are the assumptions that: (1) sociology aims to discover and to explain the impact of social facts on human behaviour, attitudes, and feelings; (2) social facts are to be treated as things that are real and external to human actions, and that determine 

human behaviour; (3) social facts can be seen in aspects of the social structure such as the norms associated with structural locations (e.g., gender, race, status, class) that guide behaviour through roles enacted in social institutions such as the family or the economy, and in social behaviours such as those in relationships, in marriage, or at work; (4) sociology is a science that seeks to describe the world in a series of universal causal laws related to the operations of social facts; and (5) this science considers that human behaviour is objectively and quantitatively measurable through methods such as experiments and survey research.

One of the most influential contributions to medical sociology from a structural-functional point of view is Talcott Parsons’s work on the  sick role  (Parsons, 1951, pp. 428–79). To understand Parsons’s concept of a sick role, it is necessary to think that each individual plays a number of roles in society. Roles are linked to norms. Roles and norms arise out of the institutions with which the individual is associated. An individual may play a variety of work roles, community roles, family roles, friendship roles, and so on. All roles reflect something of the intermeshing of the individual in society and are guided by behavioural norms. The idea of role is pivotal for conceptualizing the relationship between the individual and society in structural functionalism.

Parsons’s main concern was to describe the processes that maintain societal institutions and thus the stable workings of society. His notion of the sick role should be looked at in this context. Sickness, if not somehow integrated into social institutions, could lead to societal breakdown. This would result from the inability of the sick to fulfill their necessary social roles. Therefore sickness must be managed, and must be accorded a special position. However, this sick role legitimation is only temporary and is contingent on the fulfillment of certain obligations by the individual who claims the sick role. The sick role has four components. The first two are rights; the second two are duties. Both the rights and duties of the sick role must be fulfilled if the equilibrium of society is to be maintained.

(1) The sick person is exempt from “normal” social roles.

The truly sick individual has a legitimate excuse for missing an exam or a major presentation at work, for staying in bed all day and neglecting household chores, or for staying home from work. In order to win exemption, the individual may need formal, medical acknowledgement. The sick person may have to obtain an official diagnosis and even a medical certificate as proof of illness. Exemptions from examinations, for instance, generally require a formal written note from a physician.

(2) The sick person is not responsible for his or her condition.

The sickness must be the result of circumstances beyond the control of the individual if that person is to be accorded the sick role. Thus, the individual is not to be blamed or punished. Influenza, a cold, and a broken leg are usually considered the results of misfortune, not of personal will or desire. Therefore, sympathy rather than blame is considered the appropriate reaction of others.

(3) The sick person should try to get well.

The sick role exemption is only temporary. The person who is given the legitimacy of the sick role is duty bound to try to get well. If an individual does not want to get well or does not try to get well, then the sick role is no longer considered legitimate. Thus, if a person has received a diagnosis of pneumonia, he or she must do what the doctor orders. If not, the legitimacy of the sick role deteriorates into the shame of such a label as “foolish,” “careless,” “immoral,” or a “malingerer.”

(4) The sick person should seek technically competent help and co-operate with the physician.

The duties associated with the sick role also require that the ill person seek “appropriate” medical attention and comply with the treatment provided. For example, a person with HIV/AIDS or another sexually transmitted infection who refuses both to accept medical care and to change certain sexual interactions would not be accorded the rights of the sick role and could be subject to legal punishment.

From the viewpoint of Parsons, illness is a form of deviance. It is a potential threat to the ongoing social system unless it is managed for its benefit. Medicine is the institution responsible for providing legitimation. It is also responsible for bringing the sick back to wellness or “normality.” Medical institutions can be seen as agents of social control in much the same way as are religious institutions and the criminal justice system.

Parsons’s formulation of the sick role was primarily theoretical: it was not based on extensive systematic empirical investigation. Empirical analysis subjects his definition of the sick role to a number of criticisms. A few of these criticisms will be examined in the following sections.

(1) The sick person is exempt from “normal” social roles.

The extent to which a person is allowed exemption depends on the nature, severity, and longevity of the sickness, and also on the characteristics and normal social roles of the person. A short and self-limiting burn on the fingers merits only temporary, minimal exemptions from life roles. On the other hand, multiple sclerosis, a chronic, degenerative, and usually progressive disease, allows extensive exemptions.

The university student’s sick role is mostly informal. Usually sick role exemption is not required. Most professors do not take attendance; students can avoid the library for weeks on end without any official notice being taken. They can stay in bed half the day and stay out half the night. These things are the student’s own responsibility. It is only at the time of regularly scheduled deadlines for papers, presentations, and examinations that universities typically take any official notice of the student’s actions. At these times the student may need to adopt the sick role formally by obtaining official legitimation from a physician through a note.

(2) The sick person is not responsible for her or his condition.

This belief varies depending on the nature of the condition and the circumstances through which the person is believed to have acquired the condition. The sick person may be held responsible for having a cold, for instance, if he or she stayed out overnight and walked miles in the freezing rain without a jacket. The notion of stress that is prevalent today often has an aspect of blame attached to it—that is, people who succumb to disease because they have overworked or worried may be chastised for having failed to take preventive action. One of the implications, in fact, of the recent emphasis on health promotion through lifestyle change (moderating the amount of physical exercise undertaken, and so on) is that people who do not change and become more active may be more likely to be held responsible and blamed for any diseases with which they later are diagnosed. For example, the person with AIDS may be blamed for disease because of his or her sexual habits or intravenous drug use. A number of different diseases are thought to reflect on the moral and social worth of the individual, and when an individual succumbs to these diseases he or she may be blamed according to the degree of social  stigma  (Goffman, 1963) attached to the condition.

Even though the specific causes of particular cancers are not known, the person with the disease is sometimes blamed for receiving a cancer diagnosis. For instance, the person with lung cancer may be held responsible if he or she has smoked or still smokes. Crandall and Moriarty (1995) asked people to examine case histories representing 66 illnesses and to rate the illnesses according to a number of dimensions. They found that the diseases most likely to lead to social rejection, i.e., to be stigmatized, were those (1) that were believed to be under personal onset control and (2) that were most severe. They did not find that gender, age, or ethnicity had an impact on the stigma associated with different diseases. Today, ironically, sometimes a cancer diagnosis may be associated with a positive stigma. It may seem almost a badge of honour and an opportunity for “growth” (Seale, 2001). In fact, many think that breast cancer ought to be an occasion to learn and practise “optimism” (Ehrenreich, 2009). It is used as a marketing ploy (King, 2006). Prostate cancer has spawned its own celebratory marketing through the November growth of moustaches among millions of men for the “Movember” fundraising movement. Over the last decade a number of different identities and reconfigured identities have been associated with cancer and its meaning to those diagnosed (Kerr et al., 2018). Some of these, such as pancreatic cancer, likely reflect neutrally on the person and others may reflect positively or negatively.

(3) The sick person should want to get well.

This is only true if the sick person is not diagnosed as terminal or chronically ill. People are expected to adjust to such illnesses, not to seek healing. In fact, if people continue to want to get well when they have been thus diagnosed, they are often criticized and possibly even diagnosed with a mental illness because they may be said to be denying reality. Similarly, people with a whole range of chronic illnesses are not expected to want to get well, but rather to adapt to and cope with daily limitations and challenges.

(4) The sick person should seek technically competent help and co-operate with the physician.

The dominant medical care system is that of  allopathic medicine , which treats disease by trying to create a condition in the body that is opposite to or incompatible with the disease state. While this conventional medical care system still claims a monopoly and governmental support for the right to provide treatment and thus to legitimate sickness, there are competing medical systems with varying and possibly growing degrees of popular legitimacy. A significant proportion of Canadians use alternative health-care providers. This includes those who have used self-help and complementary and alternative medicines (CAMS), such as meditation, herbs, vitamins and minerals, music therapy, or yoga, for their health. Moreover, allopathic medical practice is the subject of growing critique by a variety of consumer interest groups (see Breggin, 2014, for ongoing opposition to the  pharmaceuticalization  of children’s mental health issues). The anti-vaccine or “anti-vax”movement, which the World Health Organization has named one of the biggest global threats to health in the future, may reflect a growing popular skepticism about conventional medicine (Ryan, 2019). Near-universal social media availability can provide an additional impetus for the rapid growth of such movements. Critical evaluations of such things as unnecessary surgery, side effects from taking prescribed drugs, and unnecessary medical intervention in childbirth raise the real possibility for many critics that care from a physician may not always be the most effectual road to good health. In the case of childbirth, for instance, there seems to have been a fairly drastic shift in Canada away from dependence on medical doctors, including specialist obstetricians/gynecologists, towards the wide acceptance of midwifery for childbirth. This is evident in state funding for midwifery since 1994 (Kaufman, 1998).

Parsons was the first to note explicitly that there are ways in which medical practice, its ideology, and its associated medical institutions serve to fulfill social control functions for the society. The concept of medicalization, which will be discussed later, has been used to describe this process.

While  positivism  is the research methodology most closely associated with the structural-functional perspective, not all positivists are structural functionalists. Contemporary positivists study human health behaviours as both  independent  and  dependent variables . An examination of the impact of a diagnosis, e.g., of cystic fibrosis, on the family of the ill person treats health behaviour related to the diagnosis as the independent variable. On the other hand, when the impact of income level on the  incidence  of disease is studied, human health behaviour becomes the dependent variable.

Today, positivists, following Durkheim, assume that the social has a constraining impact on individuals. Social-structural positions (social facts) determine individual thoughts, behaviours, feelings, and, in this case, ideas about health and illness, medical utilization, and so on. Research along these lines examines the effects of such things as gender, race, class, educational level, family type, marital status, age, rural/urban background, religious affiliation, religiosity, and political ideology on such (dependent) health-related variables as disease and death rates, prevention activities, and utilization of medical care. The  social determinants of health  perspective is a contemporary illustration of this methodology because it examines the impact of social inequities on health outcomes (see Chapters 4 and 5 for examples of this type of research).

The methodological assumptions of positivist social science are outlined in Table 1.3.

Table 1.3Methodological Assumptions of Positivist Social Science

Objectivity	Social science can be as objective as physical science and should be modelled on the physical sciences.
Generalizability	One of the most important goals of social science is to generalize and thereby to describe the world in a series of “if x then y” causal laws.
Validity: Construct	It is possible to design measures that accurately and briefly describe sociological concepts.
Validity: Internal	It is possible in any social scientific research design to say with a degree of surety that “x” is the probable cause of “y.”
Validity: External	It is possible to select a sample so that generalization from the sample to the total population is accurate with a known but limited amount of error.
Reliability	It is possible for the same research to be completed in different settings and by different researchers and with essentially the same findings.
Causality	It is possible to demonstrate probable causal relationships between social science variables.
Adequacy	The data collected adequately describe and explain the phenomenon under investigation.
Data Collection Strategies	The usual data collection strategy involves survey research with either a questionnaire or an interview, administered either in person or over the telephone. Experimental laboratory research is sometimes done.
Quantification	Sociological phenomena can be quantified in statistical data.
Probability	Analysis is based on assumptions of probability, not determinism, i.e., hypotheses are put forward as possibilities.

Conflict Theory

Conflict theory has had a somewhat less dominant role in the development of sociology in North America. It has provided a radical critique of the more conservative aspects of structural-functional sociology and of the economic and social arrangements found in society. In  conflict theory , all social arrangements, all sociological theories, and all sociological methods have political and economic bases and consequences. Traditional conflict theory tends to focus on class- or economic-based power relations and dynamics. Research topics, methodological approaches, and commitment to the use of findings are all said to reflect the political and economic interests of the researcher.

The model of this paradigm is the work of Karl Marx (1818–83). Marx was directly involved in the analysis of and the organization for changes in his society. The author of numerous books, he was the leader of the First Communist International in Europe during the nineteenth century, and was also a busy and effective investigative journalist. He asserted that human thought and behaviour were the result of socio-economic relations, and that both were alterable for human and social betterment. Believing that human beings could change their social order, Marx worked towards human liberation through a social and economic revolution.

Society, according to Marx, has historically been composed of a constantly varying balance of opposite forces that generate change through their ongoing struggle. The motivating force behind this continuous struggle is the way in which people interact with one another as they attempt to obtain their livelihood. Marx described the various modes of production with their corresponding types of social relations that occurred in consecutive historical periods as a struggle between classes. The class struggle is related to the means of production, e.g., the land or the factory, because members of one class own the means of production and members of the other class sell their labour for goods and services and cash. For Marx, an end to conflict was both possible and desirable and would happen in a communist state in which all citizens owned the means of production.

In doing sociology, conflict theorists use information from a variety of sources, but it tends to be historical and critical. As with structural functionalism, the level of analysis is the social system, because ultimately the system must be changed and a new one established. What is distinct about some conflict theorists is that they may also be highly political and social activists. Some see injustice everywhere, and try to alleviate it.

Conflict theory can be distinguished in the following ways: (1) the sociologist’s work is to discover and document injustice (and sometimes to attempt to change it); (2) all knowledge is rooted in social, material, and historical contexts; and (3) sociological research methods must acknowledge social, economic, and historical circumstances. When the conflict theorist is particularly influenced by Marx’s analysis, the primary subject of study is social classes, because they are thought of as the most important means to effect change.

Sociology from the perspective of conflict theory involves the documentation of injustice for the purpose of understanding its origins and causes in a historical and socio-political context. Social class and social injustice are everywhere, and medical institutions and patterns of disease and death are no exception.

