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The Sick Role

By DCUnsworth May 06, 2014 8113 Words
Chris Shilling

Culture, the ‘sick role’ and the consumption of
health

ABSTRACT
This paper revisits Parsons’s conception of the ‘sick role’ and examines the relevance of his writings on the cultural understanding of sickness to the consumption of health in the contemporary era. In terms of current developments, I focus on the development of pro-active approaches towards the healthy body, and the growth of ‘information rich’ consumers of health care. These have become prominent themes in sociology, and while Parsons’s writings are usually viewed as anachronistic I argue they remain highly pertinent to understanding the emergence of informed, body conscious lay people. If Parsons’s analysis of health is more relevant to current circumstances than many critics assume, however, it is not unproblematic. The residual categories associated with the sick role obscure the continued utility of his work on the general cultural values informing health care. It is Parsons’s analysis of these values, I suggest, that needs rescuing from restricted understandings of the sick role and highlighting as an important resource for contemporar y theorists.

KEYWORDS:

Parsons; culture; ‘sick role’; consumption; body; information

INTRODUCTION

Talcott Parsons’s analyses of the deep cultural values underpinning western society and the rights and obligations institutionalized within the ‘sick role’ constitute interrelated and important contributions to sociology (Parsons 1951a, 1957, 1958, 1963, 1974, 1978a, 1991, 1991 [1951]; Parsons and Fox 1952). They are interrelated because his writings on cultural values provide a context for his model of the sick role, a context mostly neglected by his critics, and reveal the scope and limits of its applicability to empirical situations. They remain important to sociology because Parsons (1978a) suggested that these values, rooted in Christian traditions and concerned with maximizing instrumental ef ciency, would continue in the future to ‘steer’ the construction, deconstruction and reconstruction of speci c social roles related to health and illness. This raises the intriguing British Journal of Sociology Vol. No. 53 Issue No. 4 (December 2002) pp. 621–638 © 2002 London School of Economics and Political Science

ISSN 0007-1315 print/1468-4446 online
Published by Routledge Journals, Taylor & Francis Ltd on behalf of the LSE DOI: 10.1080/0007131022000021515

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possibility that while the patterned contents of the sick role may have become obsolete as a model of lay behaviour, the cultural values informing the creation of this role still shape this behaviour and can illuminate contemporary developments in the consumption of health.

This is the context in which this paper revisits Parsons’s work. It begins by examining the general cultural values he identi ed as steering lay behaviour, before assessing his model of the sick role against this background and evaluating it in relation to recent developments in the consumption of health. The developments that concern us here are the emergence, among limited sections of the population, of pro-active, ‘vigilant’ approaches towards the healthy body, and the growth of ‘information rich’ consumers of health. 1 These trends have become prominent themes in sociology and are now widely recognized as important health issues (e.g. Giddens 1991; Nettleton 1995; Shilling 1993; Turner 1995), but Parsons’s writings can be interpreted as anticipating them, as helping to explain their emergence, and as qualifying their relevance to lay behaviour.

It is worth elaborating on this last point in order to demonstrate that cultural values, the sick role, and these new developments in health, are integrally related issues that are properly dealt with in a paper on Parsons’s work. Firstly, while the sick role model may be analytically limited, Parsons (1991 [1951], 1978a) acknowledges that lay people sometimes adopt active approaches to their bodily care, and are motivated to acquire knowledge and information about their health. He also recognizes that this informed lay activity is frequently constrained by the asymmetrical character of the doctor/patient relationship. The issues of embodiment and medical information examined in this paper are not disconnected from Parsons’s writings, then, but are important matters raised by them. Secondly, Parsons insisted that he was an analytical realist whose work constituted a theoretical construct, not to be confused with reality, designed to facilitate the examination of a wide variety of modern developments (Parsons and Shils 1962: 204; Parsons 1964: 218). Parsons viewed his writing, in other words, as a resource that could be used to investigate emerging issues in health care. Finally, by identifying cultural instrumentalism as an enduring foundation for the institutionalization of health concerns within society, Parsons’s work may be interpreted as not just providing us with an idealtype analytical resource, but as anticipating and even predicting the increased signi cance of body conscious, informed consumers of health. These points suggest that the current tendency to disregard Parsons’s work is premature, but this paper does not assume that it can be applied wholesale to the analysis of contemporary developments. The tendency for certain people to maximize their capacity for health and well-being appears to have assumed forms that supercede the patterning of behaviour within the sick role. If Parsons’s analysis of the sick role cannot be accepted in its entirety, however, his writings on culture can illuminate why this role has been transcended and remain a highly suggestive resource for sociologists interested in health-based issues.

