Structural-Functional Analysis of Health and Medicine

In the 1930s, Harvard sociologist Talcott Parsons began working on the issue of the doctor-patient relationship and was developing the foundation of medical sociology when he introduced the idea of the sick role into the vocabulary of scholarship. Parsons, considered to be the founding father of sociological structural-functionalism, created a new field for social studies, which has ever more importance today in the face of rising medical costs and the challenges presented by the recent developments in biomedical technologies. This article will discuss Parsons's structural-functional approach to sickness and the sociology of medicine.

Keywords Bioethics; Clinical Sociology; Doctor-Patient Relationship; Equilibrium; Health Care; Human Relations Movement; Information Society; Parsons, Talcott; Pharmaceutical Industry; Sick Role; Structural-Functionalism

Sociology of Health & Medicine > Structural-Functional Analysis of Health & Medicine

Overview

In 1929 a young lecturer named Talcott Parsons (1902-1979) was recruited by philosopher Ralph Barton Perry to set up a sociology course curriculum for a social ethics class at Harvard alongside Perry and economics lecturer Carl Bigelow. Parsons, who as a college student wanted to become a physician like his brother, had discovered social science while still at college and then studied the field in London and Heidelberg, Germany, in the mid-1920s. In London, he was introduced to the ideas of functionalism by anthropologist Bronislaw Malinowski.

One of Parsons’s most prominent teachers at Heidelberg was physician and psychologist Karl Jaspers, who at the time had already was an established philosophy teacher and who would become one of the leading voices of existential philosophy with Martin Heidegger and Jean-Paul Sartre. With Jaspers's lectures, Parsons was familiarized with the works of the founding fathers of sociology: Georg Simmel, Emile Durkheim, and Max Weber. He later discovered the work of Italian Vilfredo Pareto, whose key concepts he would integrate into his earliest publications and would also apply in his work on medical issues.

In the late 1920s, the Harvard Department of Industrial Physiology (which was located at the Business School and incorporated disciplines such as hygiene and fatigue research) in cooperation with the Harvard Medical School was undertaking studies into improving student health and improving the efficiency of industrial workers. The leading voices of these efforts were physiologist Lawrence Henderson and Australian psychologist Elton Mayo. Under their aegis, the Human Relations Movement at Harvard was created and the famous Hawthorne Study was undertaken at the Western Electrical Works in Chicago. They introduced the novel idea that a worker's social life and physical and psychological well-being had an important effect on his efficiency on the job. The motto was "bringing the human back in," and this created an interest in social science studies at Harvard, which had no Department of Sociology of its own at the time. The Sociology Department was subsequently created in 1931 with the Russian Pitrim Sorokin as department head and Parsons as lecturer and liaison with other departments and Harvard professors, including Lawrence Henderson.

Talcott Parsons & Lawrence Henderson

In 1931, Henderson, whose curiosity in social questions and problems had been sparked by many conversations with the Harvard Business School Dean and friend Elton Mayo, was introduced by Morton Wheeler to the work of Pareto. One of Pareto's central conceptions, the idea of equilibrium, was a common concept for members of the Human Relations Movement, as well as for Parsons. Henderson knew the concept from physiological studies, for the idea was handed down in studying physiological regulation from the German philosopher-physiologist Rudolf Hermann Lotze to the French physiologist and science-theoretician Claude Bernard, while Mayo was familiarized with the idea of equilibrium through the works of French psychologist and Freud rival Pierre Janet. Parsons, on the other hand, knew the concept from an economics perspective, which he initially taught at Harvard, from the work of Taussig and Frank H. Knight, and from a sociological perspective from early sociologists like Franklin Giddings, John Boodin, Charles Cooley, and Edward Ross

While working on a manuscript that would become his landmark publication, "The Structure of Social Action," Parsons worked in parallel on a medical study of the patient-doctor relationship as early as the summer of 1933 (Stingl, 2008). Unaware of Henderson's increasing interest in social problems in medical questions, he approached Henderson in the same year with his idea of using Pareto's equilibrium model to explain the questions of a patient's respect for the doctor in relation to the doctor's self-respect and the question of negotiating a treatment price between doctor and patient, which differs from the business world significantly.