A long tradition of scholarship documents the ways in which health and illness are related to unequal social arrangements. Marx’s collaborator, Friedrich Engels, in The Condition of Working Class in England (1845), showed how the working and living conditions that resulted from early capitalist production had negative health effects. Engels described how capitalism introduced mechanization on farms, resulting in a mass of unemployed rural workers who were forced to migrate to the cities to make a living. Capitalists in the city, driven to make a profit, kept their labour costs low, and thus the working classes could afford only very cheap shelter and food. The great slums that resulted were the perfect breeding grounds for the diseases endemic to such living conditions, including rickets, tuberculosis, typhoid, scrofula, and other infectious diseases. Thus, ill health was related to the living conditions of the working class and the material conditions of capitalism.

More than a century and a half later, advanced monopoly capitalism, globalization, and neo-liberalism (O’Connor, 1973; Turner, 1987; De Vogli, 2011) have generated considerably different but equally inhumane working conditions for workers and their families around the globe. Under neo-liberalism, inequality has widened in the developed world (Heisz, 2015). The share of income, beginning in the 1980s, has grown especially rapidly among the top 1 per cent of the population. By 2000, the gap between the top 1 per cent of income acquirers and the rest of the population was larger than at any time since the 1930s (Heisz, 2015). Inequity, as evident in the disparities in income, is reflected in mortality and morbidity statistics and in corresponding standards of living around the globe. Contemporary capitalism is dominated by huge international corporations such as, among the top 10, Walmart, BP (British Petroleum), Volkswagen, Exxon Mobil, Berkshire Hathaway, and China National Petroleum (see Fortune Global, 2019). These huge companies are characterized by strategies designed to provide large shareholder profits rather than to satisfy workers. Strategies include enlarging profits through increased worker productivity and new time-saving technologies, and moving from developed into less-developed countries both for cheaper wages and production costs and for new markets. As a result, a perpetual contradiction pits the needs of the workers—for a good living wage, good working conditions, adequate time for rest and relaxation, and meaningful, satisfying, and predictable work (all of which are prerequisites to ongoing good health)—against the needs or desires of the capitalists for continuous expansion and profit. This trend has also hit universities in Canada, which increasingly are relying on part-time instructors who are easily replaceable and non-tenured, and are paid considerably less. Thus, the “gig” economy has entered academe. The mental and physical health consequences of such insecure labour for the temporary labour force, including part-time university instructors, are often considerable.

Vincente Navarro (1976) has been one of the foremost conflict theorists of medical sociology in the context of the United States. He explains that there is a contradictory relationship between capitalism, which is an economic system fuelled by the profit motive, and the health needs of the population. Often, the perceived need to make a profit requires that workers labour, live, and eat in unhealthy and unsafe environments. The manufacture, sale, and tax level of cigarettes around the world illustrate how the desire for corporate profits and state tax revenues may outweigh the desire for good health for a population. For example, we are more likely to be warned about the dangers of terrorism than of cigarette smoking. Think of what you hear on the news about the threat of international terrorism as compared to cigarette smoking. The Global Terrorism Database as maintained by the US Department of Homeland Security listed the number of deaths globally due to terrorism in 2012–13 at 20,432. Cigarette smoking kills about 7 million people annually according to the World Health Organization (2018).

The tobacco industry has maintained a successful profit margin by opening up new markets in spite of anti-smoking sentiments and increasingly restrictive legislation on the marketing, sale, and packaging of tobacco products. In Canada, for example, the market has expanded into the younger age groups and women (Weeks, 2014; Begley, 2014). Though laws prohibit the sale of cigarettes to people under 18 (Abedi, 2017), they are rarely enforced, and even when they are enforced the fines for retailers are so low that they are virtually useless. Mini-cigars, flavoured as candy and lacking any warning labels, are one of the latest attempts to make inroads into the youth market (Begley, 2014). Vaping is sometimes used by smokers as a way of maintaining the smoking habit. Some states in the US have increased to 21 years old the age at which smoking is legal in an effort to diminish the number of deaths from tobacco smoking (Abedi, 2017). However, as the overall rates of cigarette smoking are declining in the developed world, until recently the rates had been rapidly increasing in developing countries around the globe. Even today, according to the World Health Organization, the rates are continuing to increase in the Mediterranean and African regions (WHO, 2018). Now almost 80 per cent of the world’s smokers live in middle- and lower-income countries, according to the WHO.

There are two main goals of contemporary capitalism: the concentration and protection of capital and the deployment of the state by capitalists to ensure protection is in place. The state intervenes in the health sector in several ways to promote capitalist goals. First, the class structures of society are reproduced within the medical sector, so that the hierarchical distribution of functions and responsibilities of occupational groups within the medical care system mirrors the class, ethnic, and gender hierarchies within the other sectors of capitalist society. Second, the medical system has adopted a bourgeois ideology of medicine that regards both the cause and the cure of illness as the responsibility of the individual. Health itself has become a commodity with a certain value within the marketplace. The medical model is a politically conservative model; it directs attention away from the social-structural causes of ill health, such as gender, racialization, class, occupation, income, and environmental degradation. Third, the state supports alienation when it is costly for people to choose alternatives to conventional physicians, such as chiropractors, naturopaths, masseuses, or dieticians. The state provides full financial support for only one type of medical service—that provided by the allopathic practitioner. Today, with globalization, many would argue that states have actually given away much of their power of governance to international capital through multinational corporations such as the pharmaceutical and medical technologies industries. This has resulted in innumerable threats to health and well-being (De Vogli, 2011).

The state also uses strategies to exclude conflicting ideologies from debate and discussion. One example is the emphasis on individual and family (primarily maternal) responsibility in the causation of disease, in promoting early detection practices (such as mammograms), and in health-promoting behaviours. Such viewpoints exclude analysis of the processes through which class origins, environmental pollutants, occupational hazards, and working conditions are significant causes of ill health Women, Health and the Family (1984) illustrates research in the conflict perspective. Although Graham’s research was carried out in Great Britain a number of decades ago, it continues to raise questions for all societies regarding the significant home health-care work that women, in particular, are expected to do for the state—with no compensation. This invisible work continues today. Policies supporting home health-care leave have not been adequately developed in Canada, and the definitions of home health work vary widely across the country (Johnson et al., 2017).

Graham demonstrates how the class position of the family is reinforced in the home health-care work done by mothers. She analyzes the impact of poverty on the availability of fundamental resources such as transportation, housing, fuel, food, and health care in the home, and notes that the relative lack of such resources has negative effects on the health status of family members.

Home health-care work  is composed of four elements. First is the provision of healthy conditions in the home. This involves the maintenance of a warm and clean home with sufficient space for rest and relaxation for all family members, sufficient and adequately nutritious foods, and clean water. Home health care also involves managing social relations and meeting emotional needs for the optimal mental health of family members. The second element is nursing the sick: much of the work of caring for the sick child or adult, and for elderly or disabled people, falls on the shoulders of the women in the home. Furthermore, increasing deinstitutionalization of the mentally, chronically, and acutely ill increases the level of intra-family responsibility. Nursing the sick is often a very time-consuming and exhausting job. It involves sleepless nights, heavy lifting, preparation of complicated menus, administering medicines, coping with bandages, and the like. A third element is teaching about health, including such things as modelling good health habits and giving instruction on diet, hygiene, and exercise. The fourth and final aspect of home health-care work is mediating with outsiders such as doctors and hospitals, making visits to clinics, talking with a social or public health worker, or getting advice from an expert in a health-related area, such as nutrition. The hidden health-care work of women continues today in Canada and elsewhere. It reinforces gender inequality.

Graham also documents the existence of class differences in home health-care work and in associated mortality and morbidity rates. She notes the consistently inverse relationship between class and some of the most sensitive indicators of a nation’s health: stillbirths, prenatal mortality, neonatal mortality, postnatal mortality, and infant mortality rates. These class differences in outcomes among infants are mirrored in the morbidity statistics for children and adults. Accidents, the largest single cause of childhood death, are probably one of the best indicators of an unsafe, inadequately supervised environment: the accident rate increases sharply among the lower social classes. Kronenfeld et al. (1997), using a survey research methodology with a sample of 1,247 young mothers, found that such parental resources as income and education were associated with better safety practices in respect to their children. Higher income was positively associated with safety behaviours such as not leaving a child alone in the house, not hiring babysitters younger than 13 years of age, not leaving a child alone in the bathtub, using an approved car seat, and a child’s wearing a safety helmet while bicycling. Poorer families were more likely to suffer from other environmentally related causes of the death of children, such as respiratory diseases. The incidence of infections and parasitic illnesses is also class-related. There is evidence that the mortality rate for some childhood cancer is inversely related to class (de Kok et al., 2008). Traffic accidents involving children are associated with class and neighbourhood (Haynes et al., 2008). Poverty is also related to mental health in children (Strohschein & Gauthier, 2017)

Samuel S. Epstein (1998) is an epidemiologist with an expertise and a lengthy list of publications on the occupational and environmental causes of cancer. In an analysis of the policies of the National Cancer Institute (NCI) he drew our attention many years ago to conflicts of interest in medical practice and the funding of health-care organizations. He was one of the first critical analysts to document the high incidence of preventable cancer deaths and the minimal research investment of the NCI in understanding these preventable deaths. More recently, Devra Davis (2007) provided a critical historical overview of the so-called “war on cancer,” which was started in the US by President Nixon in the 1970s. She documented how the “war” was plagued by ongoing conflict of interest among cancer policy-makers because of their roles as directors in other industries that were either known to or thought to cause cancer. For instance, she showed how the leaders of industry who were responsible for the manufacture, advertising, and sale of cancer-causing products such as cigarettes were also in positions of power in the supposed fight against cancer. These leaders clearly paid lip service to the eradication of cancer even while they fought to suppress the scientific evidence of many of its fundamental causes. For example, she stated: “Some of the early leaders of the American Cancer Society and the National Cancer Institute left their posts to work directly for the tobacco industry … they were hired to generate uncertainty about the association between tobacco and lung cancer” (Davis, 2007, p. xv). Davis also documented how the media presentations of public research and information about trendy new products obfuscate the potential threats of some contemporary commodities such as cosmetics and other personal care merchandise, pharmaceuticals such as Ritalin, the sugar-free sweetener aspartame, and cell phones. Davis has been trying to warn people that while the data are not all in yet, the idea that cell phones are bad for the brain should not be ignored. Meanwhile the National Cancer Institute continues to argue that the research on this link is inconclusive. In a situation in which there are powerful interests in support of such new technologies, caution in their endorsement is important. This stand on the careful and reluctant adoption of new technologies until they are proven safe is called the  precautionary principle .

Cancer rates are significantly higher among poorer people because of their relative food insecurity, smoking rates, obesity, lesser physical activity, and lack of access to good medical care (O’Connor & Gross, 2018). The strongest individual causal connector is food security. There are innumerable complex social and economic causes, too. Thus, regions with the highest cancer mortality rates can have as high as seven times the cancer incidence of those with the lowest rates. However, cancer prevention itself is also heavily medicalized and biomedicalized. Prevention is widely understood to be early detection via such measures as mammograms, hormone replacements (HRT), and mandated HPV vaccinations, for example. Early detection technologies are aspects of medicine. They reflect medicalization. They are not and should not be thought of as prevention. This link conflates two processes that should be distinguished one from another. Moreover, research has found that the safety and effectiveness of such early detection interventions as mammograms and HRT are equivocal and may cause disease at times and unnecessary anxiety in the face of false positives at other times. The fact that doctors may be financially invested in these technologies is also problematic. The guidelines for some of these early detection strategies are not perfect. For instance, there are new guidelines for mammography screening from a required frequency, depending on age, to women’s choice (Ubelacker, 2018). Such change in health policy reminds us again that scientific findings are always in process and that scientific truth is based on probability, not certainty. One additional example of the uncertainty of some medical interventions is the growing evidence that many medical devices implanted into Canadians have safety risks (McClean & Cribb, 2018).

In contrast to the emphasis on early detection, there is a relative lack of emphasis on research on prevention. For example, a vanishingly small amount of the money that goes to investigating cancer in either children and adolescents or adults is dedicated to prevention. Possible environmental causes of cancer, such as pesticides and herbicides, are seldom a research focus. Treatment and biology receive the greatest proportion of the financial investment in cancer research (see Table 1.4).

Table 1.4Values about Cancer Research Funding by Common Scientific Outline (CSO) Categories

	CSO categories
No. crt	Authors	Publication Year	Region/Year	Cancer Biology (%)	Etiology (%)	Prevention (%)	Early Detection, Diagnosis, Prognosis (%)	Treatment (%)	Cancer Control (%)	Scientific Model Systems (%)
1	S. Eckhouse & R. Sullivan	2006	EU / 2002–3	41	14	4	9	20	5	6
			USA / 2002–3	25	17	9	12	25	9	3
2	N. Shiraze et al.	2011	Western Australia / 2008–10	40	6	6	8	23	12	5
3	Canadian Cancer Research Alliance	2014	Canada / 2005	43	11	2	10	24	8	1
			Canada / 2011	30	14	2	14	30	10	<1
4	C. Gotay	2012	Canada / 2005	43.1	11.3	1.7	10.5	24.5	8.1	0.8
			Canada / 2010	31.5	13.3	2.6	12.3	29.8	10.3	0.2
5	International Cancer Research Partnership	2012	Global level / 2005	22.1	17.9	7.9	11.9	25.9	10.5	3.8
			Global level / 2008	24.9	13.8	6.8	13.3	26.7	10.5	3.9
6	S. Eckhouse et al.	2008	Europe / fiscal year 2002–3	41	14	4	10	20	5	6
			USA / fiscal year 2002–3	25	17	9	12	25	9	3
			Canada / fiscal year 2004–5	45	10	2	8	22	12	1
7	Canadian Cancer Research Alliance	2012	Canada / 2005	42.9	11.4	1.7	10.5	24.5	8.1	0.9
			Canada / 2009	32.9	12.4	2.5	13.4	28.2	10.2	0.3
8	Cancer Australia	2014	Australia / 2003–5	51	7	5	8	19	9	1
			Australia / 2006–8	38	10	2	13	27	7	3
			Australia / 2009–11	32	8	2	16	28	9	4
			Australia / 2006–11	35	9	2	15	28	8	4
			Canada / 2006–11	36	12	2	13	27	10	<1
			UK / 2006–11	41	10	3	11	25	6	3
9	Institute National du Cancer	2010	France / 2009	24.29	5.34	0.09	24.3	34.72	9.25	2.01

Source: Matei et al. (2015, pp. 9–11).