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THE CULTURAL ENVIRONMENT OF HEALTH AND ILLNESS

Writing with reference to American society, though in analyses which possessed a comparative element and are generally accepted as relevant to western modernity (Robertson and Turner 1991), Parsons (1937, 1978a) argued that the cultural patterns underpinning the social system structured normative conceptions of medical knowledge and practice. While the values of Greek democracy were relevant, it was Christianity (and the rationalistic thrust of the Protestant Ethic in particular) that provided the ideational foundations for modern modes of socialization and social institutions, including those concerned with health (Parsons 1978a). Christian ethics emphasized the rational pursuit of work and were centrally concerned with building the ‘kingdom of god on earth’ in return for the ‘gift of life’ bestowed on humans. Sedimented into modern ways of life, they obligated individuals to maximize their vocational potential and performance; to immerse themselves in a ‘worldly instrumental activism’ (Parsons 1978b; Parsons 1954).2

Parsons recognizes that formal religion has declined historically, yet suggests that the notion of the ‘gift of life’ lives on in society, informing medical practice. As he argues ‘the life of the individual patient and the physician’s obligation to protect or save the patient’s life have been taken as divinely given’; a givenness that has served to stimulate the technical capacities of medicine (Parsons 1978b: 284). The notion of repaying this ‘gift’, mediated through a normatively sanctioned instrumental action, also lives on and has important consequences for how illness is viewed. The social costs associated with bringing a life into the world, and caring for it through to adulthood, means that illness resulting in withdrawal from social roles constitutes a loss for society (Parsons 1991 [1951]: 430). This is why Parsons can argue that ‘the problem of health is intimately involved in the functional prerequisites of the social system’ (ibid.). Illness is ‘not merely an “external” danger to be “warded off” ’ by the organism, but is ‘integral’ to ‘social equillibrium itself ’ (Parsons 1991 [1951]: 431). Illness becomes ‘dysfunctional’ for the social system by preventing the ‘effective performance of social roles’ and undermining the cultural value placed on productive capacity (Parsons 1991 [1951]: 285–89, 430).

The cultural value placed on instrumental action is not just evident in the normative framework associated with illness, but underpins the scienti c basis of medical practice and its predisposition towards intervention. In terms of its scienti c basis, the cultural value placed on instrumentalism has historically made medicine as ‘rationally explicit’ and amenable to expert training as possible (Parsons 1991 [1951]: 469, 476). In terms of its interventionist tendencies, there is a ‘bias in favour of operating’: the surgeon is trained to operate and feels useful when operating (Parsons 1991 [1951]: 466). Given the cultural dominance of instrumental activism, moreover, ‘[a] decision to operate’ is usually welcomed as a sign that ‘ “something is being done” ’ (Parsons 1991 [1951]: 467).

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Parsons’s determination to view illness through the lens of culture explains why he accords such signi cance to functional capacity and ef ciency. This was not because of his productivist bias, or because he was an ‘apologist for capitalism’, but because of his assessment of the cultural value placed on instrumentalism. It was in this context that Parsons perceived health not primarily as a quality of the body, but as the ‘underlying capacity’ of individuals; a capacity that society sought to manage via ‘institutionalised roles’ incorporating ‘valued tasks’ (Parsons 1991 [1951], 1978a: 21, 1978c: 81). Parsons (1978c: 69), indeed, eventually de ned health as the ‘teleonomic capacity’ to maintain a self-regulated state that is ‘a prerequisite’ for individuals undertaking ‘successful goal-oriented courses of behaviour’ that improve the functional capacity of the social system. Illness, in contrast, constitutes a breakdown of such capacities, a ‘disturbance in the “normal” functioning of the total human individual’ (Parsons 1991 [1951]: 431).

THE SICK ROLE

In his general writings on health, Parsons (1978, 1991) suggested that cultural values concerning the maximization of functional capacity became sedimented in, yet would also outlast, speci c social roles. He also made it clear that the sick role was not a universal description of how illness became institutionalized around a set of obligations and rights, but belonged to an analysis of how ultimately religious values helped create a culture which associated illness with the capacity for instrumental action (Parsons 1958, 1978a). It was these values which guided the institutionalization of our attitudes towards sickness into a sick role concerned with adaptation and integration into the social system. The sick role itself is associated with three essential socio-structural features (Parsons 1978a). First, a state of illness is not regarded as the sick person’s fault, the individual is ‘exempted from responsibility’ for their condition, yet has a moral responsibility to regard being sick as undesirable, as something that should be overcome as soon as possible (Parsons 1991 [1951]: 437; 1978a: 21). Second, the ill individual is temporarily exempt from ‘ordinary daily obligations and expectations’; an exoneration that is not only a right but an obligation (Parsons 1978a: 21). As Parsons (1991 [1951]: 437) notes, it is not uncommon for people to resist admitting they are sick and for others to legitimize to them their condition by telling them they ought to be at home in bed. Third, the sick role incorporates the expectation ‘of seeking help’ from an appropriate, ‘technically competent’ health professional and co-operating with them in the process of recovering and returning to full social functioning (Parsons 1978a: 21; 1951: 437). This is the point, of course, when ‘the role of the sick person as patient becomes articulated with that of the physician in a complementar y role structure’ (Parsons 1991 [1951]: 437).

