S207 16 January 2007 Week 3 Parsons – The Sick Role Reconsidered  critiques of Parsons  chronic illness: implications for

the sick role?  stigma – Parsons was saying sick role places people in temporary position where they’re not stigmatized. whereas people w/ chronic illness may not be able to escape the stigma  liminality – state of being liminal. betwixt and between – state of never being in one category or another, always being something in the middle. scholars working on liminality think about the consequences it has for identity, social roles, social institutions. social institutions to deal with people in liminal situations. chronic illness = a liminal status that the sick role doesn’t handle very well.  Parsons talked about patients taking more responsibility for taking care of themselves.. he was trying to respond to critique that he was saying patients were passive. how good a job did he do in terms of resolving those critiques?  cybernetic  don’t know if he fundamentally changed his concept of the sick role. [organizational theory / organizations coordinating their actions] he talks a little bit about patients taking a more active role, but his fundamental assertion is that the relationship between doctor and patient is asymmetrical, and has to be in order for the sick role to function.  Parsons was all about a function of sick role being isolating patients, preventing them from banding together to form a disability subculture. how has this been borne out?  support groups  is it possible that patients coming together is in some way functional, and can be folded into the sick role?  recall: two exemptions, two obligations of sick role  the worried well syndrome  one could argue that one of the conditions of our contemporary era is that someone is always potentially at risk for something, or at risk for a risk… introducing a liminal aspect to our contemporary existence  dominant American values of activism, instrumentalism.. notion that one can will themselves to health  Freidson critiques the notion of being exempt from a disease. there are categorical schemes where people are held responsible for their disease. see: tables comparing illness to seriousness  structural functionalism has fallen out of favor. ASA survey 1960 - majority of sociologists characterized themselves as functionalists. this is no longer the case today. structural functionalism seen as not having strength as explanatory account of how the world works  there was a period in 1980s when people were trying to resurrect and revise functionalism (neofunctionalists), but that was a fairly short-lived moment in sociological history  by virtue of the fall of functionalism, the sick role has also fallen out of favor. but there are some elements of the sick role that feel quite familiar to us. presumption of asymmetry between doctor and patient. patient feeling disempowered vis-à-vis doctor. issue of

dominance and automatic authority that a physician / that that position/role carries with it. Freidson et al talk about professional dominance and professional control. so those concerns are still very much relevant today. idea of being sick, idea of being healthy. what has changed is the notion now that things just aren’t that clear. the way Parsons thought of sick role being this temporary and contingent status. this idea that maybe people are always potentially ill. a lot of questioning the notion of being healthy as a status, or being sick as a status. Parsons never fundamentally questioned what the entity of disease or illness meant. that was Freidson’s project. by not problematizing what it meant to be sick, that also undermines the relevance of the sick role. in those senses, the sick role has lost its explanatory power. Freidson born in 1923. died in 2005. served in WWII. graduated from UChicago. graduated in 1952. part of the same era of graduates as many other people in sociology (H. Becker, F. Davis, E. Goffman, A. Strauss, Gusfield – sociology of social problems). these Chicago graduates all trained in social constructionist tradition. what we need to pay attention to is the reality we collectively construct together. it’s through the process of interpretation, assigning and imputing meaning to phenomenon. it’s through that process that we build society and social institutions. notion that society is an achieved order. social order is a produced order, a product of human activity, it’s not something that exists outside our everyday lives. he was in dialogue w/ Parsons. in opposition to Parsons. Parsons had universalistic notion that everything was a universal phenomenon, there was universalistic rules. in contrast, Freidson said we have to be careful and historically specific. when, where, for whom. to whom do theories apply. it’s all very historically specific. that idea emerges out of broader social constructionist or symbolic interactionist notion. even an institution or organization or meaning that we construct together, it doesn’t exist forever – it must be constantly maintained. also in contradiction to Parsons, Freidson tends to see much more conflict and dynamics of power, particularly in the professions (e.g., medicine). processes of domination underway. he invokes a lot of the sense of what social theorists call hegemony – notion that the way in which people are dominated is not just through coercion or the threat of coercion, but also through a process of consent. power is much more efficient and much more self-generating when you can get people to accept it as legitimate and authoritative. give a degree of consent to the way things work. legitimacy is a status to be achieved. that’s the prevailing concern of Freidson in the domain of professions, medicine, deviance. sociology in medicine vs. sociology of medicine. he’s insistent that sociology needs to be done from a stance outside medicine. anything about medicine’s claims or positions cannot be taken for granted; everything is up for question. his prevailing project was to analyze what is the fundamental nature of the professional claim? when you say something is a profession, or under professional jurisdiction.. what that does is what we need to analyze as sociologists. what is the fundamental kernel of the professional claim?  autonomy / control over both knowledge and work. and being seen by society as having a right to have control over its work (legitimacy).  notion that professions have the right to have control for themselves.  imputed expertise.

