Medicine, Sociology of
MEDICINE, SOCIOLOGY OF•••
The sociology of medicine is characterized by a wide variety of concerns, approaches, and perspectives (Mechanic, 1978; Freeman and Levine; Fox; Waitzkin, 1991). The concerns of medical sociologists cover such diverse areas as the distribution and etiology of disease and impairments; disease concepts and their social construction; cultural and social responses to health and illness and the use of services; health and illness behavior and its determinants; sociocultural aspects of medical care and the social organization of helping services; the organization of the health occupations and the processes of providing care; social factors affecting trends in death and illness; the sociology of the health occupations; the social organization of the hospital; and comparative health organization. In collaboration with other disciplines, the field includes the study of social change and healthcare; changing technology and its role in care; medical education; public-health organization; stress, disease, and coping; social and community psychiatry; the social context of legal and ethical dilemmas; and medical politics.
Many medical sociologists attempt to illuminate how individuals define and respond to situations as they cope with the expectations and demands of their physical and social environment, how some types of response lead to stress and illness, and how services are used to reestablish social and personal equilibrium. Helping institutions can be examined similarly in terms of how the behavior of health personnel and organizations responds to problems of resources, time, and other situational constraints. All people, whether patients or health personnel, seek to establish mastery over their life and work environments, to reduce uncertainty, and to obtain gratification and esteem for their efforts.
One important aspect of medical sociology concerns how certain problems become manifest in a population, how they are defined, and how patients with these problems enter particular channels of care. The field also deals with the nature of therapeutic encounters between patients and practitioners, modes of communication and influence, types of discourse, and how all these are influenced by the cultural context, social characteristics of patient and therapist, changing knowledge and technology, organizational and payment arrangements, and resource constraints.
From a sociological perspective, medicine can be regarded as a sustaining or integrative institution in society (Parsons). Not only does it provide assistance to persons afflicted with disease and other life problems; it also serves as an important means for alleviating social distress and for excusing failures in social functioning or failures to meet social expectations (Mechanic, 1978; Kleinman, 1986). Medicine also has important social control functions that facilitate the removal of individuals from social settings to relieve tensions—whether in the family, in work settings, or in the community at large. It may also facilitate financial compensation or social benefits, for example, access to services or products, such as drugs, that are restricted to those who are not deemed ill.
The role of the physician, then, has not only technical dimensions but also social and moral ones. While the technical expertise of practitioners refers to a limited range of situations, their clientele and the scope of problems they deal with are very broad. Many of the judgments a physician makes are not medical judgments but decisions based on social considerations and values. Even those aspects of the medical role that appear to be purely technical, such as the labeling of disease, the specific management of the patient, and the choice of medications or other treatments, have profound consequences for performance of social roles and obligations as well as for future life opportunities. Patients' problems often result in part from conflicts with other persons and social groups, and the physician can sometimes help resolve difficulties by taking either the patient's or an adversary's perspective. Such conflicts are particularly evident in such areas as military, industrial, and prison medicine, where the physician is not the patient's personal agent, but they occur to some extent in many private patient-care contexts as well.
Patient flow from a community population to various helping agencies is usually thought to result almost exclusively from the occurrence of illness in that population, in contrast with other factors. Indeed, other factors distorting the selection process, such as differential propensities to seek care, are seen as disturbances that require correction through patient education or such economic disincentives as deductibles and coinsurance. Although illness is usually the major determinant of help-seeking, it fails to explain by itself much of the evident variation between those who seek and those who do not seek assistance (Mechanic, 1978).
It is common, for example, for medical scientists to assert that discovering a cure for an illness such as the common cold, one of the most frequent reasons for consulting a physician, would profoundly alleviate physical limitations, industrial absenteeism, and the loss of productive labor. But to the extent that the common cold is often an excuse rather than the reason for work absenteeism or seeking medical care, a cure might have much less social effect than commonly believed. If people who seek care for the common cold do so because they are unhappy or hate their employment, then the visit to the doctor may be little more than a justification for more complex motivations and behavior. There are various social and cultural inhibitions against persons openly acknowledging personal life problems, and often such problems are shielded by presentations of seemingly trivial illness. This process is now commonly referred to as somatization (Kleinman, 1986).