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Developed by Parsons during the 1950s, and revisited in his later writings, the concept of the sick role has fundamentally shaped the study of health and illness and exemplifes the in uence normative sociology exerted on the wider discipline. The cultural context in which these institutionalized norms associated with sickness developed, however, has been largely ignored by Parsons’s critics. Thus, the sick role has been portrayed as describing a universal set of rights and obligations, rather than being subject to social change, and has been attacked for its empirical inaccuracy, its normative undesirability, and its clinical ineffectiveness as a model of patient behaviour (e.g. Levine and Kosloff 1978; Twaddle and Hessler 1977; Turner 1995). With this assessment, Parsons’ work has been relegated to the position of a negative referent against which visions of caring are developed outside of a ‘disciplinar y’ framework of social norms (e.g. Frank 1991; Fox 1995).

Parsons is not without blame for this reception of his work: his speci c writings on the sick role rarely mention the cultural parameters underpinning its development that he discusses elsewhere (Parsons 1951; Parsons and Fox 1952). Thus, selective readings of Parsons’s work provide plenty of evidence for the opponents of ‘structural-functionalist’ analyses of health. In the absence of a careful consideration of the wider cultural values which Parsons viewed as an essential part of the context of the sick role, however, there is a case for reassessing the impact of these criticisms. This case is made even stronger because Parsons’s writings raise issues concerned with the body and with the acquisition of medical information that are important to contemporar y developments in the consumption of health. In terms of the body, Parsons (1991 [1951]: 541–2; 1969: 13) identi ed the physical organism as a ‘unit point of reference’ for sociology that ‘is never safely neglected’. He argues that people’s orientations to the body are of ‘expressive signi cance’ for the encounter between lay persons and physicians, and discusses how biomedical advances in genetic engineering, birth technology and transplant surger y are altering the limits of life (Parsons 1991 [1951]: 451; 1978b). Parsons suggests that such advances are likely to result in a variety of more active approaches to the body. Such changes, he writes, will challenge the ‘absolute ethics’ traditionally associated with biomedical views of the body, and help promote a ‘relativised ethic’ which takes into account different lay approaches to the body and a variety of evaluative principles associated with the altering bodily boundaries of human existence (Parsons 1978b: 289). In terms of medical information, Parsons sought to refute the claim that his sick role envisaged the patient as a ‘passive object of manipulation or “treatment” ’ (Parsons 1978a: 28). He notes that individuals must recognize when they are ill, take the morally and ultimately religiously informed action of seeking help from a competent professional in order to restore themselves to a state of functional ef ciency, and follow their advice in ‘trying to get well’ (Parsons 1991 [1951]: 437). More signi cantly, he acknowledges that individuals sometimes shop around for health care and

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that ‘lay people, as a consequence of their education and experience, have a certain amount of knowledge and understanding’ about illness (Parsons 1978a: 28; 1951: 438). He also investigates the challenges facing physicians as a result of lay behaviour that is steered by an increasing diversity of knowledge, information and culture (Parsons 1978b). These discussions have certain parallels with recent writings on active orientations to the body and medical information. They are not, however, unproblematic. As we now examine, while the sick role recognizes these developments in the consumption of health, it treats them as residual categories and cannot account for their full expression in the contemporary era. As the sick role is often taken to be synonymous with Parsons’ contribution to the subject of health, this limitation also obscures the extent to which his writings on the cultural values underpinning lay behaviour continue to illuminate these developments.