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common knowledge and high knowledge. esoteric, not common, for the elite. not something you’d acquire just by virtue of going through the world in everyday life.  idea that scientists are both producers and consumers of knowledge.  physicians are structurally the link between the esoteric knowledge and our everyday experience.  creating the knowledge and shaping the way we look at the world, the way we interpret our experience. so it’s not just that we’re going through having our experience of illness – physicians are creating that experience for us, creating the interpretive lens through which we see our bodies and experiences.  they create types of illness, they medicalize our existence. recap: foundations to the professional claim  having autonomy, right to control own work  power to label conditions as illness or deviance  also control the work of other people  division of labor – authority of doctors to coordinate activities.  imputed expertise. “imputed” = very central to his argument. it’s not just expertise. you can’t take it at face value or for granted. the only thing that makes someone an expert is all of us saying that person is an expert. imputing meaning to that body of knowledge. without that, it wouldn’t be a profession, it wouldn’t have any means to control our autonomy or prestige.  Jonathan: professions as elaborate edifice  profession not self-perpetuating; active process of maintenance and improving the prestige of the profession. power is something to be cultivated. fighting off challengers.  Krista: he seems to only be talking about clergy, law, medicine.  Janet: need to be sociologist of medicine, not sociologist in medicine. going from general sociological theory, using medicine as a case study. one always needs to go back up to general sociological theory. Freidson’s lifelong project = to build a theory of professions. he and others think medicine is a case that is unique in that it has very few other professions achieving a great measure of social esteem – it’s the profession par excellance, the epitome of what a profession can be. but it’s such a unique case, can it apply more broadly? the status of medicine and the cultural power it harnesses is something other professions will always try to achieve.  John: ideological component he talks about the social consequences for patients  part of Parsons’ legacy is that what he did not take for granted in analyzing the institution of medicine was its relationship to society. what function does this medical institution play in society?  Freidson takes it one step further. not only that, but in order to understand the function of an institution or practice in society, you have to problematize the very content of what it does. if medicine is about diagnosing illness, then the analytic exercise that needs to happen is: how is that thing labeled as illness? he’s taking things one step further than Parsons. Parsons just took at face value what medicine said was disease. Freidson: it’s that process that gives medicine such enormous social power. crux of profession, power to name a disease. (Prof of Med p. 244) very act of naming. fact you can name illness imputes social meaning to it. naming illness = foundation of medicine’s power. 

Parsons spends a lot of time talking about affective neutrality, etc. that is what in part gives them their special status. Freidson says no, nothing inherent about practice of medicine makes it special in particular. it’s the entire social process that surrounds it that elevates it to that status.  it’s not b/c of the technical nature of phenomenon, it’s the social apparatus that generates that phenomenon. it’s never the nature of the thing in and of itself. that nature can’t explain its status or its role or its meaning to us. it’s what happens around it. discussion question – nature of illness, compared w/ Parsons. sick role. (What is Friedson’s position on the social nature of illness? How does it compare to Parsons’ theory of the sick role?)  Parsons: our orientations toward those values is what builds social institutions. Freidson is saying it’s kind of the opposite. through medicine’s activities and how it assigns the status of deviance to an illness or condition, that becomes a vehicle for society’s values.  it’s a very different flavor of what those values mean. for Parsons, these values are very voluntaristic, very harmonious. Freidson sees it as part values and part ideology. the way in which medicine actually mobilizes or rides the coattails of what society sees as being valuable or important, or responsibility or not our responsibility, actually serves an ideological function.  this notion of professional status or something deemed professional or the achievement of professionalism becomes a veil for ideological interests, the exercise of power and domination.  a lot of this work was very critical to the notion of medicalization. he’s essentially talking about that very process. what was once socially deviant becomes a pathology. Berger and Luckmann’s social construction of reality (1966)  combined notion of social constructionism (notion from phenomenology, about nature of everyday life / an attitude about everyday life) with treatise of ______  sociology of knowledge must analyze processes by which reality is constructed  raise questions about reality, don’t take reality for granted, as well as ultimate status of knowledge  what is real? how is one to know?  whatever passes for knowledge is socially imputed by us  what counts as knowledge is not its internal validity, it’s the social process by which we impute it to be real  sociology of knowledge concerned with social construction of reality  in Freidson’s case, questions about what is real in context of medicine, what is called a disease or illness  “a cold” = a social label for something we decide deserves notice  what was considered a disease in 1900 vs. now probably differs greatly, even though the symptoms in 1900 vs. now probably overlap a lot. it’s what we decide to label a disease  what we’re calling illness, and what we’re calling deviance, and what gets mobilized by virtue of something being labeled illness.. all that needs to be understood in context of the process by which that illness is labeled Freidson also talks about a couple classifications of deviance. this is a theoretically important move he makes.  his point of departure was the sick role: where it worked, where it didn’t work. 