Samantha King (2006) has documented how popular breast cancer activism has often led to an obfuscation of the links between the economy, the environment, and breast cancer. She argues that one of the ways this happens is through products advertised as leading to the eradication or minimization of a particular problem. This type of marketing essentially obscures the responsibility of governments for caring for their citizens and intervening for prevention. It encourages people to buy products through advertising the association between the philanthropic activities of the business and the disease. Such an emphasis can disguise the disease-causing effects of the products being advertised. For example, the Look Good … Feel Better campaign dedicated to “makeovers” for women with cancer is used to advertise cosmetics and other products, some of which have carcinogenic properties. The dominance of such fundraising strategies supports the neo-liberalism and  privatization  that characterize the modern economy, including its valorization of the market along with individual responsibility or “responsibilization.”

The methodological assumptions of conflict theory are shown in Table 1.5.

Table 1.5Methodological Assumptions of Conflict Theory Social Science

Value Commitment	Rather than seeking objectivity, the conflict theorist believes that sociologists must discover, document, and record recurrent patterns and dynamics of power/class/gendered/racialized relations both because they have no choice (members of a society are committed to the ongoing action of the society) and because they believe that this is the morally correct position.
Historical Specificity	Rather than looking for generalizations, conflict theorists assert the necessity of understanding the unique features of the particular situation in its socio-historical context as an example of these recurrent patterns of power/class/gendered/racialized relations.
Validity: Construct	Formal tests of validity are considered irrelevant. Researchers, it is assumed, of necessity and because of political commitment study what they claim they are studying.
Validity: Internal	Formal statistical tests of causal relationships are not always necessary. Rather, logical meaningfulness may be the relevant criterion of causality.
Validity: External	The conflict theorist assumes that inequities based on power/class/gender/racialization relations are ubiquitous, yet analyzes the components separately in each historical situation.
Ethical Concerns	The primary importance in the research of the conflict theorist is the commitment to such ethical and humanitarian principles as justice and equality.
Data Collection	The usual sources of data are historical documents. As well, the conflict theorist may use other data collection methods, including surveys, statistical data, and methods such as unstructured interviews and participant observation that provide subjective and descriptive data.
Objectivity	Objectivity is not possible. Knowledge cannot be separated from the power/class/gender relations of the researcher and the subjects.
Quantification	While numerical data may be used to document an argument, they are not always available.

Interpretive/Social Constructionist Theory

What is the meaning of illness? Does cancer have the same meaningful impact when it happens to an 80-year-old adult as when a 10-year-old child is diagnosed? What are the processes through which the slow onset of Alzheimer’s comes to be noted by family, friends, and the patient? How do families work through their changing understanding of the uncertainty and then the certainty of the death of one of their members? How does the self-identity of the person with AIDS alter once he or she has received the diagnosis? How do others alter the ways they relate to the person with AIDS? These are the sorts of questions asked by those who study health and illness issues from the perspective of  interpretive/social constructionist theory , which is sometimes known a  symbolic interactionist theory .

Max Weber provided a definition of sociology from this perspective: “a science which attempts the interpretive understanding of social action in order thereby to arrive at a causal explanation of its course and its effects” (Weber, 1947, p. 88). There are two crucial elements in this statement, each of which exemplifies an aspect of Weber’s work. First, social action, as defined by Weber, meant action to which the individual attached subjective meaning. Second, the sociologist, while looking for what Weber calls causal explanation, was actually directed to interpret empathetically the meaning of a situation from the viewpoint of the subject.

Interpretive sociologists study how the subjective definitions of social reality are constructed and how this reality is experienced and described by the social actors. Human beings create their social worlds. As W.I. Thomas said, if a situation is defined as real, it is real in its consequences (Martindale, 1960, pp. 347–53).

The paradox here is that, just as the subjects who are being studied are busy defining reality for themselves, so, too, are the researchers. Thus, the interpretive theorist is faced with the problem, when collecting data, of intersubjectivity or reflexivity, that is, that the data are given a subjective slant both by the people being studied and by the researcher. Furthermore, the research act itself creates and changes meanings and processes. From the perspective of interpretive theorists it is impossible to gather objective data. All social reality is subjectively defined and experienced and can be studied only through the interactive subjective processes of social researchers.

Empathetic understanding, or what has sometimes come to be called, following Weber,  vestehen , is the desirable methodological stance of the researcher. Generally, sociologists adopting this stance collect data by observing social action in close participation with the subjects or by long, unstructured interviews. The level of analysis is not of the system but rather of individual interaction with others, the mind or the self, and meaning. 

This is microanalysis. The structural-functional and conflict theories, because they focus on systems, are macro analyses.

Three assumptions are characteristic of this perspective: (1) sociology is a science, the purpose of which is to understand the social meanings of human social action and interaction; (2) reflexivity or intersubjectivity, rather than objectivity or critical analysis, characterizes the relationship between the subject and the researcher; and (3) rich, carefully detailed description and analysis of unique social situations from the perspective of the subjects under investigation are typical of interpretive research.

The sociological problem to be understood and explained in the interpretive tradition is the meaning that individuals see in the actions of themselves, of others, of institutions, and so on (Weber, 1968). Analysis of society demands different methods from those used to describe and explain the natural world. It requires methods that attempt to grasp the motives and meanings of social acts. Sociology is a science that must deal with the subjective meanings of events to social actors.

A classic and historical example of work in this perspective is the study of the meaning of the diagnosis of epilepsy within the lives of a sample of people with this disease. Having Epilepsy (Schneider and Conrad, 1983) is based on long, semi-structured interviews with a number of people who have been diagnosed with epilepsy. The authors make the point that it is important that sociologists provide an antidote to medical research. It is crucial, they note, to distinguish between disease and illness. Disease is the pathology of the human body; illness is the meaning of the experience associated with a given pathology. In this research the subjects were selected for study because they have an epilepsy diagnosis. However, they live most of the time without the symptoms of the disorder being present. They go about their daily activities, eating, dressing, working, cooking, cleaning, visiting, enjoying leisure and social activities, unrestrained and unconstrained by an awareness of their disease.

Medicine attempts to understand the nature and cause of disease and to formulate methods for its treatment. One of the tasks of the sociologist is to describe the impact of disease and diagnosis on the individual’s self and on his or her relationships with others. As Schneider and Conrad (1983, p. 205) say: “We cannot understand illness experiences by studying disease alone, for disease refers merely to the undesirable changes in the body. Illness, however, is primarily about social meanings, experiences, relationships, and conduct that exist around putative disease.”

Schneider and Conrad suggest that one of the most pervasive aspects of epilepsy is a continuing sense of  uncertainty . From the earliest stages of pre-diagnosis and throughout the illness, a sense of uncertainty is a defining quality of this and many other chronic conditions. People with epilepsy, like those with Alzheimer’s disease, diabetes, or multiple sclerosis (just a few of the chronic conditions to which this analysis is relevant), at first wonder what is happening to their bodies or their minds. They wonder whether or not to take this or that small sign of change as a symptom of a disease. They wonder whether it is a symptom of a serious or a minor issue. At this stage people generally normalize their symptoms.

Once diagnosed, they wonder how severe their illness will become and whether they will live for long or only for a short time. They ask whether they will be seriously debilitated or only mildly affected. Each day is different. Planning the next day or the next week may be fraught. Relationships are altered. Others respond to this sense of uncertainty with their own confusion about the disorder and its likely course. Not only does relating to the self become tinged with ambiguity arising from dealing with constant change, but commitments to others also become difficult. The lack of easy, honest, open, and straightforward communication is frequently seen as one of the most painful aspects of the disorder. Cancer patients, for instance, have said that the difficulties of communication are frequently even more painful than the disease or its treatment (Dunkel-Schetter & Wortman, 1982). Arthur Frank (1991) has noted how we now live in a  remission society  because of the ongoing sense held by so many people who have lived through serious diagnoses that anything can happen and the disease or another just like it may (re)occur. It takes a long while for people who have survived some serious disease to feel “normal” again—if they ever do. Conceptualizing life after diagnosis and treatment in terms of the five-year survival rate adds to this continuous uncertainty for people in the remission society. As blogger BCBecky explains, “I shall never not be a cancer survivor. Breast cancer is a sickness that will always be part of my identity, regardless of how healthy I am at any given moment” (BCBecky, 2017).

Another source of uncertainty surrounding some chronic illnesses is the fact that many are poorly understood by the medical profession and by the lay public, including those diagnosed. There is a general lack of knowledge about the probable prognosis of some chronic illnesses. Some chronic diseases receive a considerable amount of press; others receive very little. Some are well recognized by the lay public; most are not. Some have been diagnosable for many, many years. Others, such as fibromyalgia and chronic fatigue syndrome, seem to be new and growing diagnoses. For some, particularly the norms of possible remissions, plateaus, and disease exacerbations have long been charted. The short history of others means few standards for what to expect.

Epilepsy is a disease with a long history. It has often been thought to reflect not just the state of the physical body, but also the moral character of the person. At times the person with epilepsy has been considered to be divine, at other times satanic. At various times and places seizures have been understood as signs both of prophetic ability and of madness.

Chronic illness requires symptom control. This is particularly necessary when the symptoms can be highly disruptive, as in diabetes, which can exhibit diabetic reaction or coma; or in colitis, which may involve unexpected evacuation; or in epilepsy, if there is a grand mal seizure. Symptom control can involve following the doctor’s orders. It can also involve non-medical procedures such as biofeedback, hypnosis, diet change, meditation, exercise, relaxation, vitamin therapy, and others. Managing medical regimens does not necessarily mean following the medical rules. Instead, people often manage their medicines according to their own values, habits, activities, relationships, and side effects.

People with epilepsy control their drug use in such a way as to moderate the number and severity of seizures to a level with which they feel comfortable. Doctors’ orders are only one of several sources of information upon which people with epilepsy choose to base their use of medication. Drug-use patterns develop as an outcome of a complex of self-perceived considerations such as (1) the meaning of the seizure to the subject, (2) the personal view of the effectiveness of the drug, (3) the personal estimation of the costs of side effects, (4) the desire to test whether the epilepsy is still present, (5) the wish to avoid having others recognize that one has epilepsy, and (6) the need to protect oneself from seizures in particular situations (Schneider & Conrad, 1983). Medication use is a social process and as such is vulnerable to the social needs and experiences of users. People then tend to interpret their illness meanings and adjust their drug regimen schedule to suit themselves.

The study of the meaning of illness is extensive today. For example, a great deal of study is occurring on how masculinities may be affecting the use of health care and the management of illness and disability. In some ways the very definition of hegemonic masculinity includes strength and action. It belies sickness and incapacity. The question asked in research by Flurey et al. (2018) is how men manage their identities when they are diagnosed with a disease that is not only more common among woman but is also defined by causing weakness and loss of, or painful, mobility. Flurey and colleagues found three typologies of response to the threat to masculinity posed by the diagnosis of arthritis. The first was characterized by retaining hegemonic masculinity, for example, by trying to continue in full-time work. The second incorporated a negotiation with the concept of masculinity by adapting work hours and responsibilities but identifying masculinity as an ability to maintain an active social life, particularly with the male friends, and engaging in male activities such as motorcycling. The third group rejected hegemonic masculinity through retirement from work along with the maintenance of a slower pace of social life. Ask yourself, how do you think men deal with their masculinity when they are diagnosed with breast cancer as compared to prostate cancer? Or how do people change or adapt as they construct their identities after receiving a diagnosis of a sexually transmitted infection?

These are the sorts of questions that have motivated research in the social constructionist/interpretive tradition, the assumptions of which are outlined in Table 1.6.

Table 1.6Methodological Assumptions of Interpretive/Social Constructionist Social Science

Reflexivity	Social researchers interpret the sayings and behaviour of their subjects from the subject’s perspectives and within the context of the researcher’s perspective. The researchers are affected by the needs and expectations of their subjects and the subjects’ knowledge of the data collection process, and at the same time, they change the subjects’ understanding. Thus, it is impossible to measure human social behaviour objectively.
Ethical Concerns	Just as it is impossible to study human social action as if it were the action of so many atoms, molecules, neutrons, and protons, so it is impossible not to change the social situation that is the subject of the analysis.
Generalizability	While the method of analytic induction, one of the operating logics of this perspective, claims universality, most research in this paradigm is based on the specificity of human social action.
Causality	Causality is recognized in this perspective as a subject of study, e.g., “I believe I have cancer because I sinned against God,” rather than the “if x … then y” causality of positivism.
Proof	The most stringent criterion of proof is sometimes required within this perspective—negative case analysis.
Validity	Validity is always hampered by intersubjectivity, but the depth and detail of the description of the data and their “meanings” are considered important criteria.
Reliability	This is considered less important than validity because it is assumed that different researchers would be researching different situations and would therefore have (at least somewhat) different findings.
Scope of Analysis	The interpretive or symbolic interactionist sociologist is generally content to describe the social world of a small population of people in rich complexity and detail.
Advocacy	Some researchers who follow this methodological approach view their work as advocacy through giving voice to the voiceless or the unheard. Others fervently argue for the value of knowledge for its own sake.