THE BODY IN SICKNESS . . . AND IN HEALTH

The idea that recent decades have witnessed major changes in how people relate to their bodies is a common sociological theme, and while Parsons anticipates this issue the body is actually excluded from the prime positive categories associated with the sick role. While the body is a ‘unit point of reference’ for Parsons, he argues that that the study of the human organism belongs to the natural sciences or psychology and becomes sociologically pertinent mainly when it malfunctions and threatens the instrumental capacities of individuals (Parsons 1991 [1951]: 541–2, 547–8). This marginalization of the body is re ected in Parsons’s treatment of medical practice. While acknowledging a growing concern with preventative health care Parsons (1991 [1951]: 429) views medicine as dealing with existing pathologies. Medicine may target the body, as an object, yet its primary aim is to restore functional ef ciency to the individual and maximize the instrumental capacities of society (e.g. Parsons 1991 [1951]: 452,457). Such a conception of the body as latent and subsidiary to instrumentalist concerns re ects a Cartesian tradition which de nes our mentally directed plans as that which makes us human. It also implies a related phenomenology which has been explicated in Leder’s analysis of illness. Leder (1990: 1,13–26) argues that individuals are typically engaged in purposeful action in which the body slips from our minds to become a ‘background canvas’ against which cognitively directed action proceeds. For Leder, like Parsons, the body emerges as a problem most acutely when illness and pain disrupt our actions.3 This ‘reappearance’ of the body makes us unusually aware of our physical being and prompts us to search for assistance in restoring our functional capacities.

The problem with this conception of the body as latent is that it prevents us from building into the prime categories of the sick role the development of non-pathological, active orientations to the body. These have been

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examined by theorists who associate the contemporar y era with a tendency for individuals to treat their bodies as projects in so far as they are regularly monitored, maintained and developed as an integral element of selfidentity (Shilling 1993; Nettleton and Watson 1998). Drawing on Tonnies’s Gemeinschaft/Gesellschaft distinction, for example, Giddens (1991: 7,98,102) suggests the body was ‘given’ in traditional societies, marked by communal signs of status, yet has been colonized by modernity and ‘drawn into the re exive organization of social life’ to the extent we are ‘responsible for the design of our bodies’. Turner (1984: 108–9) makes a related point in contrasting the pre-modern ‘housing’ of the person in a persona, a public mask incorporated into the honour of a heraldic sign, with the modern ‘presentational body’. Instead of being simply a precondition of our instrumental actions, the body now expresses our capacities as social actors. These conceptions of how increasing numbers of people are relating to their physical selves are based on the recognition (explicit in philosophical anthropology but also implicit in much classical sociology) that the body is un nished at birth and both requires, and is open to, investments of work and meaning (Shilling and Mellor 2001). They also suggest that awareness of the body’s malleability was stimulated by its prominence in consumer culture during the second half of the twentieth centur y (Featherstone 1982). This era was characterized by a proliferation of production oriented toward leisure, by the emergence of the ‘performing self ’ (Goffman 1969), and by the development of unprecedented scienti c means to alter the body (Featherstone and Burrows 1995). Such analyses imply that people are now no longer able to take their bodies for granted when they are healthy, but are faced with multiple models of body maintenance from which to choose. People confront the competing demands of a consumer culture that emphasizes the importance of self-image and pleasure, and a work culture which continues to prize the Puritan virtues of hard work alongside an increased concern with the presentation of self (Mellor and Shilling 1997). In this context, the need to develop a healthy, adaptable and instrumentally ef cient body has become an important variable in social success.

The idea that the body has assumed the status of a project for many may be excluded from Parsons’s conception of the sick role, but it resonates with his suggestion that worldly instrumental activism continues to in uence social life. This suggestion appears to be validated by developments in the eld of health. Crawford (1987), for example, has spoken of a ‘new health consciousness’ emerging during the 1980s. In the USA, the adoption of health and tness regimes have reached the point among sections of the professional middle classes where those rejecting the task of maximizing their performative potential are stigmatized (Crawford 1994). Similarly, Ehrenrich (1990: 236) examines how the middle class have ‘instrumentalized’ the body in order to acquire a form of cultural capital through exercise and an asceticism in the eld of diet. This lifestyle seeks control, power and moral renewal through the achievement and

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maintenance of a ‘hard body’. Ehrenreich’s suggestion is that middle-class opposition to smoking, heavy drinking and ‘junk food’ harnesses health to a work ethic loaded with Puritan morality which constitutes a form of distinction separating its bearers from the lower classes (Bourdieu 1984). Far from receding from people’s minds, as a background for normatively sanctioned instrumental action, individuals may be developing vigilant approaches towards their bodies concerned not just with illness, but with self-cultivation aimed at maximizing capacities for work and pleasure. It is important not to overestimate the extent of this development (it is paralleled by large numbers of people who continue to treat their bodies as vehicles of instant grati cation regardless of health considerations; Rojek 2000), but it remains an important social trend. As such, the instrumental values central to Parsons’s writings on culture are not irrelevant but appear to have intensi ed and have become internalized into the habitus of a new body conscious segment of the middle class.

THE INFORMED PATIENT?

