Professional–Patient Relationship: II. Sociological Perspectives
II. SOCIOLOGICAL PERSPECTIVES
The purposes of this article are to provide a sociological perspective of the doctor–patient relationship by sketching the models of it as they have been developed by sociology, and to summarize contemporary sociological analysis. Both are essential for understanding the issues surrounding the therapeutic relationship today.
No other aspect of medicine has attracted more sociological analysis than the medical professional–patient relationship. From a classic view of the relation between doctor and patient "as a pure person-to-person relation" (Sigerist), the full range of psychosocial and sociocultural influences has been studied. Many of the most distinguished sociologists have used this particular problem to illustrate theories of the field. At the same time, the changing facts of technology, organization, and cost were charted as the necessary context for understanding the changes in professional–patient encounters.
There are also distinctive regional-cultural interpretations of the therapeutic relationship. European sociologists consistently have emphasized the significance of power (Foucault). This perspective makes the human body, and hence the patient, the passive recipient of pathology, and sees the professional as an agent of the state (Rosen). David Armstrong, a British medical sociologist, has pointed out that in Britain, not until about 1970 was the importance of the "inherently problematic … [aspects of the] … doctor–patient relationship" recognized (Armstrong; Interdepartmental Committee on Medical Schools). Not until the Todd Report was history taking described as "a great deal more … than simply asking a series of prescribed questions and checking the accuracy of the answers" (Great Britain). Essentially, Foucault viewed the clinical examination as a technique of surveillance. Beginning in the eighteenth century, such surveillance invoked a disciplinary power and required that the body (and hence the patient) be a discrete (passive) object. The change signaled by the Todd Report suggests "the beginnings of the fabrication of patient subjectivity" or, more simply, the activation of the patient (Armstrong).
Americans, on the other hand, have been preoccupied largely with the analysis of medicine as a profession, placing emphasis upon the role of the physician as a professional with resultant claims to autonomy and dominance (Freidson, 1970b). Initially, this perspective placed the patient in a primarily passive role. The American approach, however, has been to construct models that separate each role according to its structure—its reciprocal privileges and obligations—and its function for the society, defining the doctor as the legitimizer of illness and thereby the agent of social control, and the patient as an involuntary deviant who is allowed temporary exemptions from normal social expectations but is required to resume his or her place as soon as possible. Americans have assumed that within the framework of cultural expectations, behavior in these roles is voluntary. Europeans have directed their concern mainly to questions about how the rights and obligations of doctor and patient are inherent and controlled by the state.
These distinctive frames of reference for the analysis of medical relationships are reflected in very different systems for the delivery of health care. European nations, in both financing and service organization, have constructed systems that provide universal access to healthcare. Whether by a government-run national health service (the British model) or by national health insurance (the government guarantees the payment of fees for service by an essentially independent profession), the goal is to provide healthcare as a fundamental right for all citizens. The United States, virtually alone among modern industrialized nations—South Africa is its only companion state—has not guaranteed this right for the sick nor established the obligations of the caregiver, choosing instead to rely primarily on an implicit contract between the medical profession and the society. The latter arrangement, on the premises of individualism, claims that the doctor–patient relationship is sacred, based on the privileges of the professional to autonomy and the patient's right to choose his or her doctor. The alternative approach is based on the premise that in the therapeutic relationship, the behavior of the individuals—and their rights—depends upon social controls vested in the state. "Models," the Americans choose to call their explanations, signifying the fullness and reciprocity of the interaction between doctor and patient.
However, the intellectual distance between the continents has steadily grown smaller. When one traces the full history, the American and European interpretations can be seen gradually to converge. The starting point is in the 1930s, with all the major theories of sociological thought applied to the therapeutic relationship. Although the healing art is older than—and practiced by others than—the physician, the doctor's role has been the centerpiece. Other helping roles—the nurse, social worker, and various "allied health professionals"—have received attention (Aiken), but historically it is the therapist as a professional in modern society who has most interested the sociologist, and medicine is seen as the archetypal profession.