Bringing together his own thoughts on the matter with Parsons's ideas, Henderson would write his landmark essay "Physician and Patient as a Social System," which he first delivered as a speech in front of a group of Harvard medical students in 1934.

Using Structural-Functionalism

Parsons's own theorizing continued in this direction until he discovered the prerequisites of the use of structural-functional theory from anthropology for sociology, utilizing the work of Malinowski, Radcliffe-Brown, and Durkheim. Studying functional problems that society resolved by the creation of social roles—such as the role of the father, the role of the industrial worker, etc.—he postulated that the state of being sick has the structure of a social role. Finally publishing the ideas in 1951 in his seminal work, "The Social System," Parsons created the systematic study of the medical field by sociologists where predecessors such as Louis Wirth and his clinical sociology had failed.

Parsons's predecessors, Malinowski and Radcliffe-Brown, conflated the teachings of biology and psychology to create functionalist anthropology. To modern students this is often surprising, for psychology is often tentatively thought of as the situation of consulting a psycho-analyst or therapist. But psychology in the late nineteenth and early twentieth century was originally more part of physiology in the laboratory context. At the same time, the clinical approach and the experimental or laboratory approach were in conflict over which discipline should have dominance over defining normalcy and pathology for the human organism. The most influential scholars would come to the conclusion that neither should have dominance and that they equally deserve attention to secure medical progress. Lawrence Henderson is a good example of this situation. Coming from clinical training, he went on to pursue experimental work instead for decades before eventually combining both attitudes within the scope of his research and teachings in the 1930s.

The same is true for sociology as a discipline. While Louis Wirth and others tried to establish sociology as a method of intervention and a clinical discipline, Parsons installed the Harvard Laboratory of Social Relations in the 1940s. He also followed the distinction of Tönnies, which distinguishes sociology as pure, applied, and empirical.

Medical Sociology

When studying the effects of systems, structures, and functions in health and medicine, medical sociology is not the only facet one must consider. Specifically, anthropology has rediscovered the medical field as an area of research. Since alternative medicine has experienced a boom in Western countries (in particular with the success of acupuncture and homeopathy) different classifications of health and medicine have come under scrutiny, such as Chinese medicine. It can be found that the "sick role" has an entirely different make-up, which the work of Ted Kaptchuk and Arthur Kleinman show. Similarly, Chicago sociologist Donald Levine, who is also a practitioner trained in aikido, has addressed the question of the sick role in Western sociology and in aikido philosophy and pointed to the potentials of aikido for liberal arts education at American universities, including the promotion of physical and mental health.

Further Insights

The Changing Sick Role

Being sick, from a structural-functionalist perspective, is not simply a "matter of fact" for the patient. Being sick implies the existence and application of a set of social expectations that constitute an actual role in society. For example, the sick person is considered exempt from other (normal) roles in society, such work and family, but this exemption is specific and dependent on other social factors that come into play. The exemption is only valid, for example, if the bread-winning income of a family is not endangered by the sickness. There must be resources in place, such as paid sick time or health insurance, to cover for the loss of income. These factors are attached to the constitution of sickness as a social role.

It is also imperative that society is prevented from ascribing responsibility for the condition to the patient. In Western society, a sick person is expected to seek out expert help of doctors. Thus the doctor–patient system is an essential part of the sick role. In a culture that assumes that sickness is related to magic, other individuals may be thought to be source of the ailment or the patient’s own actions or behavior may be blamed for illness. The structure and function of the sick role would therefore be a totally different in a different culture.

Of course, the sick role has greatly changed today because of several factors.

First, there is the question of health insurance, which differs within the Western countries. Therefore, several structural aspects of health care systems themselves define different types of sick roles.

It must also be considered that the role of pharmaceutical industries has changed significantly. Basic medical research has become so costly that very often governments or universities can no longer finance necessary research without the help of pharmaceutical companies. But unlike the negotiation between doctor and patient that Parsons described, which could factor in variables such as a patient's financial situation, pharmaceutical industries are owned by stock-holders, run by managers, and are profit-oriented. The sick role now includes a dimension it did not for Parsons: patient as consumer. Liberalization has afforded doctors more choice in prescribing medication and has made patients aware that they must actively pursue knowledge and research treatment options. The sick role has therefore added to patient responsibilities the tasks of seeking help and finding information on their own.