The research of Flurey et al. (2018) exemplifies the interpretive approach to understanding behaviour in health and illness. Through the presentation of meaningful comments from the subjects interspersed with sociological analysis, the authors have provided a piece with empathetic relevance to others in similar health circumstances, to their families, to health-care workers who deal with people with such diagnoses, and to the academic sociological community.

Feminist and Critical Anti-Racist Theories

Feminist theory  and feminist methods have grown rapidly in the past half-century. A number of journals in a wide variety of academic areas are now dedicated to feminist, women’s, and men’s studies and they abound in many fields of scholarship. The social sciences, in particular, have been challenged and critiqued as having been “male-stream” in subject matter, research strategies, and theoretical assumptions. Following in the wake of Betty Friedan’s The Feminine Mystique (1963), the women’s health movement can be seen as a major impetus to feminist scholarship and policy. The organization of women in the late sixties and seventies for abortion and other health-care reforms and the widespread prescription of the birth control pill were crucial steps in the second wave of the women’s movement in the twentieth century. The women’s health movement, as exemplified by such monumental publications as Our Bodies, Our Selves (Boston Women’s Health Collective, 2011 [1971]), led to a radical critique of the patriarchal, allopathic medical care system and practice. The book was updated continuously until 2011 and online until 2018.

A major theme in a feminist analysis of health has been a criticism of the medicalization of women’s lives. Much of this analysis has focused on the dominance of the medical care system, medical practitioners, and the medical constructions of knowledge and power over women, especially in regard to reproductive issues such as birth control and childbirth (Oakley, 1984), PMS (Pirie, 1988), and menopause (McCrea, 1983; Kaufert & Gilbert, 1987; Walters, 1991). Other feminist researchers have examined gender differences in disease and death as well as reactions to disease and interactions with the health-care system. A variety of theorists and researchers have explained how women’s (poor) health is a result of social-structural inequities, such as class, racialization, participation in the labour force, or familial and domestic roles (Hankivsky et al., 2011). The work by Flurey et al. (2018) discussed in the previous section is an example of a “spin-off” of gender studies, i.e., men’s studies, with a particular concern to understand men’s lives, including their health and illness.

Today in Western democracies including Canada, sexuality, pregnancy, birth, and child-rearing are understood within the prisms of gender, knowledge, and power. All of these aspects of women’s lives are subject to the risk-based, uncertainty characteristic of the political turn to the right along with neo-liberalism and gendered public health policies. Godderis (2010) shows how women’s bodies and minds are increasingly likely to be subject to medicalization in areas related to reproduction, such as the period of time immediately after childbirth. In the 1960s some few women were thought to become depressed after childbirth. By the 1980s this experience acquired a name and a specific, serious, and much more common diagnosis of PPD or postpartum depression. This condition was situated as a disease that constituted one more instance of a greater proclivity for women’s passage through formerly “normal” life stages to be accompanied by mental illness. Pre-menstrual syndrome was previously considered a variable experience that included a variety of personal challenges including acne, tiredness, and tender breasts. Through expanding medicalization it became a specific diagnosis (and with it came specific treatments) of premenstrual dysphoric disorder (PMDD). Further, according to Godderis (2010), the new diagnosis of PPD was linked to a continuum of suffering said to beset up to 92 per cent of women after they had given birth, including baby blues, postpartum depression, and, in the worst-case scenario, postpartum psychosis. The spread of the discourses surrounding these issues opens up new requirements for the surveillance or monitoring of women’s bodies and minds during these life transitions. Having a baby has become a risky endeavour, as have many other public health concerns involving potential illness in the “risk society” (Beck, 1992). Ironically, too, much of the concern regarding the possibility of PPD focuses on the duty of mothers to “watch themselves and get help if they need it” for the sake of their children. Another women’s issue, abortion may be the most controversial women’s health issue today. Shepherd and Turner argue that it is over-medicalized to the detriment of women (2018), particularly poor women. Should abortion be allowed outside of the medical care system?

Today there is a prevailing dogma that breast-feeding is best for both mother and baby. It has been linked to better physical health for babies and to emotional health for mothers. Many women in the developed world have the sense that breast-feeding is a moral imperative (Crossley, 2009) and something they must do for the health of their babies. It is described as having benefits that will last a lifetime. But Crossley argues that this may be costly for both mothers and babies (Johnson, 2016). Colen and Ramsey (2014) studied 25 years of data from the National Longitudinal Study of Youth and found that the previously documented effects of breast-feeding were largely the result of selection pressures into breast-feeding due to socio-economic status and race differences. All but one of the previously accepted benefits of breast-feeding were found to be insignificant in case-controlled studies. Courtney Jung, in a book called Lactivism (2008), has argued that, to their emotional peril at times, women are subject to significant pressures to breast-feed their babies. This often leads to shame and suffering for those who cannot or do not want to breast-feed for one reason or another.

Critical anti-racist theory  adds another important lens for understanding the social world of health and illness. It focuses on the fundamental significance of racialization (Sefa Dei, 1999). This theoretical position asserts that all knowledge is racialized and, filtered through a racialized lens, is associated with power and wealth. Individual identities around the globe are patterned by racism, just as they are by gender, class, and sexual identities. There is no objective truth outside of that which is constructed in the context of racism and corresponding inequality. In this context, power and dominance are gained by those who possess (or claim) knowledge because of their skin tone; and this knowledge effectively determines what people think, feel, believe, and so on. Colonialism has led to the hegemonic dominance of European/Western knowledge and thought processes. As Sefa Dei says, “there exists a racialised, gendered, sexualized, and classed discursive practice.” In practice this means that, for example, black immigrants are 76 per cent more likely than other immigrant groups to consider themselves to be unhealthy (Nestel, 2012). Furthermore, racial status predicts health and health-care outcomes. For example, both black and Latino people with diabetes had poorer health outcomes over time than did other “race” groups (Nicklett, 2011). Veenstra (2017) found that black Canadians had more hypertension and poorer self-rated health than white Canadians.

Differences in health and health care mirror racial and other inequitable distinctions. Furthermore, how questions are asked, topics are chosen for consideration, and definitions of health and illness are created take place in the context of racism and are therefore are not objective.

All knowledge is questionable because of potentially racist assumptions. According to  intersectionality  theory it is crucial to move beyond attention to one variable (such as race or gender) at a time to a consideration of the dynamic interplay of multiple identities in the context of shifting powers (Hankivsky et al., 2011). From this point of view, none of us is merely “gendered” or “raced”; we also can—and must, for a good understanding of our health determinants and related health policy—be described in terms of our education, age, sexual identities, gender identities, “abilities,” citizenship, and so on. However, from an activist’s standpoint it is often best to focus on one oppressed status at a time. We will look at the health of people of First Nations status, along with other race-based analyses, at some length in Chapter 5. Racism continues to be a major source of inequity and consequent suffering throughout the life course. For instance, and as one example only, as I write this the news of the day is reporting that the likelihood of being shot by police is 20 times higher for black Canadians living in Toronto than for other citizens of the city (Branigan, 2018).

With the death of George Floyd in Minneapolis under the cruel knee of one policeman with three police witnesses, and a number of phones set to videograph this atrocity, a world wide movement has started and continues. There are protests in the streets against police violence and against racism in countries around the world. The demand to “Defund the Police” has become a rallying cry and a symbol of the possibilities of restructuring societies so that they become more equitable, provide social services and income to the poorest among us. This is a cry against criminalization. It is a cry for racial justice that began in the Unites States but resonates virtually everywhere.

Table 1.7 presents some of the methodological considerations for research from the theoretical perspectives of feminism, anti-racism, and intersectionality.

Table 1.7Methodological Assumptions of Feminist and Critical Anti-Racist Theories in Social Science

Objectivity	It is impossible to be objective in social research. Therefore, it is important to be as clear as possible about the biases brought to any research study. The necessity for continuous reflexivity in research is acknowledged.
Generalizability	Class, gender, race, and power differences between researcher and subjects limit generalizability.
Subjectivity	Often focuses on women’s experiences and those of racialized people and/or other marginalized viewpoints.
Subject Matter	Gender and race and other inequalities are always an important component of the investigations.
Language	Uses gender-neutral and non-racialized language where appropriate and specifies actual gender/race etc. when relevant.
Data Collection Methods	All methods are used but a collaborative approach between researcher and subjects of research is advocated. Triangulation is suggested.
Purpose	Feminist and anti-oppression anti-racist and intersectional research usually has change as one of its goals.

Post-Structuralism

A number of theorists are associated with the field now called  post-structuralism,  but the most influential for health and medical sociology is Michel Foucault. The work of Foucault both builds on and provides a radical reconsideration of the work exemplified by the perspectives described previously in this chapter. Rather than framing power or inequalities as structural forces that exist outside of some individuals who might have been called powerless, Foucault directs our attention to the ways that power is imbricated in mutual relations and infused by socially constructed knowledges and everyday micro practices supported by state policies and circulating discourses. One of the most important of these for our purposes is biopower. Biopower is Foucault’s answer to how social control and power occur in bodies in modern democratic and capitalist states. The population is controlled, in his view, by the government categorizing, counting, and developing policies related to managing “bodies” through “public health,” science, and medicine. The medical or clinical gaze is part of a new technology of power. Thus, our very notion of what constitutes a human body—anatomy, physiology, relation to the mind, and so on—is determined by circulating disciplinary knowledge such as medical science through popular discourses. What we consider to be disease, illness, wellness, and good functioning are continually recreated as we are subjected to, produce, and resist prevailing discourses via everyday conversation and the mass media and by interaction with the medical care system.

Foucault’s influence in the English-speaking world was originally due to his work on mental illness: Madness and Civilization (1964), The Birth of the Clinic (1973), and the three-volume The History of Sexuality (1978, 1984) in which he developed the notion of biopower. His early work was consistent with the writings of the powerful anti-psychiatric movement ideas articulated by scholars such as Thomas Szasz in The Myth of Mental Illness (1974 [1961]) and The Manufacture of Madness (1997 [1970]) and R.D. Laing and A. Esterson in Sanity, Madness and the Family (1970 [1964]). It was consistent, too, with Howard Becker’s labelling theory as found, for instance, in Outsiders (1963). Today, through his influence on the field of mental illness, medicine, and sexuality, Foucault’s ideas have moved well beyond reinterpreting and contributing to our understandings of mental illness to problematize all notions of the normal and abnormal body and their links to notions of governmentality, identity, and the medical or clinical gaze. In a sense, our ideas about and practices surrounding health constitute a sort of policing to ensure the “normal” functioning of the body/mind by individuals and by many others, such as professional groups including psychiatrists and other medical doctors. Table 1.8 outlines the assumptions of post-structuralism.

Have you been vaccinated against HPV? Has vaccination affected how you think about other methods for preventing cervical cancer, such as Pap smears or barrier methods of protection?

Komsan Loonprom/Shutterstock.com

Table 1.8Methodological Assumptions of Post-Structuralism in Social Science

Objectivity	It is impossible to be objective as a researcher in the social world because the linkage between power and knowledge imbricates the entire social world through circulating discourses.
Generalizability	Generalization is irrelevant because of the focus on micro practices in historical social contexts.
Subjectivity	Researchers and their subjectivities are irreducibly tied to the social and the historical.
Subject Matter	Disease and wellness are understood through concepts such as biopower, the medical gaze, and governmentality.
Language	Uses gender-neutral language where appropriate and specifies actual gender when relevant. Uses non-racialized terminology.
Data Collection Methods	Historically situated practices are studied as discourses and through Foucault’s genealogy and archaeology.
Purpose	To understand and critically expose circulating power/knowledge discourses.

One recent Canadian example of powerful governmentality is the rapid, widespread uptake of the human papillomavirus (HPV) vaccine for young girls, ostensibly to prevent cervical cancer and genital warts (Connell & Hunt, 2010). The authors of this study analyze the ways in which the speedy adoption of the vaccine across countries was publicly justified through new and particular types of power/knowledge that were linked among governments, pharmaceutical interests, biological and medical scientists, and medical organizations. In 2006 a new vaccine, Gardasil, was approved by Health Canada. By the beginning of 2007 the National Advisory Committee on Immunization recommended that all Canadian girls between the ages of nine and 13 be immunized. The federal government assigned $300 million to this end. A number of medical groups such as the Canadian Paediatric Society, the Canadian Cancer Society, and the Federation of Medical Women of Canada supported this decision. Stories addressed both to mothers and to their daughters advocating the vaccine and emphasizing the risk to young women of not being vaccinated spread through a sudden deluge of mass media. School boards took up the call and offered schools as locations for vaccination. Notably, too, these dominating discourses raising concerns about the risks of cervical cancer and warts in young women prevailed, despite the fact that cervical cancer has the lowest incidence of all female cancers, has had a very stable rate of incidence for many years, and was already well controlled in the presence of the early detection mechanism of the Papanicolaou (Pap) test. A less expensive and less aggressive intervention might have been to ensure that marginalized populations who had not taken the Pap test would do so. As HPV expert Dr Diane Harper reports on the dangers of Gardasil:

Pap smears have never killed anyone. Pap smears are an effective screening tool to prevent cervical cancer. Pap smears alone prevent more cervical cancers than can the vaccines alone.

Gardasil is associated with serious adverse events, including death. If Gardasil is given to 11 year olds, and the vaccine does not last at least fifteen years, then there is no benefit—and only risk—for the young girl. Vaccinating will not reduce the population incidence of cervical cancer if the woman continues to get Pap screening throughout her life. (Yerman, 2011)

In addition, the long-term consequences of the vaccine, including side effects, were not known, nor was it clear how frequently the three-“shot” administration would have to be repeated and over how many years. Further, it was targeted at girls/women even though boys/men were clearly implicated in its transmission and were themselves vulnerable through the same viruses to penile, anal, and back-of-the-throat cancers as well as genital warts (see also Lippman et al., 2007). A few years later it was also approved for young men (Weiss, 2019).