Medicine involves a distinctive set of meanings that limit the interpretations of patients' concerns (Waitzkin, 1991). Such meanings may obscure social problems and dilemmas and their causes, narrowing the range of possible remedies. This medicalization subsumes important social and ethical issues within clinical judgments that escape careful scrutiny. The differential diagnostic approach, which structures how doctors are educated and how they address problems, affects the ability of doctors and patients to explore comprehensively the sources of distress and disease as well as their implications for well-being (Waitzkin, 1983, 1991; Kleinman, 1986).
Social Distribution of Health, Illness, and Medical Care
Although the concept of health is difficult to define, numerous studies demonstrate that longevity, absence of impairment, and less illness and disability are associated with favorable socioeconomic conditions (Mechanic, 1989b). Many of the health problems of the poor stem from unfavorable environmental conditions, poor nutrition, and lifestyles harmful to health. Because persons of lower socioeconomic circumstances are less likely to receive high-quality services—whether because of limited income, less readiness to seek necessary care, or inaccessibility of facilities—they are more likely to suffer from disabilities, higher mortality, and secondary conditions (Bunker et al., 1989).
Secondary conditions, such as decubitus ulcers, cardiopulmonary problems, and psychological depression, are often causally related to an initial illness and occur because the primary condition is poorly managed (Institute of Medicine). Since 1965 social programs in the United States have given some attention to the equity in the provision of medical services, and the historic inverse relationship between socioeconomic status and use of physician services has been reversed. But socioeconomic differences continue to persist for many specialized services and for preventive care. Although mental disorders are very prevalent in the lowest socioeconomic groups (Robins and Regier), psychological and social services are particularly inadequate for the poor.
The poor suffer from other problems in the medical care sector. They are least likely to share assumptions and meanings with health practitioners, and thus most likely to suffer from misunderstandings and confusions resulting from such incompatibilities. They are likely to feel more embarrassed, anxious, and intimidated in dealing with medical personnel, and are less likely to receive care congruent with their values or life perspectives. They are frequently used as subjects for teaching and research, particularly in experiments that bring no particular benefits to the patient (Barber et al.); and they are more likely to have difficulty granting informed consent, particularly where explanations are quick and perfunctory (Gray). The poor not only have more illness and problems and less access to medical care relative to need but also are treated with less consideration and respect than affluent patients.
Above and beyond socioeconomic status differences, race and ethnic differences account for variations in health. Although much of the excess in mortality and morbidity among blacks and Hispanics is attributable to socioeconomic disadvantage, other factors associated with race and ethnicity are pertinent, including differences in culture and health-relevant behavior, discrimination, and biological differences.
Still other aspects of social stratification, including age and gender, are important determinants of health status. Age and gender affect exposure to risk and disease occurrence through both biological and social pathways linked to these characteristics. The prevalence of chronic disease and disability increases with age but is influenced as well by the individual's social participation and social networks, sense of personal efficacy, and subjective well-being, which vary over the life cycle.
Large differences in health indicators and health behavior are also found between men and women. The fact that women live longer than men is in part biological, but it is also substantially affected by different styles of behavior and response among men and women. Most of the higher mortality in men can be attributed to behaviors such as substance abuse, poor nutrition, risk-taking, and violence. Many other social factors, such as marital status and household structure, are associated with patterns of health and disease (Mechanic, 1978).