Parsons (1978a: 28) objected to the claim that he analysed the patient as a passive object of medical practice, but his recognition of lay activity and knowledgeability is compromised heavily by his portrayal of the relationship between the technical expert in the eld of health and the lay person as asymmetrical (Parsons 1991 [1951]: 439; 1978a: 24–5). The sick patient is in a situation of ‘helplessness’ and ‘technical incompetence’, being ‘liable to a whole series of irr- and non-rational beliefs and practices’ (Parsons 1991 [1951]: 440–46). The lay person is not quali ed to evaluate the competence of or choose between physicians, and their knowledge about health is often highly limited (Parsons 1991 [1951]: 441). The active and knowledgeable lay person is acknowledged as a possibility in Parsons’s work, but is erased from the positive categories central to the sick role even though evidence has long suggested that this is an inaccurate view of patients. Stimson and Webb (1975), for example, found that individuals mediate their concerns through a biomedical conception of the body more likely to receive a positive response from the doctor (see also Mishler 1984), while Strong and Davis (1977) and Crawford (1987) demonstrate how people lter the advice of physicians through their own frames of reference. Another problem with Parsons’s passive conception of the lay person is that it cannot account for developments that are consequential for the cultural signi cance he himself attaches to normatively sanctioned instrumentalism and the capacity of the social system.

Parsons’s use of cybernetic theory (the science of systems) highlights the capacity of knowledge and information to steer social relationships: it was doctors’s command of these resources that consolidated their power over patients. In this context, those studies that suggest we have entered an ‘information society’ – that provides individuals with the potential to access

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an unprecedented amount of medical information – seem particularly relevant to his analysis. While there exists diversity between its proponents, the information society thesis generally suggests that individuals and social systems are faced with increasing quantities and velocities of information stemming from local, national and international sources (Webster 1995). One central medium through which the information society has grown is the internet, and this serves as a useful example through which to assess the relevance of Parsons’s writings for living in what Castells (1996) refers to as a ‘networked world’. Internet use has grown enormously. In 1993 there were 130 computer servers that underpinned the internet, yet by 1999 this gure had increased to an estimated 9.5 million servers. Ninetytwo million adults were linked to the internet in the USA in 1998, while in the UK 20 million people regularly used the internet by the end of 2000 (NUA 1998). Globally, it is generally accepted that health-related information is second only to pornography as a subject searched for on the net. Most western governments have encouraged the provision of healthrelated information on the internet on the basis of assumptions about ease of access, and a concern to increase the public’s involvement in health care decisions, while several factors have attracted people towards the internet as a means of avoiding the ‘helplessness’ Parsons associated with illness. These include previously unavailable access to information about health (Good 1994). Voluntary and commercial organizations have created online information resources, while complementary and alternative practitioners are increasingly using the internet to advise and advertise services (Parente 2000). Other resources include a profusion of life-style counsellors, new age treatments for stress, diet and the management of emotion, and a global market in plastic surgery and other operations which allow some individuals to circumvent their domestic health system. User groups have utilized the internet as a means of supporting others suffering from particular illnesses. Finally, the internet provides an anonymous space in which advice can be sought about stigmatizing health problems (Burrows et al. 2000). In short, the internet allows individuals to traverse boundaries between different knowledges, professions and practices, and constitutes a medium for what has been described as the new medical pluralism (Cant and Sharma 1999). Users can access a massive diversity of information and services which appears to promise for those who can afford it an unprecedented degree of choice in health care decisions. If individuals have been encouraged to access health-related information, they may also utilize this source of data as way of avoiding the limitations associated with what Parsons viewed as the ‘technical experts’ of health care. There has been a widely reported growth of public scepticism about health professionals in recent years (Annandale and Hunt 1998), linked to a broader, post-Enlightenment loss of con dence in the power of science and the capacity of experts to deliver to us control over our bodies (Beck 1992). More immediately, this scepticism is tied, at least in the UK, to a series of scandals involving doctors, consultants and medical