The link between the HPV vaccine and a decline in cervical cancer is still debated. Some research has documented numerous side effects. Some studies suggest the rates of HPV not covered by the vaccine are increasing. Other researchers have suggested that the rate of cervical cancer may actually increase in the wake of the uptake of the vaccine, possibly because people have become less vigilant about barrier means of protection (Gartland, 2018). Nevertheless, it is important to observe that as a result of aggressive and effective marketing of the vaccine it is used in a sizable minority of 40 per cent of the countries around the world, as Figure 1.1 indicates.

Figure 1.1Countries with HPV Vaccine in the National Immunization Program

Source: Data from: WHO/IVB Database, as at 29 May 2013. Map production: Immunization Vaccines and Biologicals (IVB), World Health Organization.

Summary

1. 1.Illness is experienced in a social context: we learn to think and talk about it with a vocabulary that others share and we learn what to do about it through interactions with family and friends, the formal medical system, and the media.

2. 2.The sociology of health and illness describes and explains the social causes and consequences of illness, disease, disability, and death. The sociology of medicine is the study of the institutionalized medical recognition of and response to illness.

3. 3.Sociologists use a number of perspectives to study the social world: structural-functional theory, conflict theory, interpretive/social constructionist theory, feminist and critical anti-racist approaches, and post-structuralist theory. Each of these perspectives makes different assumptions about the social world and, therefore, has different ways of understanding it.

4. 4.Structural-functional theory was first discussed by Émile Durkheim. Its goal is to understand the social causes of social facts; it does this by studying the causal relationships among institutions. The parts of society are inextricably bound together to form a harmonious system. Human beings are constrained by the external world and they are, therefore, predictable and controllable through the knowledge of social facts.

5. 5.The origin of the conflict perspective is attributed to Karl Marx. Conflict theorists study competing groups within societies through history. The basic competing forces are the different classes. Conflict theorists are committed to the description and documentation of injustice through the understanding of economic arrangements and their impact on other conditions of social life. In the conflict perspective, health and illness are related to the unequal social arrangements found in capitalist, patriarchal societies.

6. 6.Interpretive/social constructionist theory is based on the definition of sociology given by Max Weber. These theorists, also called symbolic interactionists, attempt to understand the subjective meanings and causes that social actors attribute to events. The meaning social actors give to their diseases affects their self-concepts and their relationships with others.

7. 7.The feminist and critical anti-racist perspectives provide a critique of sociology and a corrective to its narrow, neglectful, or biased representations.

8. 8.Post-structuralism highlights the ways that power produces its effects through the bodies and minds of individuals and populations. It describes how changes in public health and medicine provide new ways of governing populations.

Chapter 8

Introduction: The Sociology of Medical Knowledge

Is scientific knowledge universally true? Is scientific knowledge objective? Medical knowledge is based on science, but is influenced also by human, cultural, and social factors. This complex of considerations makes choosing among possible diagnoses and treatments complicated for patients and for medical practitioners. For example, after a cancer diagnosis, patients, at times, along with their doctors, have to decide whether to use chemotherapy and/or radiation or to do visualization, botanicals, immunotherapy, or something else. The evidence as to which approach is the best, when, why, and how, may be confusing and contradictory. Within medicine, debates prevail about the “reality” of some diseases such as chronic fatigue syndrome, which some people believe is just “yuppie flu” experienced only by spoiled middle-class and upper-middle-class women. In the next chapters of the book, we discuss questions such as the following: Do allopathic doctors have a “better” theory of medicine than chiropractic or naturopathic doctors? Does the introduction of a new technology, for example, pharmaceuticals, the CAT scanner, or MRI equipment, occur as the logical final stage of a process of rational decision-making, including cost–benefit analysis and an evaluation of the efficacy and efficiency of the new technology? Or are such decisions influenced by, among other things, the profit motive? Do medical science and practice reflect problematic cultural attitudes, such as racism, sexism, and homophobia, or are they a neutral and dispassionate endeavour?

This chapter will investigate the sociology of medical science and medical practice. To say that there is a sociology of medical science is to say that it is reasonable to examine how medical and scientific knowledge are discourses that can be seen as determined, created, and constructed by social conditions. Medical ideas result from the productive link between power and knowledge. It is worthwhile exploring how medical science affects or constructs social conditions and how the social and the scientific/medical worlds are frequently mutually reinforcing. Moreover, in the tradition of conflict theory, we can ask whose interests are served by a particular form of medical knowledge, organization, and practice. The symbolic meanings and constructions of medical science and practice are also relevant topics for discussion.

The argument of this chapter is as follows. “Science” is not perfectly objective and universally true. Science is produced by humans. It has resulted in “institutions” and discourses that have become embedded in wider social structures and maintained and resisted through processes of negotiation by some actors who live in a particular time (history) and place (culture, society, social strata) and by the associated disciplinary bodies of knowledge and practices. Medical practice is based on aspects of this socially constructed science and is also influenced by other social forces, such as the particular social characteristics of the medical care labour force and the socio-economic backgrounds from which the members of the labour force have been drawn and within which they continue to live at any given historical time period.

Medical and Scientific Knowledge: Historical and Cross-Cultural Context

Positivism, the model of science on which medicine is based, is described by attributes such as objectivity, precision, certainty (within a specific degree of error), generalizability, quantification, replication, and causality. Its search is for a series of law-like propositions designed to explain the operation of the body, the operation of medicine, the causes of disease, and the optimum methods of cure and management. These formal characteristics portray science as if it is superior to other ways of perceiving the human body in the world. Science, in this view, is outside of culture and social structure; therefore, the subjects of its study, the methods of studying human subjects, the findings from study and their interpretations, and the publication and dissemination of scientific knowledge should be objective and thus be true everywhere and at every time in history. Medicine and medical practice are similarly valorized. However, there are many reasons to challenge these assumptions.

A number of social theorists and researchers have demonstrated that beliefs regarding scientific objectivity are problematic. Kuhn (1962) has described the historical development of science and how the methods, assumptions, and even the very subject matter of science are infused with cultural categories. In Madness and Civilization (1964), an abridges translation of his 1961 doctoral thesis (the entire work, translated into English as History of Madness, appeared in 2006), Foucault describes the different understandings of and ways of “treating” those called “mad” in various societies over a long period of history. Freund, McGuire, and Podhurst (2003) have specified the value assumptions of contemporary medicine as mind–body dualism, physical reductionism, specific etiology, machine metaphor, and regimen and control.

Mind–body dualism is said to have begun with Descartes, the philosopher who effectively argued for the concept that “mind” or “spirit” is separate from the body. Descartes’s writing and thinking became possible in a historical context of increasing secularization, which allowed for his belief in the separation of the body from the soul/mind. Not until Christian doctrine determined that the “soul” could be sent heavenward after death, without the body, could the notion of a non-spiritual human body following death make the cadaver “acceptable” for scientific investigation. Foucault (1973) describes the changes in the eighteenth and nineteenth centuries that allowed the physician to view the patient’s body directly through the “clinical gaze,” and not merely indirectly through the patient’s verbal, subjective descriptions. Technological inventions such as the stethoscope gave physicians direct access to bodily functioning. With a stethoscope the doctor could observe, categorize, and understand the patient’s body (or a part of the body) without the conscious awareness or involvement of the patient. Dissection of cadavers opened up a new world of speculation surrounding the patient and of medical language for description and explanation. Such inventions further entrenched the distinction between the soul/mind and the body as they made the body a precisely describable and observable empirical entity.

Physical reductionism emphasizes the physically observable at the expense of other aspects of the individual, such as the subjectively experienced mental, sensual, and emotional. It also leads to a disregard for the social, political, and economic causes of ill health. The modern notion of the body as a group of potentially pathogenic organs made visible through technologies such as MRIs, CAT scans, and X-rays illustrates this reductionism.

René Dubos (1959) was the first to write that the doctrine of specific etiology is another characteristic of modern medical science. The primary assumption of this view is that each disease is thought to be the result of a particular pathogen or malfunction. It developed from the discoveries of nineteenth-century researchers such as Pasteur and Koch, who noted the specific effects of particular micro-organisms on the body. It has led to an exaggerated emphasis on the discovery of a “magic bullet” to cure one specific disease after another. Dubos notes that this emphasis is overly restrictive because it ignores the fact that the very same micro-organisms may assault any number of people but only a certain proportion of these people respond by becoming ill. It is also problematic because it has tended to ignore how a treatment for one disease may lead to side effects that may cause other diseases. It can also be associated with ignoring subjectively described symptoms such as fatigue (e.g., chronic fatigue syndrome) and pain (fibromyalgia) that lack “objective” medical measurement by available tools designed to see organ pathologies and whose symptoms may change frequently.

The machine metaphor for the body emphasizes discrete parts, such as individual organs, and their interrelationships with other discrete parts. This idea has led to medical specialization (e.g., cardiology, otolaryngology, urology, gynecology) and to highly skilled types of interventions such as the removal and replacement of parts of the body, including the heart, kidney, liver, blood, bone marrow, limbs, patches of skin, and even the face.

Finally, regimen and control are outgrowths of the machine metaphor. They assume that the body is to be dealt with, fixed, and continually improved. Not only strictly medical procedures but even health promotion policies imply that the body is perfectible and under the control of the individual through such actions as exercise and diet, and by maintaining healthy habits, such as not smoking and consuming alcohol only moderately. An emphasis on control through such things as the correct number and spacing of medical checkups, as well as the use of early detection technologies, reinforces this notion of the medically perfectible body. The burgeoning field of cosmetic surgery, discussed in Chapter 7, is just one significant outcome of this perspective. Stein has noted how Western, particularly American, medicine has adapted to such American cultural values. As he says:

disease conceptualization and treatment are embedded in the value system of self-reliance, rugged individualism, independence, pragmatism, empiricism, atomism, privatism, emotional minimalism and a mechanistic metaphor of the body. (Stein, 1990, p. 21)

In an expanded analysis of the foundations of the medical model, Manning and Fabrega (1973) articulate the elements of what they call the biologistic view of the body. The biologistic view of the body includes the following tenets: first, organs and organ systems, and their specific functions, are identifiable and observable as discrete entities; second, the normal functioning of the body goes on pretty much the same for everybody unless disturbed by injury or illness; third, people’s sensory experiences are universal; fourth, disease and experience of disease do not vary from one culture to another; fifth, boundaries between self and body and between self and others are obvious; sixth, death is the body’s ceasing to function; and seventh, bodies should be seen objectively to be treated medically.

Sociological research provides critiques of all of these assumptions about science and medicine. First, few people today consider the mind/body to be separate. Awareness of the possibilities of research on the body/mind connection is, in part, the result of the Eastern medical tradition including that mind and body are one. This has led to greater interest in meditation in Western countries, as well as the discovery that the brain is “plastic” (Doidge, 2007) and that neural pathways can be reconstructed following such injuries as stroke.

Second, it has become clear that much of the research on the “normal” person has been on the male-bodied person. Thus, less is known about the functioning of the female body (except her reproductive function) with respect to a whole range of disease categories including heart disease. As a result, medical findings cannot necessarily be generalized from one gender to another. They have to take into consideration the whole sexed body. This challenges both the notions of the body as mere machine and the doctrine of specific etiology. The body is not a mere machine: it is understood to be much more complex than that now.

Third, cross-cultural, anthropological, and linguistic studies have shown how people’s bodily experiences can be articulated only from their available language. Fourth, cross-cultural research has shown that what is considered “disease” in one culture may be accepted as “normal” in another. Fifth, contagious diseases such as AIDS demonstrate anew that the boundaries between people are vulnerable. Thus regimen and control exceeds, at times, the boundaries of the body. Sixth, even the definition of “death” is now acknowledged to be very problematic (and not organ-specific) because of the possibility that, for instance, respirators and defibrillators can keep people alive even when they are “brain-dead.” Seventh, bodies cannot be seen objectively and as only a system based on organs. That is an impossible value to achieve. The values implicit in the medical model and in the biologistic view of the body reflect particular cultural histories, biases, and predispositions. Medical science and practice are not objective, are not consistent across the discipline, and are not necessarily superior to other treatments and social practices.

Medical Science and Medical Practice: A Gap in Discourses

A significant gap frequently occurs between published biomedical research and the scientific treatments documented by such research and the actual daily practice of medicine (see Montini & Slobin, 1991). To try to minimize the distance between researcher and practitioner, the National Institutes of Health in the United States, through the Office of Medical Applications of Research, began in 1977 to convene Consensus Development Conferences (CDCs). The Canadian government and medical associations have a similar ongoing process for developing agreement between science and practice called evidence-based medicine or evidence-based practice. The Cochrane Collaboration is perhaps the best-known organization to provide systematic reviews of evidence about various medical issues. Medical practice is said to be guided today by what is termed evidence-based medicine (EBM).

The goal of EBM is to provide practitioners with information gleaned from scientific studies published in reputable journals and evaluated for quality. The goal of the Consensus Development Conferences was to bring together researchers, to inform practitioners of the latest scientific findings, to inform scientists of the practical issues facing practitioners, and to work towards the development of timely, national standards of practice. Unfortunately, a number of obstacles to the immediate integration of research findings into medical practice exist. Montini and Slobin have shown how various differences in the work cultures of clinicians and researchers may play a role in limiting their amalgamation. These limitations relate to distinct value differences between researchers and practitioners, including: (1) certainty versus uncertainty; (2) evolutionary time versus clinical timeliness; (3) aggregate measures versus individual prescriptions; (4) scientific objectivity versus clinical experience; and (5) constant change versus standards of treatment. We now examine each of these limitations in more detail.