The result has been a changing portrait of both doctor and patient—from a dominantly psychological perspective to a sharp turn when Talcott Parsons introduced the social-system frame of reference (Parsons), shifting the analysis to the social roles of therapist and client, instilled in each individual by agents of socialization like the family and schools. The idea was that the qualities of patienthood were part of social development. We learn what to expect of physicians and how to behave as patients. Such roles were interpreted as "functional" components fashioned to maintain the society. Within this framework, the doctor's achieved high level of expertise is described as essential to modern scientific healthcare, and as a consequence, medical education is spotlighted. The medical school is seen as the principal source of attitudes and values as well as of training in skills and knowledge. That approach enhances the physician's image of awesome technological accomplishment and heroic personal attributes, while the patient is relegated to a subordinate, fragile state in which the only requirements are to be motivated to get well and to consult the physician toward that end.
The reaction to this approach, beginning in the 1960s, changed the role images dramatically: Complex bureaucratic forces were elevated to predominance over the voluntaristic choices of individuals (Starr). The "monopoly of dominance" replaced "technological achievement" as the more popular view of the doctor; the patient came to be viewed as "exploited" by the physician as much as or more than he or she was victimized by the primarily organic forces of illness. The doctor and patient became antagonists, each from a separate world, and their adversarial relationship was described as a "clash of perspectives" instead of a balanced, interdependent system.
In this changing approach, sociological thought has run parallel to the public's attitude toward the medical profession. The sociologists' picture of the physician, at first cautious and respectful, reflected the peak of public prestige and trust that allocated to doctors the privilege of virtually complete autonomy as "high priests in the temples of science" (Churchill). That pedestal was not an easy resting place, however. Physicians became the objects of public exhortation, government regulation, and legal attack.
The implications of the ethical standards by which physicians are judged are profound. After centuries of struggle to win the right to take risks, under conditions of uncertainty (Sigerist; Fox, 1957), in the "best interests of their patients," doctors now find themselves confronted by a fresh demand for accountability. The responsibility that was once assumed in trust is increasingly subject to the formal controls either of state-run systems or of various forms of peer review and medical audit. The added pressure of changing definitions of both the onset of life and its termination, stimulated by new technologies, has intensified the challenge to social values (Fox, 1979).
The therapeutic relationship is also responding to changes in the age profile, particularly of the populations of the United States and other modern industrial nations, and altered patterns of illness and disability. The challenge for physicians increasingly has become less a matter of cure and more of maintaining function (Mechanic, 1985).
At the same time, the sciences basic to medical practice—represented by modern molecular biology, genetics, and the neurosciences, together with computer-related technologies—have produced what has been called a "paradigmatic leap" that must profoundly affect the basic human relations of medical practice (Marston and Jones). As medical knowledge and technology have expanded, public expectations of physicians' expertise and caring have become higher than ever before, complicated by patient needs for a more active, sharing role in therapy.
The development of sociological interpretation of the therapeutic relationship must be viewed as an expansion rather than a linear growth. It is not possible to say that the models have emerged successively, each more valid than its predecessor. The theories represented are still hypothetical. We present them in historical order.
The System Model
FUNCTIONALISM. As applied to both biology and sociology, functional theory proposes that the relationships between the basic elements, whether chemical and physiological or social roles and institutions, are arranged in systems rather than as sums of their parts. Also basic in this conception is that the system is inherently driven toward equilibrium, a homeostatic balance that is reasserted whenever an intervention or change occurs. This dynamic toward balance and stability is the source of the term functionalism. It is assumed that living processes, including but not limited to the social, are dominated by relationships that function to maintain or reassert stability to the whole. Thus the terms system, function, and equilibrium are often used interchangeably: Functionalist theory is system theory.