p. 241 – he offers an example of the movement between the different cells very elegant categorization of different kinds of deviance what is he saying are the implications of this? it’s a demonstration of the power of social attribution, of our interpretation of these things, to where people are, to the severity of the kinds of social consequences people are going to have.  we as a society have decided there are minor deviations, and they should be differentiated from major deviations, and the consequences should differ. responsibility for a condition also matters/differs. legitimacy is purely a product of what we decide to be legitimate or not. whether people are conditionally legitimate, or _________ .. this is an illustration of the power of social imputation, and what Freidson says becomes the core of medical authority, b/c it is medical authority which in part defines where people are  Freidson makes the point that, while what’s inside the cells may change, the axes for the most part will stay the same. minor vs. major makes a difference. what gets categorized within those classifications may change, but those classifications will persist.  the imputation of responsibility is so socially central to how we assign meaning to that form of deviance, that that becomes an abiding characteristic, an abiding way to classify different forms of deviance.  Elena: where is individual responsibility?  Janet: if you look at Table 2.. we can say that in fact, a lot of these things where the individual is held responsible. there are now increasing imputations of individual responsibility for some illnesses. what does this do to our notions of legitimacy or illegitimacy? that might be an appropriate critique of Freidson. our notions of causality have changed, _____ encompassing risk. professional powers. how Freidson analyzed the power of medical knowledge.  everyone says knowledge is power, but Freidson asks, exactly how is it power? knowledge is this entity, how does it then actually come to have power over people and people’s experiences?  what are some of the connections.. how does knowledge come to have power, in Freidson’s view?  Beth: elite knowledge is undemocratic, b/c not everyone can have it.  going back to notion of social constructionism – it’s not the essential nature of a thing that explains the social implications of the thing – it’s not just that it’s esoteric knowledge unavailable to everybody; it’s the intervention of human activity. knowledge is a human production and a human activity, it’s that human element that makes the difference , that knowledge comes to have power. knowledge only has social force in that it is created and possessed by humans. quite central to the way Freidson thought about things, and a way he distinguished his position from that of Parsons.  p. 9 of Professional Powers: formal knowledge has power b/c it has agents associated with it. knowledge must have human creators and consumers in order to have impact on social world. we cannot understand the role of formal knowledge without understanding the characteristics of those who create it.  Beth: just b/c the technocrat has knowledge, doesn’t mean they have power.  we need to avoid the trap of assuming knowledge itself is a system of domination.  he’s looking at the human creators, consumers, and mobilizers of formal knowledge.    

Paul Starr. what are some of Starr’s arguments re: how medicine came to assume such a position of prominence?  Jonathan: dependence  Beth: Starr and Freidson looking at different things. Starr looking at how medicine got power economically + rise to sovereignty + authority; Freidson looking at medicine as case study in sociology of knowledge, indicators of profession (autonomy).  Janet: their project inherently somewhat different. what did Parsons, Freidson, Starr all agree on?  medicine has dominant position in society.  medicine is a profession.  Freidson talks a little about how a profession gains a position of authority.  political process of profession-to-be showing elites how they can serve their beliefs or values or at least be harmless. they develop a relationship of patronage  Starr talking about how they’re not going to be dependent on this patronage relationship forever; they will develop strategic position and economic power in their own right.  Beth: notion of cultural authority  medicine as industry or set of industries. Starr says part of medicine’s sovereignty or inability to be touched by what’s going on is that it’s able to make and remake all these other associated industries kind of in its own image (insurance, hospitals).. it’s in some ways able to shape the world it has to survive in. what were some of their ideas about what the future of professional autonomy or professional sovereignty will be?  Jonathan: Starr, p. 16 – the growth of science reducing professional autonomy by making doctors dependent on organizations.  the administrative principle - taking a social objective and breaking it down into small tasks. that principle falls under bureaucratic organization. Freidson is saying that professional = different way of organizing. Starr saying salaried physicians working for administrators, where the content of their work is being controlled.. is a threat to the professional sovereignty of physicians. reviews are now due at 5 PM Mondays