(1) Certainty versus uncertainty. Doctors’ work involves patients who want and need immediate and certain responses. Scientific work does not depend on or even expect certainty; rather, probability is the focus of laboratory science. Time-related concerns are considerably different in those two contexts. The practitioner needs at least enough certainty to make decisions about caring for a particular patient at a specific point in time. By contrast, the scientist works within a world of probabilities—thus, uncertainty—in a time frame determined by funding, the nature of the investigation, the parameters of the experimental paradigm, the intrinsic limitations of equipment, the training and abilities of the researcher, imperatives embedded in the research institution, and so on.

(2) Evolutionary time versus clinical timeliness. Science does not progress by proof so much as by failing to disprove. Caution is always implied in drawing conclusions. Scientific truth develops in incremental stages as more and more hypotheses are disconfirmed. However, the clinician must make timely decisions in response to the expressed and observed needs of individual patients.

(3) Aggregate measures versus individual prescriptions. While the scientist, in working with probabilities, deals in aggregates, the practitioner must deal with the suffering individual. Again, because of the immediacy of the sufferer, clinicians are forced to rely on what they are learning from their experience and are finding to be “tried and true” in their practice. They may be uneasy about relegating a given individual to a clinical trial or a new treatment, the outcome of which is unknown and will likely remain unknown for a considerable period of time. They may, for example, use medications “off-label” because of word of mouth of their colleagues.

(4) Scientific objectivity versus clinical experience. The scientist tries to control all variables in the interests of objective and generalizable findings. The clinician, in contrast, is faced with a unique individual reporting subjectively experienced symptoms that the clinician cannot control and needs to deal with immediately for the patient.

(5) Constant change versus standards of treatment. The researcher is aware of continuous change in research findings as new hypotheses are put forward and supported or rejected. The clinician must practise medicine under the direction and with the support of practice standards but must also make assumptions that current knowledge is “good enough” and its implementation will be beneficial to the patient. The doctor has to assume that current treatments will be helpful and have a longer “shelf life” than frequently changing scientific hypotheses on the frontiers of medical developments.

The idea of  evidence-based medicine ( EBM) has been growing in influence in medical practice. Evidence-based medicine involves using statistical and other evaluative techniques for the meta-analysis of scientific literature related to all manner of potential medical diagnoses in order to inform continually the everyday practice of medicine. The goal is that a patient’s care be based on the most up-to-date, valid, and reliable medical/scientific information, rather than on the practices long in use. Further, EBM assumes that the best evidence is gathered and assessed through systematic and thorough means. Doctors need up-to-date knowledge because textbooks quickly become outdated; experts may be wrong and medical journals too prolific to allow any individual practitioner to stay current. In addition, doctors often are rushed in their everyday work. Now, however, as a result of the Cochrane Collaboration, physicians can access timely reviews of the best evidence published in refereed scientific journals for many of the medical issues they face. In addition to the limitations itemized above there are many limitations to EBM including the fact that published research may not be actually representative of the best and most recent research, partly because of the time it takes to undertake and then publish research. Some populations are under-studied (e.g., women, racialized groups, and people sick with more than one disease concurrently). When researchers are funded by private corporations such as drug companies, published findings may be restricted (by the terms of the grant) to those who support the use of the intervention financed by the company in question (see, e.g., Olivieri, 2003). Furthermore, not all evidence is accessible because negative findings often are not publishable.

Medical Technology: The Technological Imperative

New medical technologies continue to be developed, manufactured, distributed, and employed. Among the new technologies are cardiac life-support, renal dialysis, nutritional support and hydration, mechanical ventilation, organ and stem cell transplantation and various other surgical procedures, pacemakers, chemotherapy, MRIs, CAT scans, and new, more powerful antibiotics. The question that we ask here is: What is the relationship between medical science and this evaluation process that culminates in the use of new technologies? Available evidence suggests that practitioners tend to adopt new technologies before they are evaluated and that they continue to use them after evaluation indicates they are ineffective or unsafe (Rachlis & Kushner, 1989, p. 186). The power of new technologies has been called the  technological imperative . The numerous people who are made sick or who die as the result of the technological imperative can be found in the statistics for medical error in Canada and the United States. In Canada, the Canadian Institute for Health Information along with Statistics Canada reported that between 30,000 and 60,000 Canadians die annually from medical error (Finlay, 2016). Not all of these are the result of new technologies or of improperly used technologies, but some are. Drugs introduced into the market or that stay on the market despite accumulating negative evaluations are cases in point. For example, the acne drug Diane-35 (a hormone-secretion modifier designed for birth control) is said to have killed 11 Canadian women and to have caused serious and minor side effects in hundreds of others (Zlomislic & Teotonio, 2013), and the proliferation of opioids has resulted in many deaths and broken lives.

The adoption of new medical technologies is vulnerable to social variables related to four social forces (Butler, 1993): (1) key societal values, (2) federal government policies, (3) reimbursement strategies, and (4) economic incentives.

(1) Among key societal values, a number of social commentators have described the love affair of North Americans with new technology of all sorts. Enthusiastic optimism rather than realistic caution typifies our attitude to new technology. While we have yet to understand all of the possible constraints to freedom, privacy, and democracy created by the Internet, plus other threats that may easily result from global electronic communication, it already exists and is in widespread use. Some people are protesting that we don’t yet know enough about the long-term effects of “wireless” technologies to use them as widely as we do, even among children in their schools. For example, the effects of the use of cell phones have not been precisely determined, but an extensive WHO review of studies reports evidence of increase in glioma (a malignant tumour that begins in the brain or spine) and schwannoma (acoustic neuroma), a non-malignant brain tumour (Dellorto, 2011). Is this a situation calling for the precautionary principle? The development of other new and related technologies often precedes considerations of and safeguards for possible deleterious health and social impacts.

(2) In the health area, the federal government, through such bodies as the Canadian Institutes of Health Research, the Heart and Stroke Foundation, and the National Cancer Institute of Canada, quietly funds biomedical research. Taxation policies, free-trade agreements, support for education and science, and other federal incentives encourage the discovery of new technologies. Our national medical care system fosters growth and expansion of the use of medical technologies immediately upon their development. However, such undertakings have not always proven desirable or fruitful. While Butler’s study is based in the US, there is no reason to assume that Canadian legislation provides greater safeguards, and, in fact, available evidence indicates that in some situations, e.g., the thalidomide disaster of the 1950s and 1960s, Canadian regulation may be much poorer. Further, post-market surveillance of the effects of the introduction of new technologies in Canada is far from perfect (Fuller & Saibil, 2005). Chapter 14 considers this issue in more detail.

(3) and (4) While there are no definitive studies of the costs of new technology, a variety of studies taken together suggest that 20–50 per cent of the annual increases in health-care costs during the past 25 years or so are the result of progressive innovations in medical technology, including pharmaceuticals. In fact, the increase in the use and cost of pharmaceuticals is the driver of the increasing costs of medical care in Canada. A few new technologies appear to save lives and costs. Most new technologies are expensive and some may be ineffective or lead to negative side effects; however, they add costs to the medical care system whether or not they work. A great deal of controversy is expressed about the ethics of including cost-effectiveness in health-care provision; thus, this conversation has been less likely to occur in Canada (see, e.g., Donaldson & Dunfee, 2002). As long as the medical-industrial complex is even partly guided by privatization and the profit motive, the development and dissemination of medical technological innovations will result, in part, from market principles rather than from planned, rational, health-benefiting, and evaluated strategies for change. Consider this example: babies weighing as little as one pound can now be kept alive at a cost of, at times, millions of dollars per baby through neonatal intensive care for several months, and then continuing care for those babies and children who may have ongoing medical and other health, educational, and social needs. By contrast, a low-technology approach to preventing low-birth-weight babies that would include feeding pregnant women nutritious diets and maintaining minimal equitable socio-economic standards—via, for instance, a guaranteed annual wage for all—is a much more cost-effective and efficient strategy for a healthy citizenry—but this prenatal support has yet to be implemented.

An example of the tendency to first adopt new technologies and evaluate them later is electronic fetal monitoring. Designed for use with high-risk births, the fetal monitor was to provide doctors with information regarding the health of the fetus during labour. If a fetus showed dangerous vital signs the physician could actively intervene in the labour process by, for example, performing a Caesarean section. Electronic fetal monitoring (EFM) was initially made available in the 1960s. By the 1970s EFM and ultrasound were widely available in most hospitals. By the 1980s, 30 per cent of all obstetricians had EFM in their offices to detect prenatal problems. Rapidly, EFM became a standard monitoring device, even for low-risk situations. Its widespread use was associated with an increase in the diagnosis of prenatal problems. The Caesarean section rate, at 4.5 per cent of all births in 1965, rose to 16.5 per cent by 1980 and 24.7 per cent by 1988. In 2001–2, C-sections accounted for 22.5 per cent of all in-hospital deliveries in Canada. Studies of this phenomenon have found that the rate varies substantially by region, ethnicity, socio-economic status, and availability of insurance for payment. According to the Canadian Institute for Health Information, in 2010–11 the C-section rate for first-time C-section was 18.1 per cent and for subsequent births by C-section the rate was 82.3 per cent. Despite the variation in rates across the country and in different hospitals, it is clear that many think the rate is too high and potentially dangerous (Murphy, 2015). Caesarian sections are also at least twice the cost of a regular vaginal birth. In 2016–17, C-sections in Canada comprised 28.2 per cent of all births (Young, 2018). It must be noted that not all C-sections result from perceived prenatal problems. Some are necessary because of a previous C-section; some are elected by women who want to schedule their births; and some are the result of complications during labour that prevent women from being able to deliver vaginally.

Despite the rapid growth in the use of electronic fetal monitoring, randomized, controlled trials undertaken since 1976 have failed to demonstrate benefits of EFM in comparison with simpler methods of monitoring, such as the stethoscope. Moreover, EFM leads to certain risks for fetus and mother. The safety of ultrasound still remains to be completely established. In addition, there is substantial agreement that the use of new technology is a major driver for the increase in the costs of health care. Other important examples of the introduction of a new technology prior to evidence of its safety and value are: (1) the widespread uptake of Vioxx, a highly popular drug for arthritis pain used by millions of people that apparently caused up to 140,000 heart attacks before it was acknowledged and withdrawn from market in 2004 (although the pharmaceutical company knew much earlier it could cause seriously problematic cardiovascular events) (Bhattacharya, 2005); and (2) the ongoing prescription of hormone replacement therapy (HRT) to millions of women despite its association with breast cancer after three or more years of use (Australian Government, 2010). Furthermore, in an ironic turn of events, the use of some anti-depressants, not only among young people, has been linked to an increased rate of suicide (Nischal et al., 2012).

McKinlay and McKinlay (1981) developed a model—the seven stages in the career of a medical invention—that could be used to explain the social forces involved in the dissemination of new medical technologies before they are adequately tested.

Stage 1:A promising report.

Stage 2:Professional and organizational adoption.

Stage 3:Public acceptance and state (third-party) endorsement.

Stage 4:Standard procedure and observational reports.

Stage 5:Randomized controlled trial.

Stage 6:Professional denunciation.

Stage 7:Erosion and discreditation.

The most important point is that evaluation, which is purported and believed to be the bedrock of scientifically based treatment innovations, occurs at stages 4 and 5, long after the introduction and widespread use of a medical invention. The concept of “disease-mongering” introduced in the British Medical Journal (Moynihan et al., 2002) explains the tendency to active intervention as the result of the profit motive of pharmaceutical companies.  Disease-mongering  is the corporate construction of new diseases for the sole purpose of business profits, “extending the boundaries of treatable illness to expand markets for new products” (Moynihan et al., 2002, p. 886). Further, Moynihan et al. note that alliances between pharmaceutical companies, doctors, and patients are encouraged to frame new conditions as widespread, debilitating, and severe. In their argument they documented three case studies. The first involved the medicalization of baldness around the time that Merck developed a hair-growth drug. Merck sponsored news articles emphasizing the extensiveness of the problem of baldness and the severe level of suffering that people experienced as the result of baldness. The company suggested that panic and emotional difficulties were associated with baldness. In addition, the company sponsored the founding of a new International Hair Study Institute. Thus, baldness came to be considered a treatable “disease.” The second case involved the pathologizing of mild digestive symptoms into the disease “irritable bowel syndrome” as a part of the marketing of a new drug by GlaxoSmith-Kline. The third instance, social phobia or social anxiety disorder, was introduced into the public and medical consciousness at the time of the development of an anti-depressant by Roche, and both the terms and such drugs can be overused in cases of what might be called excessive shyness. Most recently, the highly reputable Berkeley Wellness report underscored how ADHD drugs are sometimes over-prescribed. Certainly, the wide differences in different countries and in different geographic parts of the same countries suggest that more is at work in the prescription of ADHD drugs than objective science would merit (Tuller, 2014; Whitaker, 2010). In fact, ADHD has been shown by some researchers and clinicians to be an ear-based condition that can be treated without drugs but with high-frequency sound (e.g., Doidge, 2015, pp. 280–302; Bérard, 1993, pp. 18–37).

Perhaps two of the most interesting historical examples of disease-mongering in the interests of profit are from the nineteenth century: the diagnosis of  drapetomania , which caused slaves to run away from their masters, and  dysaethesia aethiopis , which referred to poor work habits among slaves. The first can be seen as an instance of a diagnosis used to serve financial interests because slaves could be costly to own and, thus, slave owners stood to lose money whenever a slave ran away. Similarly, slaves who had poor work habits were costly to their owners. Calling these actions “diseases” reinforced the moral superiority of the owners and justified the actions they “had” to take to return the slaves home or to demand better work (Freund et al., 2003: 197).