Although not the first functionalist in social thought, Lawrence J. Henderson pioneered the application of an equilibrium model to the doctor–patient relationship (Henderson, 1935). This he did only in midcareer, after having established himself as an outstanding biological scientist by translating Willard Gibbs's model of physicochemical systems for use in the study of blood physiology. Known as the formulator of the acid-base equilibrium, he applied his functional model with simultaneous equations to explain the quantitative relationship of eight variables of the blood.
Functionalism in physics, chemistry, and biology replaced the linear, cause-and-effect positivism dominant in the nineteenth century. The introduction of this theoretical framework and its mathematical proofs had produced revolutionary effects in biology, and Henderson believed they would be duplicated in social science. The essence of his reasoning was expressed as follows:
Because every factor interacts in a social system, because everything, every property, every relation, is therefore in a state of mutual dependence with everything else, ordinary cause-and-effect analysis of events is rarely possible. In fact, it must be regarded as one of the two great sources of error in sociological work (Henderson, 1970, p. 29).
Henderson's application of the functionalist model to social systems produced a limited conception, and his model was mechanical and simplistic. As a result, his achievement in social science was mainly that of the seminal teacher: to inspire and challenge colleagues and students to take his model further.
Henderson's was soon followed by other interpretations of the social-system model. Illustrations and applications of the theory were drawn from all the major social institutions, especially the industrial and educational, but the doctor–patient relationship remained important. The major functional analysts of the therapeutic relationship, their illustrative examples, and their special contributions to knowledge are listed in Table 1.
Talcott Parsons, more than any other, carried forward the discussion of the doctor–patient relationship as a social system, giving it full expression as part of sociological theory. He argued that human social relationships can be described as patterns rooted in cultural expectation about the social roles of group members; that the fundamental process of behavior is communication; and that the integrity of the system is maintained by homeostasis, defined as a dynamic force that reacts to any change or intervention by reasserting a balance in the system that enables it to perform its intended function.
Parsons conceived of the doctor–patient relationship as a social-role interaction in which the sick role is voluntary; for instance, a person can be ill—say, with a cold—but choose not to be "sick," a status that invokes privileges and obligations determined by the cultural expectations of the society. The sick role is a form of social deviance that must be controlled to prevent the abuse of the dependency of illness. The professional role combines healing the patient and social control as the agent of the society. Accordingly, the sick role is temporary, undesirable, and socially disruptive. The professional is a technical expert who legitimizes the claim to illness and is responsible for returning the sick person to his or her normal role in society.
Criticisms of Parsons's views are of two distinct types. One is intellectual, challenging his theoretical premises and argument (Freidson, 1970a). The other is political, interpreting the work of both Henderson and Parsons as a conservative political response to the historical events of the early 1930s, particularly the Great Depression and the rise of communism (Gouldner).
The theoretical criticism of the model focuses on Parsons's emphasis on the asymmetry of the therapeutic situation—that is, the professional dominance versus the client's dependence—and in the distancing effect of that asymmetry. Parsons is interpreted as a defender of the technical elitism of the modern physician. His patients must be "controlled," lest they take advantage of the privileges of the sick role to prolong dependency; his physicians must be "protected" from emotional overinvolvement with their patients. The consequences, the criticism asserts, are not just to explain a role asymmetry based upon the achieved technical expertise of the professional, but also to categorize and label the roles so that the passive, dependent patient and the expert doctor become hardened stereotypes.