Organization of Medical Care
If medicine has social and ethical as well as technical dimensions, how do we develop organizational settings that can apply the necessary technical expertise in ways that respond to the patients and their unique individual and social needs? Even the very best hospitals and medical organizations often treat patients without empathy or respect, and show limited interest in managing their medical problems in light of their family, work, and community circumstances (Duff and Hollingshead; Kleinman, 1988). The personnel who carry out these institutions' medical functions behave as they do, not because they are inhumane, but because the pressures and constraints of work, the priorities they have been taught, and the reward structures of which they are a part direct their attention to other goals and needs. Successful modification of service institutions requires significant revisions in the organizational arrangements and incentives that affect the work of personnel and the tasks they perform. In a materialistic culture where persons may respond to money and prestige incentives more readily than to more lofty motivations, the design of economic and prestige incentives and an awareness of how they affect decisions become important elements in shaping behavior.
Some attention has been devoted to how the economic structure of medicine affects the work of physicians and other personnel. Fee-for-service incentives often result in high levels of professional commitment, a willingness to work hard, and responsiveness to those who pay the fees. They also often encourage excessive use of medical, surgical, and pharmaceutical modalities to earn more income. Data from a variety of nations suggest that when attempts are made to manipulate the system by increasing payments associated with certain procedures, these incentives shape what physicians do (Glaser). The difficulty with any such piecework system is that it tends to discourage procedures that are important but for which only modest or no remuneration is provided. Since payment systems typically reward technical procedures, the most neglected aspects are those concerned with social care, listening to the client, patient education, and grappling with ethical issues. Physicians are best rewarded financially when they provide the largest number of discrete technical services.
One antidote to the perversities of piecework medicine is to pay by salary or capitation (a uniform payment for each person the physician cares for), but these approaches also have disadvantages. Under such systems physicians are more likely to limit their work efforts, appear less committed to their work, and seem less flexible and responsive to the individual needs and circumstances of their patients (Mechanic, 1989a). Thus, the same incentive conditions that make it possible for physicians to allocate their time within their own concepts of the value of varying types of caring and curing—conditions that may dampen a tendency to overutilize expensive and perhaps dangerous therapies—may also encourage withholding necessary services or result in an unwillingness to respond to important concerns of patients.
Doctors paid by capitation seem to adjust their efforts in relation to the payments they receive, a form of perceived distributive justice. This concept is shaped by knowledge of the circumstances of other doctors with comparable training in different work settings. Many of the difficulties in capitation payment result because patient load is heavy and payment is small for each patient. The heavy patient load and the doctor's limited work hours encourage a pattern of care that many patients find unresponsive. But time and patient demand are not the only factors involved in the way physicians deal with social and ethical problems in their practice. Physicians may have more or less tolerance for a wide scope of work; may be more or less willing, and feel more or less competent, to deal with family problems, alcoholism, sexual adjustment, or child-care problems. To the extent that physicians are properly trained to deal with the broader problems of medical care, and thus feel more competent in their clinical management, they may be more willing to deal openly with social and ethical challenges. Many physicians probably avoid dealing with psychosocial issues because they feel an effective therapy is lacking; however, they often readily accept the responsibilities to treat physical illnesses for which they also lack effective treatment. It may be that a sense of confidence and clinical experience are more important than the objective efficacy of the care.
In the creation of new medical settings, the problem is how to maximize the advantages of both fee-for-service and capitation medicine while compensating for their more undesirable aspects. People are ingenious in undermining and thwarting incentive systems that are not sensitive to their work problems, that increase their uncertainties, or that appear inequitable. To design an organizational system adequately requires intimate appreciation of how individuals actually manage their work, rather than utopian but unrealistic conceptions of how people should function.
Sociology of the Health Occupations
The attention in this article to doctors, in contrast with nurses, technicians, pharmacists, or social workers, is no accident. Although physicians constitute less than one-tenth of personnel in the health sector, they define and dominate the nature of decision making and the division of labor in medicine (Freidson; Starr; Mechanic, 1991). Physician dominance is in part a process in which doctors gain political legitimacy that protects them against economic competition from other health workers and helps preserve their professional autonomy. Increasingly, the physicians' dominance is being challenged by a variety of forces in the society: by administrators wishing to achieve economies of production through shifting traditional medical tasks to less trained personnel; by government wishing to control the growing costs of medical care; and by such professional groups as nurses who wish to improve their own political power, income, and status. Thus, the health sector is characterized by increasing political acrimony and collective politics (Stevens).