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institutions and concerning such issues as the resuscitation of the elderly, the illegitimate removal of organs, the lack of choice over the MMR vaccination, and even (in the case of Harold Shipman) murder. Internet information is not always, however, clinically credible in its potential to facilitate healthy lifestyles and effective treatments. Unregulated and global in extent, the internet represents a challenge to users who have to contextualize information within the backdrop of boundaries set by national health policies, professionals and practices, and make decisions about quality criteria. It also challenges the trend towards evidence based practice founded on the ‘gold standard’ of the Randomized Control Trials (RCTs). As Giddens (1991) suggests, the internet provides a mass of potentially useful, con icting, and confusing information from which people may hope to develop strategies to cope with health hazards and risks. We cannot be sure about how developments such as the internet will eventually shape medical practice, and should be cautious about the futuristic and optimistic claims made by certain proponents of the ‘networked society’. Nevertheless, the growth of health-related information is clearly consequential for two key assumptions built into Parsons’s sick role model. First, while exclusivity and the asymmetrical nature of the doctor/patient relationship are central to Parsons’s analysis, the information lay people can access on the internet may challenge these parameters ( Jadad 1999; Hardey 1999, 2001). It increases the potential people have for ‘shopping around’ for health care, and for second opinions unmediated by their physician. It also means that doctors may be used as secondar y, rather than primary, sources of health advice. Individuals may consult them not as a consequence of assuming obligations contained in the sick role, but as a means of assisting their own health-related concerns. Positioning the doctor as an advisor in this way, however, revises the universal elements underpinning the doctor/patient relationship. It may also be one reason behind increasing doctor complaints about consultations involving ‘trivial’ issues (Lupton 1997).

Second, the internet provides individuals with numerous avenues through which information about a condition can be gathered, and with unprecedented opportunities for checking diagnoses and prescribed treatments. Users of the internet may increase their capacity to challenge the opinion of conventional health professionals, and seek help from nonorthodox practitioners (Eysenbach and Diepgen 1999; Jadad 1999; Kiley 1998; Turner 1995: 47). It has been suggested that challenges to medicine from pressure groups and self-help organizations have become more global in their scope as a result of using the internet to post and exchange information (Kelleher 1994). Furthermore, the frequency with which personal home pages contain narratives of recovery from illness and even advertisements for health products offers the possibility of eroding the lines of authority delineating the professional/lay relationship, of blurring the distinction between producers and consumers of health, and of encouraging new consumerist orientations towards health (Hardey 2001). Again,

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this has the potential of altering the balance of power and technical expertise in the doctor/patient relationship (Eysenbach and Diepgen 1999). It is important, however, not to present these possibilities as concrete events. While the internet may eventually help to democratize medicine, recent studies do not yet suggest that greater patient access to knowledge has led to such outcomes. Traditional authorities continue to exert substantial and often decisive control over the organization and delivery of medical services, while studies on such groups as patients with RSI and parents of children with cancer show that lay knowledge is often disregarded by doctors (Arksey 1999). This can result in a general distrust of medicine rather than a willingness to acquire information and engage actively with medical authorities. The potential of the internet has also to be quali ed because not even the most body conscious individual is going to be citing to the doctor internet-based information at ever y consultation. Routine consultations are likely to be governed by routine exchanges. These quali cations raise the issue of lay relationships with health professionals.

RELATIONSHIPS WITH HEALTH PROFESSIONALS

We have seen that the development of pro-active orientations to the healthy body, and the ability of increasing numbers of lay people to access healthrelated information, assume the status of residual categories in Parsons’s conception of the sick role even if they support his suggestion that cultural instrumentalism would exert an enduring impact on lay behaviour. This marginality not only has implications for Parsons’s capacity to analyse the institutionalized actions of lay people through the notion of the sick role, but for his concern with the doctor/patient relationship.

Parsons (1951: 438) conceptualized doctor/patient interaction as structured by the values contained within the ‘pattern variables’. These involve universalism/particularism, achievement/ascription, functional speci city/diffuseness, affective neutrality/affectivity, and collective orientation/self-orientation, and constitute the media by which the general cultural values of a society are translated into particular role requirements.4 The doctor/patient relationship was shaped in more than one way by these pattern variables, as a result of their signi cance for medical knowledge and practice (Parsons 1951: 454–65), and the following provides a summary of his model which allows us to highlight how it may have been challenged by recent developments.

The roles assumed by physician and patient are based on universalism with respect to the criteria through which they interact. This is meant to prevent unjusti ed sectarianism in the application of medical practice, to prevent favouritism or personal bias entering into doctors’s judgments, and to prevent the patient from seeking to ‘assimilate the physician to the nexus of personal relationships’ (Parsons 1991 [1951]: 456). Both roles display an