In 1982, Harvard sociologist Paul Starr published a lengthy study on the historical transformations that the American medical system has gone through, emphasizing various bureaucratic and economic aspects that showed valid counterpoints to Parsons's analysis of the medical system as centered around the sick role.

But it should be taken into account that Parsons had considered many structural factors, including the economic situations of a patient and the doctors. He initially also tried to describe the situation of the patient-doctor relationship engaging the patient's family. But the size of the average family in recent decades has shrunk dramatically, while the life expectancy of patients has increased. Ailments are more age-related, therefore, rather than the result of disease, and elderly patients often lack a support system to provide concern, advice, or encouragement.

Viewpoints

Talcott Parsons was initially interested in the relation of the rise of economic individualism and laissez-faire capitalism on social institutions such as the medical system and the doctor. He pointed out that in Western civilization the doctor has taken over the role that magic played in earlier cultures.

In his view, the doctor has to be adept at being a craftsman and in creating confidence. For the family and the patient, Parsons argued, sickness implies a sense of impending danger. The most important thing is to create the feeling that something is being done to make the patient well. The doctor therefore has to carry out tasks on the patient for the effect of creating confidence. This pressure on the doctor from the social context, according to Parsons, sometimes forces the doctor to do unnecessary procedures — which lead to the same kind of situation that gives rise to magic. Interestingly enough, Parsons once used the same kind of mechanism to compare the rise of Marxism to magic.

Medical Ethics

But today, every action or withholding of action is viewed in the light of medical ethics or bioethics. The role of specialists who deal with ethical concerns in the medical system has risen in importance, for technology has allowed for an ever larger repertoire of possible interventions into patient health and ultimate end of life.

Only in his later years did Parsons begin to see the question of death on the horizon of sociology and of medical sociology. Now, doctors, philosophers, and law-makers continually struggle with such questions. The function of answering ethical questions has transformed hospital and government structures. Ethics committees can be found on both levels, and hardly any doctor can finish his training today without having visited a class in medical ethics. But the questions do not just involve whether a patient should be allowed to "die in peace" or whether or when abortion is ethically justified. Clinical experiments and whether a clinic or the hospital is a proper place for medical research continues to be debated.

While there is an ever stronger movement among researchers to open up on this question, US legislation has created even higher restrictions on experiments with human subjects.

What is Sickness?

Another issue is the question of what sickness itself is. Behavioral disorders such as ADHD or depression are no longer the problems of a small group of patients or considered easily treated by a few psycho-therapists. An increasing number of children, adolescents, and adults find themselves in clinical care and subject to drug treatment. The definition of health and sickness, normalcy and pathology has drastically changed, and with it the sick-role and the structures and functions of the medical system have changed. In essence the new guideline that biomedical progress has set is to perceive the human being as a bio-chemical system that needs to be optimized. Every human, therefore, is considered potentially or even clinically sick, even if he or she does not yet feel or display any symptoms. To be healthy is therefore the exception. Indeed, in some ways, the line between healthy and sick is becoming blurred since the physiological make-up of every human being can be improved by the use of drugs.

Terms & Concepts

Bioethics: After the realization of the extent of the human experiments conducted by the Nazis during the Second World War, a canon of research guidelines, called the Nuremberg Code, was implemented to prevent further atrocities of the kind. However, in the 1970s it became obvious that not all researchers had followed these principles, and in 1974 the National Research Act became a law that entailed a charter for the creation of a commission to rule on ethical matters regarding human subjects, institutionalizing bioethical concerns. With issues of prenatal diagnostics, human cloning, and the like, bioethics became one an important field of discussion in philosophy, politics, and sociology.

Clinical Sociology: In a general sense, clinical sociology is more of a method, having "the clinic" as a subject. The historical context came down from a long conflict between the clinic (as practice) and the laboratory (as the experimental method) in physiology, anatomy, psychology, and medicine. Adopting the clinical approach, it was hoped that sociology could actively effect social situations and resolve social problems.

Equilibrium: The concept of equilibrium in sociology has a long history, even though it became controversial in the 1960s. Critics of that time interpreted the idea of equilibrium as a static and conformist state of society. The concept, which was introduced into social and economic thought in the nineteenth century, has been made popular first by Vilfredo Pareto and then by Talcott Parsons. For these scholars, it was a dynamic concept that allowed for social conflict and change, while for later critics the idea of equilibrium displayed the inability of sociological theory to account for progress, conflict, and social change.