Ethical Dilemmas and the Sociology of Healthcare
The advances of medical knowledge and technology confront modern society with awesome social and ethical dilemmas. Among these questions is whether an ever-increasing proportion of our gross national product ought to be spent on expensive modalities that provide marginal gains in health and longevity. Are such investments not better made in preventive approaches and environmental amelioration or in other social goals?
Bioethics has been more an activity with a normative focus than a field of inquiry that seeks to investigate the implications of varying courses of action (Wikler; Fox). During the two decades in which bioethics has grown as a discipline, relatively few bioethicists have utilized sociological materials and methods, and relatively few sociologists have studied bioethics (Weisz). Ethical reflection in healthcare could be very much enhanced by a sociological perspective that examines the empirical setting and implications of a given ethical choice. Whether to accept organs from live donors or allow subjects to participate in experiments posing possible danger to themselves must depend at least to some extent on the actual psychological and social consequences of such participation. The fact that such volunteers often experience great satisfaction from their participation is no small part of such policy considerations (Fellner and Schwartz; Gray). Similarly, the willingness to expend great resources in heroic efforts to extend life, irrespective of function, must be weighed against the consequences of extended lives for such patients and their loved ones. Sociological perspectives and methodology can contribute to the ultimate ethical decisions by clarifying some of the human factors relevant to resolving the conflicts between competing social and ethical values.
david mechanic (1995)
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The American Heritage Dictionary (4th ed., 2001) defines socialized medicine as “a system for providing medical and hospital care for all at a nominal cost by means of government regulation.” This leaves room for considerable craftsmanship in the construction of socialist systems. Indeed existing socialized medical systems in, for example, Great Britain, Cuba, Finland, and Switzerland conform to this definition, but are far from monolithic.
Because every aspect of a socialized health care industry is controlled and provided by the government—most doctors, nurses, medics, and administrators are government employees—the system, such as the National Health Service (NHS) in Britain, determines where, when, and how services are provided. Of course citizens may seek care outside the system, in the private sector.
Socialized medical systems are designed to eliminate the insurance industry and marginalize profit while providing health care for all. According to many recent studies, socialized systems outperform free-market profit-driven systems in terms of availability, quality, and cost of care. In addition a report from the Johns Hopkins University Bloomberg School of Public Health stated that the United Kingdom’s socialized medical system outperforms the U.S. system in patient-reported perceptions (Blendon, Schoen, DesRoches, et al. 2003). In other words, the people with direct experiences report greater satisfaction with their health services under a socialized system than they do in a free-market system. These results must be considered along with the fact that the U.S. per capita health care expenditures ($4,887) are nearly triple those in the United Kingdom ($1,992). In the year 2000 the United States spent 44 percent more on health care than Switzerland, the nation with the next highest per capita health care costs. Nevertheless, Americans had fewer physician visits, and hospital stays were shorter compared with those in most other industrialized nations. The study suggests that the difference in spending is caused mostly by higher prices for health care goods and services in the United States.
The British system is probably the most instructive example for Americans to evaluate because of the similarities in economy and government structure between the two nations. According to the NHS Web site, the system “was set up on the 5th July 1948 to provide healthcare for all citizens, based on need, not the ability to pay” (National Health Service 2007). Originally conceived as a response to the massive casualties of World War II (1939–1945), the system survives and continues to evolve in the early twenty-first century. The NHS is funded by taxpayers and managed by the Department of Health, which sets overall policy on health issues. Individual patients are assigned a primary care center (with doctors, dentists, optician, pharmacist, and a walk-in center) managed by a primary care trust (PCT). The NHS explains its system of referrals this way: “If a health problem cannot be sorted out through primary care, or there is an emergency, the next stop is hospital. If you need hospital treatment, a general practitioner will normally arrange it for you” (National Health Service 2007).