The continuous development of functionalist interpretations of the therapeutic relationship was broken abruptly
|Functional Models of the Doctor–Patient Relationship, Illustrative Cases, and Effects on the Field, 1930–1965|
|Models||Effects on the Field||Illustrative Examples|
|SOURCE: Adapted from Bloom and Speedling, 1989, p. 115.|
|Lawrence J. Henderson 1935||Cancer patient: socioemotional determinants of system process||Established legitimacy of medical relationship as a subject of scientific inquiry|
|Talcott Parsons 1951||Institutional case: the profession a social system||Contributed to general theory of social behavior|
|Florence Kluckhohn, John Spiegel 1954||Psychiatric patients, studied according to cultural value orientation||Contributed to general theory of behavior, combining sociological with psychoanalytic concepts: transactional theory|
|William Caudill 1958||The hospitalized mental patient||Applied social-system theory to analysis of mental hospital; conceived hospital as a functional social system|
|Thomas Szasz, Marc Hollender 1956||Acute, ambulatory, and chronic diseases, to illustrate behavioral implication of biological symptoms||Operationalized role theory in medical terms; articulated system theory for education of physicians and to improve clinical practice|
|Michael Balint 1957||Ambulatory patient of general practitioner||Expanded biomedical model (in Great Britain) to include socioemotional; broke down mind-body dualism.|
|Samuel W. Bloom 1963||Diabetes, mental illness, and multiproblem patient to illustrate sociocultural determinants||Applied functional theory to health care in historical/developmental terms|
|Kenneth Arrow 1963||The medical-care market||Adapted Pareto to general economic theory by conceptualizing optimum equilibrium as a theorem of competitive systems|
|Edward Suchman 1965||A population of "seriously ill" patients: a survey||Operationalized social-system explanation of health-services utilization|
in the 1960s with the appearance of studies that emphasized the structural, situational determinants and directly challenged the validity of the functional.
STRUCTURAL CONFLICT THEORY. Eliot Freidson is the major spokesman for the application of the structural conflict theory to the professional–patient relationship. The therapeutic interaction, he argued, is most effectively analyzed as a clash of perspectives. "The professional expects patients to accept what he recommends on his terms; patients seek services in their own terms. In that each seeks to gain his own terms, there is conflict" (Freidson, 1961, p.171). The patient, in this formulation, is assumed to be governed by an interpersonal order equal in complexity to that of the professional. The asymmetry of Parsons's model underscoring the physician's technical expertise is discarded. The patient responds largely on the basis of current experience and sources of influence, not as a result of deeply embedded beliefs and expectation derived from long-term cultural socialization. Between doctor and patient, negotiation, not persuasion, occurs. The critical factor is structure, not function—the structural social positions based on the separate statuses and interests of the client and the professional. The deviance of the sick role, within this framework, becomes more central and more complex than in Parsons. A distinctive influence is assigned to stigma. For example, mental illness and sexually transmitted diseases, Freidson argues, are perceived by society on a variable scale of deviance and stigmatized accordingly; they are not lumped together as diseases that are beyond the control of the patient.
Freidson's critique of Parsons was very specific. First, the Parsons model sees the doctor–patient relationship from too limited a perspective, most essentially that of the physician; it does not pay attention to the varying expectations of all members of the "role-set," including the patients (or, more inclusively, their lay associates as well) and the nurses and other persons involved in the process of treatment. Second, expectations are presented by Parsons as though they are the primary influence on actual behavior; they are only an ideal standard against which actual behavior is judged. Third, influence does not inhere in the expectation but in the position of the person holding it; only from the structure of the situation and the limits imposed by it can one weigh the possibility of an expectation's being met. Fourth and most important, the functional model ignores the necessity of conflict in human relationships. Insofar as each person, the professional and the patient, seeks to gain his or her own terms from the other, there is conflict.
This approach spawned a succession of studies about the therapeutic situation. The major examples are listed in Table 2. Through these studies, the view of the patient was transformed. Fully equal to the physician, the patient might behave passively, influenced either by personality or by the structure of the situation. Nevertheless, the patient role was no longer inherently subordinate by virtue of the physician's technical expertise or of the patient's lack of adequate knowledge.
Neo-Marxism, Bureaucracy, and the Politics of Health
The high point of structural conflict theory occurred with the 1970 publication by Freidson of the second of his two books about the medical profession. Marxist critiques followed by Howard Waitzkin and Barbara Waterman in 1974 and by Vicente Navarro in 1975.