Are there any other diagnoses that you know of today that might be seen to further the interests of profit-making?

A study comparing the approval for commercial use of two drugs in Japan and the US demonstrates the potential role of social and political pressure to adopt or not adopt new drugs irrespective of drug safety and efficacy information (Hollander, 2006). The two comparison drugs were Viagra and an abortion pill in the US and Viagra and a birth control pill in Japan. In both Japan and the US, Viagra was shepherded through the drug approval processes within six months. In the US the abortion pill was approved 17 years after related research was first allowed and four years after application was made for distribution. In Japan, the birth control pill was approved for use 35 years after the first application for approval. Ostensibly, drug approval is linked to drug safety and efficacy and is the result of scientific investigation. However, Viagra has been associated with heart attacks, irregular heart rhythms, stroke, chest pain, and increased blood pressure. On the other hand, the side effects to the mother of the abortion medication and the birth control pill appeared to be minor and included cramping, nausea, vomiting, and bleeding. The most serious side effect required a blood transfusion. Clearly, then, other factors were at play in the adoption of these drugs in Japan and the US.

In another example, a tonsillectomy is a very common surgical procedure, yet there is considerable variation in its use from geographic area to geographic area and from hospital district to hospital district. The proper treatment for tonsillitis is debatable. One of the ways this debate is resolved appears to be along the lines of specialty preferences. For instance, pediatricians tend to favour recurrent use of antibiotics to control tonsil flare-ups, whereas otolaryngologists are more likely to prefer the surgical procedure and to remove the infected or inflamed organ. It appears that the ideology of the specialty is buttressed by scientific research based on clinical trials and published in specialty research journals tending to favour one procedure over another. Although it may seem that economics might drive the preferences for action chosen by each different type of specialist, even in jurisdictions where physicians are on salary these specialty group differences remain. These findings suggest that belief in one’s own procedure may have more influence than direct material interests. The interests may be indirect and reflect the need to protect and promote the hard-earned skills necessary for the long-run success of the specialty (Chow, 1998). One implication of this conflict in treatment procedures is that the knowledge base of doctors is much greater in their own specialty and, at times, they may be myopic with respect to looking at all of the alternative treatments. A specialist should not be expected to be able to offer an evaluation of the exact health costs and benefits of different types of treatments (based on different specialties), even though this would likely be in the interest of the health of the patient and the costs to the health-care system.

Medical Science Reinforces Gender-Role Stereotypes

Scientific medical knowledge is portrayed as an objective, generalizable, and positive accomplishment. Yet, what is taken to be objective medical science has been shown to reflect fundamental cultural and social-structural beliefs (Clark et al., 1991). Normative categories of social relations, in fact, have infused medical conceptions. Findlay (1993) studied the 10 most highly circulating texts in obstetrics and gynecology in the 1950s in Canada, as well as a representative selection of academic articles from five major obstetrics/gynecology journals and from the Canadian Medical Association Journal. Her research showed that physicians’ descriptions and understandings of the female body guarded and reflected family values. The scientific and medical publications emphasized the importance of separate spheres for men and women, of stable marriage and family life, and encouraged fertility among women (who were assumed to be white and middle-class). Findlay noted that the essence of the “normal” woman during this time period was portrayed as if she ought always to be potentially fertile. Women’s bodies were described largely with respect to fluctuations in their hormones and menstrual cycles. They were described as living to reproduce. As Findlay reports, one influential obstetrician/gynecologist explained: “The desire for children by the normal woman is stronger than self-interest in beauty and figure, stronger than the claims of a career, [while] in the man it is less intense” (Jeffcoate, 1957, in Findlay, 1993). By contrast, the abnormal woman was defined as one who had sexual or reproductive problems.

The women’s movement of the 1960s and beyond has focused on eliminating such prejudices. However, women still are seen as reproductive bodies and viewed as largely responsible for birth control and for accepting or refusing sexual intercourse. Women continue to be used for experimental treatments in regard to their reproductive systems. For example, the vaccination against the human papillomavirus (HPV) was initially approved for use in Canada among young women and girls. It was and continues to be advertised as a cervical cancer preventative despite the fact that the safety and efficacy of the vaccination over the long term are yet to be determined. Also, considering that HPV is a sexually transmitted disease, the initial rationale for excluding boys and young men in trials and utilization is not clear. The consequences of HPV to males may be as severe (predominately genital and anal warts and genital and throat cancers) as the consequences to females (cervical cancer; cervical cancer with metastases). However, the infection of males can lead to the infection of more females.

Emily Martin’s The Woman in the Body (1987) also instructs us about gender biases in medical conceptions of women’s bodies and their functions. She demonstrates how culture shapes what biological scientists see. One interesting illustration of her thesis is how assumptions about gender infuse descriptions of the reproductive cycle and its elements, such as the egg and sperm. For instance, the female menstrual cycle is described in negative terms. Menstruation is said to rid the body of waste, of debris, of dead tissue. It is described as a system gone awry. By contrast, while most sperm are also “useless” and “wasted,” the life of the sperm is described as a “feat.” The magnitude of the production of sperm is considered remarkable and valuable. Whereas female ovulation is described as a process where eggs sit and wait and then get old and useless, male spermatogenesis is described as continuously producing fresh, active, strong, and efficient sperm. While the eggs are swept and drift down the fallopian tubes like flotsam, sperm actively and in a “manly” and machismo fashion burrow and penetrate.

Ideas such as these infuse the work of medicine and can be seen in differences in the care of men and women with the same conditions. Cho and her colleagues (2019) found that when elderly men and women broke a hip, women were more likely to be treated in a cursory manner without preoperative investigations. Women can also have poorer quality care from family doctors (Wexler et al., 2005) when it comes to diabetes. Women have a long history of poorer quality cardiac care and problem identification, and this continues to be so (Regitz-Zagrosek, 2010) even in regard to very high-tech interventions such as heart transplants (Humphries et al., 2001). In addition, current medical practice assumes unitary gender and gender identity as well as heterosexuality, meaning that medical practitioners may not be aware of or sensitive to the particular health concerns of LGBTQ or gender-diverse individuals. With the increased inclusion and acceptance of diversity in these areas in many aspects of life (such as the legalization and celebration of same-sex marriage) it is time that medical practitioners adopted more progressive attitudes and behaviours (Pinto et al., 2019).

There is evidence, as well, of stereotyping regarding hegemonic masculinities. For instance, these masculinities have long been seen as risk factors (e.g., risk-taking of males has been seen as the cause of their higher incidence of automobile accidents and homicides) and are now being medicalized (Rosenfeld & Faircloth, 2006). Erectile dysfunction is a case in point. Medical definitions of erectile functioning link the performance of masculinity to the ability to “accomplish” (Loe, 2006, p. 31) an erection. According to Moynihan (2006), another recently discovered disease is “motivational deficiency disorder,” otherwise known as “laziness” or maybe “extreme laziness.” In another example, attention deficit hyperactive disorder (ADHD) is a frequent diagnosis for children and young people that functions to control their behaviours, particularly in school. What has been less documented is the fact that the diagnosis of ADHD, and the subsequent prescription of Ritalin for its treatment, serves, in a way, as a medicalization of boyhood because the vast majority of prescriptions (approximately 75 to 80 per cent) are for young boys because of their “disruptive” or “boyish” behaviours in classrooms (Hart et al., 2006).

The recent development of pharmacogenetics—the study of how drug response depends on genetic makeup (Helman, 2007)—has led to the targeting of drugs to specifically racialized groups. For instance, in 2005 a heart drug was approved by the US Food and Drug Administration (FDA) for the treatment of heart failure among African Americans. The success of the Human Genome Project in mapping the genetic makeup of human beings is making it possible to design drugs with a more exact fit to genetic makeup. These developments raise important ethical debates. Some argue that such precisely targeted medical interventions, in a racist society, could be used to reinforce and even act on racism or against other marginalized groups. It is possible to imagine the “discovery” of a disease that leads to consequent stigmatization and isolation in only one “race” or marginalized group. Furthermore, the genetic makeup is subject to alteration, which is how species evolve; targeting the genes of individuals is a way of interrupting evolutionary processes that have been underway for millennia and are far more complex than is yet known.

The Sociology of Medical Practice

Just as medical/scientific knowledge is a social product with social consequences, so, too, is the everyday practice of medicine. Have you ever left your doctor’s office only to realize that you had forgotten to tell or ask him/her about something? Have you ever left the office unclear about what the doctor has said about your problem/disease, your medication, or something else? Have you ever felt that you “couldn’t get a word in edgewise” in a conversation with your physician? Have you ever seen a sign in the examining room to the effect, “Please restrict your visit to one symptom or medical problem”? Have you ever asked for a second opinion or been skeptical about a doctor’s diagnosis?

Considerable evidence demonstrates that the day-to-day practice of medicine is profoundly affected by social characteristics of patients and doctors. First, with regard to patients, there is evidence that physicians tend to prefer younger patients and to hold negative images of elderly patients. Elderly patients tend to be seen as both sicker and less amenable to treatment than younger patients. The older patient, “far in excess of actual numbers, represents the negative idea of the uncooperative, intractable, and generally troublesome patient” (Clark et al., 1991, p. 855). The elderly may be over-treated, in general (Hadler, 2011), particularly when they spend their last days, weeks, or months and then die in hospital. Or under health-care rationing, they may be under-treated (Smith, 2009).

Physicians’ attitudes and actions in regard to racialized characteristics reflect those of the wider socio-cultural context of which physicians are a part. For instance, several US-based studies have demonstrated that black patients tend to be referred to specialists less often, are treated more often by doctors-in-training, are more likely to be placed on a ward, and are admitted less frequently to hospital except when they are involuntarily hospitalized for mental health problems (see Chapman et al., 2013). Black patients also tend to receive less aggressive workups and interventions. Differences have been documented in the way that physicians treat patients of different class backgrounds. For example, patients with poorer backgrounds are likely given poorer prognoses and less state-of-the-art treatment (see Chapters 4 and 5 for a more detailed discussion of racialization, class, and health). The social characteristics of physicians themselves, including gender, age, professional training, education, and form of practice, have also been shown to influence their work (Chapman et al., 2013).

Cultural Variation in Medical Practice

In an intriguing study, Lynn Payer (1988), a journalist, travelled and visited doctors in several countries: the United States, England, West Germany, and France. To each doctor she presented the same symptoms. She also examined morbidity and mortality tables and read medical journals and magazines in each country. Using this casual and commonsensical method, Payer found strong cultural differences in diagnostic trends and patterns that seemed to reflect fundamental differences in history and culture. Diagnoses and treatments varied widely from country to country, even under allopathic medical care. “West Germans, for instance, consume roughly six times as much cardiac glycoside, or heart stimulant, per capita, as do the French and the English, yet only about half as much antibiotic” (Payer, 1988, p. 38). In general, Payer found that German doctors were far more likely to diagnose heart problems than doctors in other countries. English physicians, by contrast, are characterized as parsimonious. For this reason, Payer describes the British as the accountants of the medical world. They prescribe about half of the drugs that German and French doctors prescribe and perform about half of the surgeries of American doctors. “Overall in England one has to be sicker to be defined ill, let alone receive treatment” (Payer, 1988, p. 41). By contrast, the Americans are spendthrift and aggressive. They have a tendency to take action even in the face of uncertainty. They do not, however, focus on a particular organ. Among the French, most ills are ultimately attributable to the liver.

Payer argues that these patterns reflect the German emphasis on the heart—on romance, in literature and music, for instance; the French focus on the pleasures of eating and drinking; the English have a preoccupation with rationalizing the national medical care system; and the American emphasis is on getting things done and getting on with it. Payer’s work suggests, in broad strokes, something of the relationship between culture and medical practice. More cross-cultural research needs to be done and more is being undertaken (see, e.g., Lakoff’s 2004 work on the links between anti-depressant use and the economic crisis in Argentina).

Class and Resistance to Medical Knowledge

One way that lay people interpret, accept, or resist “medical knowledge” is described in relation to a cancer education project developed for a white, working-class, inner-city area in the United States that was known as a “cancer hot spot” because of the relatively high rates of cancer mortality (Balshem, 1991). The problem was believed by the local inhabitants to be largely the consequence of air pollution from nearby chemical plants and occupational exposure of those who worked in the plants. With this belief system in mind, the community rejected “health education” about nutrition and cancer. To illustrate the resistance, Balshem, who was working as a health educator at the time, describes the aftermath of her slide show and talk about the cancer prevention possibilities of a diet that is high in fibre and low in fat. Immediately after this talk Balshem asked if there were any questions. She was met with silence. Then she raffled off a hot-air popcorn maker. People responded warmly, with pleasure. After that, there was silence again. The meeting adjourned and the subtext of the silence emerged. One person talked about her old neighbour (93 years old) who ate whatever she liked and was still alive. Another teased Balshem: “You mean your husband will eat that stuff; mine sure won’t.” Still another confessed that the people in the room liked their kielbasa (spicy sausage) too much to eliminate it from their diets. Finally, Balshem was invited to their next church supper for some really good eating. Balshem describes the meeting finale as follows:

Then, the social climax: I am offered a piece of cake. The offerer, and a goodly number of onlookers, can barely restrain their hilarity. 

Time stops. Then I accept the cake. There is a burst of teasing and laughter, the conversation becomes easier, the moment passes. We eat, pack our equipment, and leave. (Balshem, 1991, p. 156)

While the general atmosphere of these meetings was amiable, the explicit health messages were ignored or indirectly criticized as impractical and as being of less importance than things such as pleasure, family feeling, and “human” nature in the pursuit of health. To the participants the environmental causes identified by the people who lived there were the obvious culprit and cause of cancer.