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achievement orientation. Professional training is a prerequisite for appointment to medicine, while being ill is a (negative) achievement of the individual. Functional speci city marks out the medical arena in which the physician has privileged and legitimate access to the patient’s body and history, but also places responsibility on doctors not to exploit this access. Affective neutrality de nes the ‘expected attitudes’ governing doctor/patient interaction. Finally, a collective orientation obligates doctors not to let the pro t motive interfere with their judgment, and the patient to co-operate with the doctor in the normative task of getting well (Parsons 1951: 463–4). Parsons’s analysis of doctor-patient relationships has been vigorously defended (e.g. Gerhardt 1987) as relevant even though such developments as the professionalization of nursing have changed the role and status of medical knowledge and practice over the past two decades (Haug 1988; Williams et al. 1993). Nevertheless, the residual categories related to his conception of the sick role, and associated with his view that medical practice involved intervention in order to rectify an existing pathological state, excludes from view an analytical consideration of interaction between health professionals and informed, body-conscious consumers of medicine. If there is emerging a new ideal type lay person that has embodied an intensi ed concern with the cultural value of instrumentalism, however, there is need for a different conception of the lay/health professional relationship. Attempts to reconceptualize the sick role have been made previously (e.g. Szasz and Hollender 1956; Hart 1985), but the developments examined in this paper suggest a quite speci c restructuring. This does not always involve a reversal of the pattern variables Parsons associated with doctor/patient interaction, but is associated minimally with a signi cant shift in their expression.

In contrast to universalism of criteria for judging a state of illness, the health-related goals pursued by informed, body-conscious individuals may be characterized by considerable variety and vary from traditional biomedical views of restoring the organism to functional equillibrium. Athletes, for example, may seek advice about supplements and drugs that can provide them with an edge in competition but may eventually damage their bodies (Monaghan 1999). In contrast to an achievement orientation based on professional training and certi cation, lay people may visit alternative practitioners whose expertise comes from experience and apprenticeship, and who justify their status on the basis of ascribed qualities. While governments often monitor complementary and alternative therapies, various activities which promote themselves on the basis of increasing well-being escape such regulation. Yoga and T’ai Chi Chuan, for example, are promoted as means to relaxation and well-being, yet escape the controls associated with orthodox medicine. In contrast to the authority bestowed on the physician’s delineated expertise as a result of functional speci city, informed, body-conscious individuals may seek a more diffuse, holistic approach to their health. Patients also appear to be demanding more frequently that practitioners justify their expertise in

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terms of methods, advice and results (Calnan and Gabe 1991). In contrast to affective neutrality, ‘new age’ treatments and ‘lifestyle counsellors’ offer a personal engagement with the emotions of individuals that may appeal to those seeking intimate routes to well-being. In contrast to the collective orientation, and the distance Parsons places between medical practice and the pro t motive, the proliferation of health-related practitioners is associated with commercialism and self-orientation. Health and tness clubs often market themselves as producers of health. Perhaps the biggest contrast with the traditionally conceived doctor/patient relationship concerns ‘shopping around’. Parsons argues that there is a huge contrast between seeking quali ed health care and buying a car, and that the routinized character of most consultations show that patients rarely consume medicine in the way they do other products. Nevertheless, in those situations where individuals are choosing a health product and practitioner in relation to speci c health goals, amidst increased options, ‘shopping around’ may become increasingly necessary.

If doctor/patient interactions become affected by these values, they also call for quali cations to be made to Parsons’ analysis of the ‘reintegrative’ motivational elements embedded within this relationship. All ‘good medical practice’, according to Parsons (1991 [1951]: 478) is concerned with ‘the general processes of “coping” successfully with the psychological consequences’ of experiencing ‘strain in social relationships’. Parsons is concerned here with the alienation of the ill person from social roles (Parsons and Fox 1952: 237), yet the informed, body-conscious consumer of health is perhaps more likely to be driven by egoistic motives that bring a different dynamic to interactions with health professionals. Instead of seeking ‘escape’ from social responsibility, individuals may be looking to maximize their functional capacity in a manner which transcends the parameters of the sick role but remains consistent with Parsons’s emphasis on ‘worldly instrumental activism’.

Such changes are analytically excluded from Parsons conception of doctor/patient relationships and his concern with medicine as intervention, yet are not isolated examples and resonate with broader shifts in health provision (Coward 1989). Ashton and Seymour (1988), for example, identify from the 1970s a new phase of public health in North America and Europe characterized by a shift from biomedical interventionist models of health towards a concern with environment, lifestyle and prevention, and by speculation concerning the demise of the doctor/patient relationship. The continued increase in complementary/alternative medicine in western economies provides consumers with greater choice, while the diversity and increasing status of many therapists presents a challenge to the medical monopoly enjoyed by orthodox professionals (Saks 1995; Select Committee on Science and Technology 2000). The commodi cation of therapies by the direct sale of over-the-counter preparations to consumers, furthermore, enables people to invest in ‘health’ outside of signi cant contact with health professionals. It is, however, once again

634

Chris Shilling

important to comment on the scope of these developments. The mantle of valid science in the sphere of medicine remains with traditional authorities. Some patient groups and lay activists have managed to exert an in uence on their relationships with health professionals, but they often come from backgrounds rich in cultural capital while others have experienced only frustration in seeking a more active and responsive relationship with health professionals (Epstein 1996; Arksey 1998).