The new Marxism built its argument on the classic conception that social behavior is essentially organized according to principles of social stratification or social class, based on materialistic determinants, and inevitably dominated by one class, leading to monopolistic control of resources and markets by the dominant class and to the exploitation of subordinate groups for profit or gain of the more powerful class. Waitzkin illustrated what he called the "micropolitics" of the doctor–patient relationship, using the following types of cases: (1) a young worker with occupationally caused sterility; (2) neonatal death attributable to neglect caused by poverty and racial discrimination; (3) an elderly man burdened by costs of technically oriented medicine. Waitzkin analyzed more than 300 taped doctor–patient interviews in an effort to demonstrate that medicine, like other social institutions, functions as part of the "ideologic state apparatus," with the doctor as the agent of ideology and social control. The micropolitics of the doctor–patient relationship, he argued, revealed contradictions that no current political system resolves (Waitzkin).
The boundaries between this view and that of the earlier structuralists were not as sharp as the demarcations with functionalism. Nevertheless, there are important differences. In Freidson, for example, there is no hint of patient exploitation. Nor does the drive among doctors for "professional autonomy and dominance," as described by the structuralists, mean anything similar to the Marxist description of the physician as a self-interested manager of health resources. What neo-Marxists like Waitzkin added to forecast subsequent trends was the analysis of how both doctor and patient have become captives of monopolistic trends in the healthcare industries.
The focus of the 1980s was on the same monopolistic big business, but with a different interpretation. Paul Starr (1982), for example, argued that rational behavior leads to large-scale privatization and the absorption of healthcare into the marketplace. He described the corporatization of the healthcare system of the United States in five dimensions:
- Change in the type of ownership and control, shifting from nonprofit and governmental service organizations, especially hospitals, to for-profit healthcare companies.
- Horizontal integration, the decline of freestanding institutions and the consequent shift in the locus of control from community boards to regional and national healthcare corporations.
- Diversification and corporate restructuring, the shift from single-unit organizations operating in one market to conglomerates involved in a variety of healthcare markets.
- Vertical integration, the shift from a single level of care organizations, like acute-care hospitals, to organizations that embrace the various phases and levels of care, such as health maintenance organizations (HMOs).
- Industry concentration, the increasing concentration of control of health services in regional markets and the nation as a whole.
The implications of these trends, it was argued, are to depersonalize the therapeutic relationship and to change the nature of the social roles. The doctor, increasingly a salaried
|Models of the Doctor–Patient Relationship, Their Illustrative Cases, and Effects on the Field: Structuralism (Conflict Theory, Labeling), 1960–1975|
|Models||Illustrative Examples||Effects on the Field|
|SOURCE: Adapted from Bloom and Speedling, 1989, pp. 122–123|
|Erwin Goffman 1961||Hospitalized mental patients||General theory of structured deviance; labeling; social stigma. Concepts: total institution, moral career of patients|
|Eliot Freidson 1961, 1970b||Health-care institutions; HMOs; the medical profession||General theory of conflict behavior determined by situational factors; clash of perspectives mediated by negotiation; professional autonomy and monopoly; patient networks|
|David Mechanic 1962||Illness behavior in various contexts||A multivariate theory: synthesized social psychological with situational variables; designed to operationalize for research; problem-oriented. Based on Volkart and W.I. Thomas. Health behavior as coping|
|Julius A. Roth 1963||Hospitalized tuberculosis patients||General theory: management of illness by normative timetables; institutional organization of illness response|
|Thomas Szasz 1964||Disabled patients, mental and physical||Critique of functionalism; contribution to deviance and labeling theory|
|Thomas Scheff 1966||Hospitalized mental patients||General theory of social deviance; labeling|
employee instead of an individual entrepreneur, is losing autonomy and, in effect, is becoming proletarianized. The patient, as a result of pressures to join large healthcare organizations, cannot freely choose a doctor or join with the doctor in certain decisions because cost control by the organization intervenes.