To understand the community and its responses, Balshem engaged in survey research, long open-ended interviews, and focus-group research strategies. One of the findings was that the community members had sharply contrasting attitudes towards heart disease and cancer.

The causes and treatments of heart disease were both fewer and considered more responsive to lifestyle alterations. Cancer, by contrast, was described as the result of a horrible fate. It was seen as caused by almost everything in their environment. Many of the respondents directly denied the dominant scientific discourses regarding cancer causation and prevention. In particular, there were direct denials of smoking and of fat as cancer-causing agents. By contrast, no one questioned the standard scientific discourses about the prevention and causation of heart disease. Balshem called this response “resistance” and explained that:

maintaining a rebellious consciousness is part of constructing a valued self, valued community, valued life, in a subordinate class environment. Self and community, valuing and supporting each other, process myriad insults, betrayals, and frustrations. Local belief and tradition, it is asserted, are superior, as is local insight into the workings of authority and hegemony. (Balshem, 1991, p. 166)

For an abundance of reasons, class and community solidarity proved to be more important than expert health knowledge, beliefs about disease causation, and prevention strategies.

Despite the power of “medicalization from above,” there is always resistance, or as Cornwell (1984) says, “medicalization from below.” Calnan and Williams (1992) demonstrate another type of resistance to medical thinking and hegemony. They studied lay evaluations of the trustworthiness of doctors with respect to nine specific medical care issues. In particular, they asked whether or not laypersons would unquestioningly accept medical opinion with regard to the following nine interventions: (1) prescription of antibiotics; (2) hernia operation; (3) operation for bowel cancer; (4) prescription for tranquilizers; (5) hip replacement operation; (6) hysterectomy; (7) heart transplant; (8) test-tube babies; and (9) vasectomy. Their findings indicated that in only one case, antibiotics, would the majority of respondents accept medical intervention without question: 54 per cent said they would accept antibiotics without question. Yet even here, 41 per cent said they would only accept the doctor’s recommendation for antibiotics with an explanation. Moreover, the views of the public regarding all interventions varied according to gender, class, age, and health categories. Although this study is now old I wonder how many of you accept medical opinion without question, even with regard to antibiotics, in an age of antibiotic resistance.

Calnan and Williams note that in making their decisions respondents were guided by certain fundamental values of their own. A good intervention was characterized in the following ways: as life-saving rather than life-threatening; as enhancing rather than diminishing quality of life; as natural rather than unnatural; as moral rather than immoral; as necessary rather than unnecessary; as restoring independence rather than promoting addiction/dependence; and as giving good value for money rather than being a waste of money.

The lay population knows that medical knowledge does not form a consistent whole. Nor do the different conceptions of medical knowledge necessarily complement one another: “The medical world is a melting pot of contradictory theories and practices, controversies and inexplicable phenomena about which doctors and lay people are in constant debate” (Bransen, 1992, p. 99). For example, after decades of encouraging women to examine their breasts for suspicious lumps and to have regular mammograms, the medical profession has begun to withdraw those recommendations. Mammograms, for instance, are recommended at different frequencies and ages for women today. False positives and costly exploratory surgery have levied a significant toll on women and costs to the system. Controversy still swirls around whether the potential side effects from mammography testing are worth the few cases of breast cancer that are found early enough for treatment to make a difference, as this review of 25 years of mammography use indicates (Klarenbach et al., 2018). Similarly, the usefulness of PSA testing in men has been called in question in the event that the only “treatment” is watchful waiting. HRT was first heralded as the new wonder drug for the prevention of breast cancer and then later found implicated in other diseases.

Patient groups are organizing to seek their rights in Canada and around the world. The World Health Organization states that everyone in the world should have the right to accessible, affordable health care. This is not yet the case, as you will see in Chapter 15. For example, the Affordable Care Act, which does not cover every American, was introduced in 2010 by President Barack Obama, then hotly debated and threatened with a rollback under President Trump.

Medical Knowledge Becomes Popular Knowledge

Magazines, newspapers, and audiovisual media have long been important as sources of health-related information and attitudes in modern mass societies. These channels are currently being surpassed, however, by information available through the electronic superhighway. This trend has been dubbed escaped medicine (Nettleton, 2004) and m-medicine, that is, mobile-medicine or mobile-health (Lupton, 2012). Daily updates of scientific/medical news are available through the Internet, where there are probably billions of pages of information available at the click of the mouse. Some websites are affiliated with major medical institutions or disease-related charities such as the Heart and Stroke Foundation and the Canadian Cancer Society. Many of these are professionally run and present dominant discourses that are widely considered to be scientific, valid, reliable, and current. Others are full of invalid and unreliable information. Privacy and confidentiality are not always protected. Some sites are outdated. Some represent various commercial interests. Some reflect the concerns of special disease or treatment preference interest groups. If you investigate any number of disease-specific websites for sponsorship you will notice that pharmaceutical companies are often behind-the-scenes financial supporters. The extent to which this “pharma” sponsorship biases the information available in favour of one drug or another needs further investigation. A related investigation examined direct-to-consumer (DTC) advertisements, which are legal in the US and said to be highly regulated as to safety information. However, DTC advertisements present a rosy picture of the benefits while diminishing the possibilities of side effects and long-term effects. Undoubtedly, DTC ads also drive up pharmaceutical use and health-care costs. The information provided varies in accuracy and accessibility. Moreover, people interpret information according to their own culture and socio-economic, gender, age, educational, and psychological characteristics.

Studies of health information on the Internet paint a fairly pessimistic picture of its validity and reliability. One study sought to find out how people use the Internet by establishing a website to provide information about cardiology. The researchers found that users were seeking information “correctly,” that is, 95 per cent of those who asked for information asked pertinent questions (Widman & Tong, 1997). Another study evaluated information regarding pharmaceuticals. Here the researchers found that about 50 per cent of the information provided was correct, another 50 per cent was incorrect, and 10.4 per cent of that incorrect information was potentially harmful (Desai et al., 1997). In an evaluation of the quality of information regarding how to detect and manage childhood fevers, researchers found that only about 10 per cent of the websites providing information on childhood fevers adhered closely to recommendations in peer-reviewed guidelines (Impicciatore et al., 1994). Clearly, these are issues of concern to those who use the Internet for health information. Another study, this one of breast cancer sites (Hoffman-Goetz & Clarke, 2000), found inadequacies with respect to the validity and reliability of information, the presence of references, dated information, dead-end sites, lack of acknowledged ownership, security and privacy protection, widely different reading levels from site to site, and the dominance of the English language.

Although the above research is quite dated, it still appears that the Internet offers a Wild West approach to health information. The quality of sites varies markedly, and as yet there are no enforced reliable standards (Fahy et al., 2014). People use the Internet widely for health information and can trust many well-known sites such as that of the World Health Organization and the Public Health Agency of Canada. However, validity and reliability are still elusive for many other sites. To date the Internet is open, free, and unregulated. Debates flourish about whether this is the best strategy in the long run. Some researchers and institutions are working to develop indices and software that would provide organization, guidelines, and maps for users. In the meantime, technology leads social change and people are running to catch up! Different people use different types of media, and people use different media for distinct types of information.

Moyer and her colleagues (1994) evaluated, over a two-year period, the accuracy of scientific information as it went from original research/medical sources to the various mass media, including newspapers and women’s, science, and health magazines. They began with 116 articles in the mass media. Of those, 60 included traceable citations. There were 42 content-based inaccuracies including misleading titles, shifts in emphasis, treating speculation as fact, erroneous information, omitting other important results, omitting qualifying information, over-generalizing findings, and inaccuracies in personal communications. Women’s magazines had the highest percentage of inaccuracies in traceable citations, at 88 per cent. “Quality” newspapers had the fewest inaccuracies, at 25 per cent.

Furthermore, readers typically misunderstand at least some of the information they receive through the mass media. Yeaton et al. (1990) surveyed a small sample of college students regarding their understanding of popular press articles on health issues such as surgical alternatives for breast cancer, drug treatment for congestive heart failure, use of starch blockers for weight reduction, dietary cholesterol, heart disease, and skin transplants for burns. The overall rate of misunderstanding was 39 per cent. The fact that this level of misunderstanding exists among college students raises serious questions about the accessibility and quality of the health information accessible to the average citizen. If media-based information is both inaccurate (to an extent) and misunderstood (to an extent), we have to wonder about the quality of the health information that exists among the general population.

It must be emphasized that the media do not just provide background noise. They can have very real effects on health and health behaviours. A recent study of suicide reiterated the findings that reporting on suicide increased the rate of suicide (Sinyor, 2018).

Doctor–Patient Communication

Doctor–patient communication reflects the broader social structure and culture. It also reflects the particular characteristics of both patients and doctors. Physicians and patients each embody their own particular social spaces as carriers of culture and structure. In a study based on ethnographic fieldwork that entailed joining the surgical ward rounds at two general hospitals, Fox (1993) examined the communication strategies used by doctors to maintain authority and power in their interaction with surgical patients. When patients tried to ask questions, such as why they felt the way they did, how soon they would feel better, and when they could go home, the surgeons tended to ignore them. Instead, the surgeons maintained verbal and other sorts of control by focusing on the success of the surgery with respect to the specific goals of surgery (e.g., absence of infection, minimal scarring) and its specific outcome. Fox demonstrates that ward rounds can be understood as a systematic strategy entered into by surgeons to capture and maintain their discursive monopoly. By keeping the discussion focused on surgeon-centred themes, the doctors allow patients few opportunities to introduce their own views, concerns, or worries.

One area of social life around which there is a great deal of ambiguity and ambivalence is sexuality. On the one hand, sexual relations are more openly discussed, portrayed, and symbolized in all of the mass media today than in the past. Acknowledgement of the pervasiveness of sexual activity outside of the bounds of monogamous marriage is widespread. Accompanying the “liberalization” of sexuality, and particularly of women’s sexuality, is the belief that a satisfactory sex life is an important part of a satisfactory life as a whole. Yet, many are still ambivalent about sex and many still believe it to be a shameful duty to be kept secret. Today, people are more likely to consult doctors when dissatisfied with their sexual functioning (Weijts et al., 1993). Sometimes, women’s dissatisfaction with their sex life seems to be hidden behind complaints about physical functioning, including such things as vaginal infections and pain during intercourse (Stanley & Ramage, 1984).

It is useful to understand how such ambiguity and ambivalence are manifest in personal relations and in talk between doctors and their female patients. One study of doctors’ and patients’ talk showed constructions of sexuality were managed in the doctor’s office quite “sensitively” so as to reinforce gender stereotypes about the “shame” and “mystery” surrounding female sexuality (see Table 8.2). The strategies used to discuss such “delicate” matters are best characterized as delay, avoidance, and depersonalization. Reflected in the talk and in the silence is the construction of the “delicate and notorious” character of female sexuality in the context of the possible discourse with an often more powerful and male doctor (Weijts et al., 1993).

Sociological discussion of “talk” is not trivial. It is important both theoretically and practically. “Delicacy”—or the shame and privacy norms passing as “delicacy”—with respect to sexuality, particularly female sexuality, is a major factor in unwanted pregnancies, sexually transmitted diseases, and the transmission of the HIV/AIDS virus in heterosexual populations. To the extent that women remain unable to talk clearly and confidently about their sexuality, about their genital and reproductive health, and about birth control and health and safety devices such as condoms, they may be more likely to be unable to refuse unwanted and/or unprotected sex. In a context in which there is a high prevalence of STDs and STIs (sexually transmitted diseases and sexually transmitted illnesses) and unprotected sex by teens and young people, often with several partners and without protection, it is important that sexually active people feel comfortable asking for regular STD and STI checkups.

One important aspect of doctor–patient interaction is the emotion regulation of patients and doctors. Some aspects of emotional display are expected or at least allowed among patients. Crying, withdrawal, and even modulated anger are appropriate emotions for patients to display when receiving bad news, for example. Doctors, however, are expected not to show such emotions even when they are frustrated, disgusted, or angry. Talcott Parsons thought of this as a part of the affective neutrality that doctors were taught to show to patients. One recent study examined the effects of emotion regulation among doctors on their patients (Kafetsios et al., 2014). Patients’ satisfaction was found to be dependent on the emotion regulation (or suppression of emotion) displayed by their doctors. Evidently, emotion work is an important part of the skill set required for good medical practice and patient satisfaction. Doctors join other service workers in selling their emotional labour as a part of how they work (Hochschild, 1983). This suppression of emotion can be detrimental to the life and job satisfaction of doctors.

Summary of the whole chapter

1. Medical knowledge is socially constructed. It reflects cultural values and social-structural locations. It has varied historically and cross-culturally.

1. Some of the specific values of contemporary medicine include mind–body dualism, physical reductionism, specific etiology, machine metaphor and regimen, and control. Sociological research provides a critical overview of these medical assumptions.

1. A large and significant gap exists between the findings of biomedical research and the implementation of the consequences of these findings in medical practice. The values of medical scientists and medical practitioners are, in many ways, at odds with one another.

1. Available evidence demonstrates that new technologies are usually adopted (even widely) before their safety and effectiveness have been ascertained.

1. Medical science has been infused with cultural and gendered stereotypes such as those described by Emily Martin.

1. Research shows that medical practice, too, is infused with cultural stereotypes, including those that pertain to age, gender, class, and race.

1. One cross-cultural study of medical practice by Lynn Payer offers provocative evidence of cultural differences in diagnosis and treatment.

1. Significant class differences exist in public understanding and acceptance of medical knowledge.

1. Lay views of medical practice vary according to gender, class, age, and specific health categories.

1. Media information about medical knowledge is frequently inadequate or inaccurate.

1. Medical doctors employ various discursive strategies in an attempt to maintain control over their own definitions of reality in the face of patient questioning.