CONCLUSION

This paper has made several connections between Parsons’s writings on cultural values, his conception of the sick role, and contemporary developments in the consumption of health. Parsons could not have known how developments such as the internet would become central to his concerns. Nevertheless, his view of ‘wordly instrumental activism’ anticipates the image of lay people searching for information and advice about their health, even if his model of the sick role treats such possibilities as residual categories (‘facts known to exist’ which are nevertheless excluded from the major positive categories of a theoretical system; Parsons 1937: 17). The existence of residual categories, as Parsons himself emphasizes, signi es theoretical weakness. Furthermore, as it is the sick role that has dominated Parsons’s reception by subsequent theorists of health, these omissions have obscured to contemporary analysts the continued relevance of his writings on cultural values.

This obfuscation suggests the need to re-emphasize the distinction Parsons himself makes between the enduring cultural values underpinning lay behaviour and the more transient institutionalization of these values into speci c social roles. By doing this, it becomes possible to argue that developments in the consumption of health represent an extension of those instrumentalist values identi ed by Parsons; values which steer lay behaviour beyond the restricted con nes of the sick role. In concluding, however, it is important to comment on the extent and current impact of this instrumentalism.

Even if people’s access to medical information grows in a manner suggested by the more optimistic commentators on the ‘information society’ (Turkle 1995), the effects of this access are unlikely to be socially neutral. Sociological literature has long shown how factors such as social class and gender shape people’s health beliefs, and new sources of healthrelated information are unlikely to render these in uences redundant. As Bourdieu (1984) and Bernstein (1996) argue, different patterns of socialization result in class-based orientations towards symbolic knowledge which affect the degree to which the social world is seen as open to individual intervention. Similarly, the notion ‘body project’ was developed in the context of a recognition that it was those with the nancial resources, time and cultural capital who were most able to treat their body as a phenomena

Culture, the ‘sick role’ and the consumption of health

635

to be re exively moulded in line with their changing sense of self (Shilling 1993). In this context, the traditional Parsonian approach towards the sick role may continue to retain some value for analysing the medical relationships of those who are unable to access, or who are alienated from the proliferation of health-related information.

Parsons was interested in his later work in how integrative social developments might lead to the promotion of a truly inclusive societal community (Alexander 1998). It is not impossible that body-conscious internet users may one day help contribute towards this outcome in the sphere of health, but this remains at present something of a distant possibility. As Fuller (2000: 28,45) notes, ‘knowledge does not empower to the same extent ever yone who possesses it, while the organisational power of the medical profession also means that many individuals experience themselves as being on the receiving end of ‘knowledge transfer’ from health professionals’. Thus, Giddens’s (1991) suggestion that the proliferation of health-related information can provide the means for health conscious individuals to contribute to a full-blown re-skilling of lay users in negotiations with practitioners seems utopian. In contrast, Parsons’s argument that the enduring values surrounding medical practice are concerned with maximizing functional capacity, yet can assume a variety of manifestations within different social roles, remains suggestive precisely because it allows us to be more circumspect about the outcomes of such developments. Irrespective of present constraints on lay behaviour, increasing numbers of people may need and want to operate with maximum functional ef ciency in an increasingly competitive economy, and in a consumer culture that provides them with unprecedented opportunities to develop their self identities. In this context, Parsons’s work continues to warrant serious scrutiny. (Date accepted: May 2002)

Chris Shilling
School of Social Historical and Literary Studies
University of Portsmouth

NOTES

1. This paper focuses on consumers
rather than on producers of health. While
Parsons rejected the term ‘consumer’ of
health because of its commercial connotations, he recognized that individuals sometimes behaved in ways approximating
to those of a consumer (Parsons 1991
[1951]). Consequently, it is not invalid to
talk about consumers of health in examining contemporar y trends in relation to Parsons’s writings.
2. Parsons’s analysis of the ‘secular’

impact of Christian values resonates with
the idea in historical sociology that
Protestantism unwittingly provided capitalism with an industrious labour force. 3. Leder also identi es changes associated with ageing and pregnancy as making us aware of our bodies, but focuses on

illness and pain as conditions in which the
body occupies our consciousness as a
problem. Implicit in Parsons’s writings is a
similar view, though one he quali ed when
recognizing that states such as pregnancy
could not be viewed in terms of illness even
though they involved the assumption of

636
rights and responsibilities analogous to
those within the sick role.
4. Commentators often confine discussion of Parsons’s analysis of pattern variables to the doctor’s role, but Parsons
also uses them to describe the values underlying patient behaviour and doctor/patient interaction (Gerhardt 1987).

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