The PCTs are responsible for planning secondary care. They look at the health needs of the local community and develop plans to set priorities locally. They then decide which secondary care services to commission to meet people’s needs and work closely with the providers of the secondary care services to agree about delivering those services.
The NHS may be the world’s most sophisticated socialized medical system, but the modern world’s first such system was established by the former Soviet Union in the 1920s. Whereas the NHS demonstrates that socialized medicine can exist within a capitalist economy, the failures of Soviet medicine demonstrated how corruption within a society can distort any system. China, Cuba, Sweden, and most of Scandinavia have successful and completely socialized health care systems.
Life expectancy and infant mortality rates are two of the best indicators of overall health. Average life expectancy in Great Britain was 77.4 years in 1998; in comparison, life expectancy for the U.S. population reached 76.9 years in 2000. Infant mortality in Finland is below 4 percent; in the United States it is 7 percent. Health services are available to all in Finland, regardless of their financial situations.
Single-payer systems such as Medicare are not socialized medicine. In socialized systems the government owns, operates, and provides every aspect of the health care services. Although it is true that in a single-payer system the government collects and disperses the capital for services rendered, its decision-making responsibilities end there. Even without socialized medicine’s additional powers to limit corporate profits, studies by the U.S. General Accounting Office and the Congressional Budget Office show that single-payer universal health care would save $100 to $200 billion dollars per year while covering every currently uninsured American and increasing health care benefits to those already insured (U.S. Government Accounting Office 1991; Congressional Budget Office 1993).
Outside of the United States, health care in the twenty-first century is increasingly seen as a basic human right that deserves to be protected and provided at an affordable fee to all citizens of civilized societies. This idea—that medical procedures and health care in general should not be subject to or motivated by market forces— is one that, in the late twentieth century, evolved back into favor only after repeated experiments with the capitalization of health care led to systematic and catastrophic failures, resulting in grotesque profits on the supply side contrasted with the suffering of millions of disenfranchised patients on the demand side of the equation. Socialized medicine is an egalitarian system that addresses these iniquities.
SEE ALSO Egalitarianism; Human Rights; Medicine; Morbidity and Mortality; National Health Insurance; Public Health; Socialism; Union of Soviet Socialist Republics
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medicine, sociology of
Notwithstanding these territorial difficulties, the sociology of medicine, broadly defined, has flourished since the 1950s. Although its roots lie in part in the social medicine of the inter-war years and earlier, its sociological impetus came primarily from Talcott Parsons's influential work on the medical profession and the sick role, which put medicine and illness into the mainstream of sociology.
Leaving aside the questions concerning health and illness, the sociology of medicine in its narrower definition focuses on two major issues. A first and dominant concern is to analyse the nature, extent, and origins of the power of the medical profession, and the relation of the medical profession to other allied professions. The work of Eliot Freidson in The Profession of Medicine (1971), with his emphasis on autonomy as the defining feature of a profession, exemplifies this tradition. It has been further developed by a number of feminist writers, such as Ann Oakley, who have examined the exclusionary tactics deployed by the medical profession in the medicalization (a term particularly associated with Ivan Illich's study Medical Nemesis, 1976) of events such as childbirth–a medicalization that not only excludes the female midwife but also increases the powerlessness of women who are giving birth.
Doctor-patient relationships constitute the second major focus of the sociology of medicine, with work ranging from in-depth studies of doctor-patient interactions, including analyses of tape-recorded doctor-patient exchanges, to large-scale surveys of doctor-patient satisfaction, the time spent with patients, and so forth. The care of the dying has received especial attention, as has the socialization of medical students. Ruth Laub Coser's Life in the Ward (1962) illustrates this tradition.
However, whilst these two areas will no doubt remain at the core of the sociology of medicine, it seems likely that the activities of the medical profession will be increasingly located within the context of the study of other health workers and the wider health-care system (see U. Gerhardt , Ideas about Illness: An Intellectual and Political History of Medical Sociology, 1989). Emily Mumford 's Medical Sociology (1983)
is one of the many textbooks dealing with this specialism.