Such interpretations were buttressed by the increase in large-scale organizations for the delivery of healthcare, but the interest of scholars in psychosocial factors in therapeutic encounters continued to be strong. Compliance, the extent to which patients follow the recommendations of their therapists, for example, remained an important problem independent of the organizational framework for healthcare. Marshall Becker and Lois Maimon (1982) described a "health belief model" that made individual motivations and beliefs about the validity of treatment methods the central factors of health behavior. Attempts to quantify the sociobehavioral determinants of compliance preoccupied many researchers during the next two decades. The physician, at the same time, has been scrutinized in comparable empirical and quantitative detail as a "decision-maker" (Elstein et al.).
This quantitative trend is reflected in the training and assessment of medical students and residents. With the increasing orientation toward the use of measurements of clinical reasoning and behavior, didactic teaching and memorization are being replaced by problem-based learning and experiential learning situations such as simulations of clinical cases, called standardized patient (SP) methods (Woodward and Gerard). The goal of these efforts to change how physicians are trained is to create a more patient-oriented approach and, at the same time, influence doctors to become active, lifelong learners in order to maintain effectiveness under conditions of rapidly advancing basic medical sciences (Marston and Jones).
The Nonmedical Healing Professions
The history of the healing professions has been dominated by medicine. Although nurses, public-health workers, dentists, and social workers have been major contributors to the health of individuals and communities, their professional status and power have always been less than those of physicians. However, dramatic changes have expanded the need for the care of health and disease, challenging the monopoly of doctors. Constantly advancing technology applied to diagnosis and treatment, the increase in life expectancy and consequent growth of the elderly population, and changed patterns of illness and disability have forced physicians to depend on partnerships with members of other healing professions.
Nursing is the outstanding case in point. Nurses, although much more numerous than physicians (four nurses for every doctor), increasingly professionalized (over 100,000 have master's or doctorate degrees), and performing tasks in health settings previously restricted to physicians, continue to struggle for release from the view, argued by Freidson, that, following precedents established by Florence Nightingale more than a century ago, "All nursing work flowed from the doctor's orders … [so that] nursing became a formal part of the doctor's work, a technical trade.… Nursing thus was defined as a subordinate part of the technical division of labor surrounding medicine" (Freidson, 1970b, p. 61). There is some evidence that success in this struggle is at last being achieved.
Advanced-practice nurses, for example, are registered nurses with specialty training, usually at the master's degree level, in primary care (i.e., nurse practitioners and nurse-midwives) or acute care of in-patients (i.e., clinical nurse specialists). Mary Mundinger writes:
The practice of nurse practitioners has been evaluated since 1965 when the role was developed by Henry Silver, M.D., and Loretta Ford, R.N. When measures of diagnostic certainty, management competence, or comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by nurse practitioners is equivalent or superior to that provided by physicians.… Over the past few years, state legislatures have broadened the authority of nurse practitioners to receive direct payment and write prescriptions, and the barriers to independence have fallen. As a result, nurse practitioners can establish independent practices that parallel those of primary care physicians (either solo or health maintenance organizations), or they can establish collaborative practices in which doctors and nurses care for patients together. (Mundinger, p. 211)
Initiatives from private foundations and the government have encouraged the professionalization of nursing and the other healing occupations, rewarding the creation of both educational and healthcare reforms that foster the creation of teams working together as equals. Nevertheless, these other professions remain in the shadow of medicine. As a consequence, nurses, probably the highest-status members of the paramedicals, earn an average of less than a third of physicians' incomes; their training, except for the 5 percent who have earned higher degrees, is considerably shorter and less rigorous; and nursing is almost totally a women's profession, a fact that, regrettable though it is, remains a classic indicator of low occupational status.
However, as indicated by the testimony of Mary Mundinger above, the status of nursing as a profession has changed. Increasingly, nurses are both trained in and responsible for the complex knowledge and technical aspects of patient care. In 1960, 83 percent of new graduates were trained in hospitals, the rest in colleges and universities. By 1980, those figures had reversed.
We are witnessing, therefore, a historical development in nursing reminiscent of the changes that occurred in medicine in the 1910s. Like medicine in the post-Flexner era (1910 and following), nursing is seeking to increase its professionalism by extending its training in close association with the university. Included is new emphasis on biomedical science and research.
The value implications of these changes are of particular concern. Professionalism for nurses tends to emphasize intellectual and technical skills in an occupation whose major function has been as much the ministering of nurturant and humane care as technical prowess.
For the patient, the options seem to narrow as knowledge and technical skill increase. Whereas once it seemed reasonable to expect physicians to combine technical expertise with emotional sensitivity and skill, and nurses to complement them in both, now the patient gains equality and independence but with increasing emotional distance from caregivers.
Under the current conditions of healthcare, social workers would seem to have a strategic role. They are, after all, uniquely trained in the skills of interpersonal relations, and professionally are intended to function as the patient's advocate for well-being, both within the period of illness and in preparation for the recovery period. Yet, here, too, the pressures for professional status take an ironic toll. A trend toward private practice with fee-for-service financial rewards attracts social workers toward professional status on the medical model and away from the team model in which their function is to balance the technical with the social.
The same value dilemma confronts all the healing professions. A polarization has developed between two orientations, one centered on the what of healthcare and the other on the how. The former has been called a reductionistic approach, emphasizing biomedical knowledge and technology; the latter is the "social ecology" or "humanistic" approach.
The values of these two approaches are significantly different. The more traditional, reductionistic approach is dominated by faith that all problems of health and illness have rational solutions, and by a dedication to competence in practice and to a community of science that transcends personal interest. Patient, societal, and ethical issues are seen as matters of opinion not susceptible to rational discourse (Pellegrino; Fox, 1979).
The approach of social ecology, on the other hand, rests on a very different set of values. The social and behavioral sciences and even the humanities are here as pertinent as the biological sciences; students are selected on the basis of social concern and interest in people and their problems; emphasis is on caring as much as on curing. The community, not the university hospital, is the proper locus for the education of health professionals.
Although one can say that neither of these approaches has sought or gained exclusive dominance, their differences are important enough to generate partisan claims from each about the failures of the past, the needs of the future, and the implications for patients and society. Both the value of modern science and the critical need for enlightened social and ethical orientations can be found in the way national commissions are addressing the problems of today's healing professions (Marston and Jones).
Summary and Conclusions
The definition of the professions is the foundation of sociological analysis of the professional–patient relationship. Uniquely among modern occupations, a profession has been seen as an activity that requires extensive training based upon a continuously developing knowledge base coupled with the application of such knowledge for the general welfare of society. Therefore, although the rewards of professional life have been substantial, it is assumed that the professional is not free to exploit such skills and knowledge for personal gain alone, as other entrepreneurs may—the socalled principle of caveat emptor (let the buyer beware). On the contrary, the professional is granted unusual privileges involving access especially to the personal and biological privacy of patients, but only on an implicit contractual premise that such professional rights will conform to general rules of the welfare of society.
Medicine has been the primary subject of such analysis because it is seen as the archetype of professions. Virtually every person needs the help of healing occupations; the other classic professions, the law and the clergy, are not so ubiquitous. Therefore, a large sociological literature grew out of the study of medicine as a profession. However, the practice of medicine has changed radically in modern times and continues to change. Research in the biomedical sciences is usually considered the major driving force of this transformation, but changes in the social organization of the delivery of health services, the application side of the medical profession, have been no less dramatic.
In the wake of both the bioetchnological and application developments, new ethical issues have appeared and earlier ones have deepened. Bioethics as a separate discipline has grown significantly, very likely as a direct consequence of these changes. Sociology, meanwhile, has spawned its own forms of interest in medical ethics. In part, sociologists have followed the tradition of individualism, which interprets behavior as a social psychological process determined by the values individuals learn and carry with them into social encounters. A different perspective emphasizes the material technologies and organizational constraints that dominate the therapeutic relationship. For example, the bureaucratization of medicine has advanced, creating a situation in which both doctor and patient meet less as individuals than as members of groups. The resulting formalization has altered the emotional quality of the exchange and the nature of responsibility and accountability for those involved therein.
Conventional wisdom has suggested that the ethical problems of current therapeutic relationships are driven mainly by technical imperatives. Sociologists, in the main, however, have argued that bioethics is determined by the value context in which medical technology must be managed, not by the intrinsic qualities of the technology. The dilemmas—the extension of life at the sacrifice of quality of life, the increased efficiency of neonatology at the cost of disability—are seen as only part of the current medicoethical challenge. Equally important is the unequal access to the benefits of technological advancement for populations that are disadvantaged by poverty, by race, or by other sources of discrimination.
Pressures are increasing for comprehensive entitlement to medical care but, as in the past, the chances for such change remain in doubt. As analysts have noted, the proportion of national income that will be invested in healthcare is both a value judgment and a product of the political process. As a result, David Mechanic writes:
When faced with competing claims on national resources, government finds it easier to restrain growth in programs affecting the poor and disabled, who constitute relatively weak constituencies, than to reduce subsidies shared by large, articulate, and sophisticated segments of the larger American public.…The imminent risk we face is not a deterioration in medical care overall, but more a continuing erosion of access and appropriate care for our most unfortunate populations.… Between 1976 and 1984 the proportion of poor and near poor covered by the Medicaid program decreased from 65 to 52 percent. (Mechanic, 1985, p. 454)
In the pluralistic society that America epitomizes, attitudes have become polarized. At one extreme are those who view the system as basically sound and strongly support the conventional structure of medicine. At the other extreme are those "who view the delivery system as so flawed in its structure and priorities and so dominated by special interests that only major reorganization offers any promise of an equitable and effective delivery system in the future" (Mechanic, 1985, p. 190).
The struggle between these polar opposites will be strongly affected by the values that are basic to American thinking and that inevitably must be reconciled in the policy decisions that will be made. The trend at this time appears to be toward universal health insurance. The methods reinforce organizational development that fosters large corporate structures. Those who cling to the right to choose one's personal doctor, and believe that no healthcare system can function effectively otherwise, feel they have been put on the defensive against pressures for cost-effectiveness, even rationing, but nevertheless persevere in a time-honored American belief in individualism.
The contributions of sociologists, if they follow the patterns of the period since the 1940s, will continue to focus on the microrelations of medicine, especially the doctor–patient relationship (Stacey). They will also explore the ethics of human research, and issues of public policy such as equality of access to care and the role of the professions in determining the availability of medical and healthcare services (Sorenson and Swazey).
Renée Fox lists the primary values of American society as follows: individualism, contractual relations, veracity, the fair allocation of scarce resources, and the principle of benevolence. Individualism, for Fox, is "the primary value-complex on which the intellectual and moral edifice of bioethics rests" (Fox and Swazey, p. 352). It starts with a belief in the importance, uniqueness, dignity, and sovereignty of the individual. From this flows the assumption that every person has certain individual rights. Autonomy, self-determination, and privacy are fundamental. In addition, individuals are entitled to the opportunity to find, develop, and realize themselves and their self-interests. They are entitled to be and do as they see fit, so long as they do not violate the comparable rights of others.
Can these values be reconciled with the changes in modern American society, especially those that foster large organizational structures? Sociologists will certainly devote themselves to such questions, and include the fate of microrelations such as the professional–patient relationship.
samuel w. bloom (1995)
SEE ALSO: Autonomy; Beneficence; Care; Competence; Conscience, Rights of; Healing; Managed Care; Medical Codes and Oaths; Medicine, Anthropology of; Medicine, Profession of; Medicine, Sociology of; Nursing as a Profession; Patients' Rights;Profession and Professional Ethics; and other Professional-Patient Relationship subentries
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