Human Relations Movement: The Human Relations Movement has its origin at the Harvard Business School and the research undertaken in the field of industrial physiology. The human relations movement focused on the role that social context played for workers' efficiency at work and that organizational research must always take the human factor into account.

Information Society: The concept describes a form of society where production, distribution, use, and conservation of knowledge/information is the main factor in all social aspects from the political to the economic and the cultural sectors.

Sick Role: In his 1940 lectures on medical sociology, Harvard sociologist Talcott Parsons (1902-1979) introduced the concept of the sick role (published in his book The Social System, 1951). Being sick, from this perspective, is for the patient not simply a matter of fact, but comes attached with a set of social expectations that constitute an actual role in society, exempting the "sick person" from other (normal) roles in society such as in his job or in his family, but also preventing responsibility for the condition being ascribed to the patient. On the other side, a sick person is expected to seek out expert help.

Structural Functionalism: Structural Functionalism argues that various elements in a social system evolve to perform certain tasks within the society by resolving a problem. For example, the economy as a sub-system of society emerged to resolve the problem of efficient allocation of resources. Systems can be analyzed in accordance with a presupposed form of order and the elements of the system are in a state of mutual interdependence. Systems tend toward establishing or re-instating equilibrium. In reductionist versions of structural functionalism, this equilibrium is a static state that does not allow for structural variations, social progress through civic engagement or social conflict to occur as an agent of structural change. Parsons's system-theory equilibrium is a dynamic property of systems that work as a regulative ideal that is never fully established, but works as a tendency that allows for social conflict, revolution and change, while there is a tendency towards cooperation and communication to resolve conflicts and reinstate a minimal order to proliferate cooperation and organization.

Bibliography

Burnham, J. C. (2012). The death of the sick role. Social History of Medicine, 25, 761-776. Retrieved November 1, 2013, from EBSCO Online Database SocIndex with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=82975643

Fairchild, A. L., & Merritt Johns, D. (2012). Beyond bioethics: Reckoning with the public health paradigm. American Journal of Public Health, 102, 1447-1450. Retrieved November 1, 2013, from EBSCO Online Database SocIndex with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=78276758

Henderson, L., (1935). Physician and patient as a social system. New England Journal of Medicine, 212: 819.

Henderson, L., (1935). The relation of medicine to the fundamental sciences. Science, 82: 477.

Henderson, L., (1936). The practice of medicine as applied sociology. Transnational Association of American Physicians, 51: 8-22.

Iaconetti, K. (2012). Parsons's sick role and children. National Social Science Journal, 38, 31-38. Retrieved November 1, 2013, from EBSCO Online Database SocIndex with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=77668361

Kaptchuk, T. (2000). The web that has no weaver. Boulder, CO: McGraw Hill.

Morantz-Sanchez, R. (2000). Sympathy and science: Women physicians in American medicine. Chapel Hill: University of North Carolina Press.

Parsons, T. (1949/1937). The structure of social action. Glencoe, Ill: The Free Press.

Parsons, T. (1951). The social system. New York: Free Press.

Parsons, T. (1958a). Social structure and the development of personality: Freud's contribution to the integration of psychology and sociology. Psychiatry 21: 321 - 340.

Starr, P. (1982). The social transformation of American medicine. New York: Basic Books.

Stingl, A. (2008). The house of Parsons: The biological vernacular from Kant to James, Weber and Parsons. Lampeter: Edward Mellen Press.

Stingl, A. (under review). The concept of equilibrium in early American sociology: Industrial Physiology and Harvard University. Unpublished Manuscript.

Suggested Reading

Gillet, G. (2006). Medical science, culture, truth. Philosophy, Ethics, and Humanities in Medicine, 1 .

Heyl, B. S. (1968). The Harvard Pareto cycle. The Journal of the History of the Behavioural Sciences 4: 316 - 314.

Levine, D. (1991). Martial arts as a resource for liberal education: The case of Aikido. In Featherstone, M. et al. (eds.) The Body: Social Process and Cultural Theory. 209 - 224. London: Sage.

Levine, D. (2002). Extending the way: Aikido for the 21st century. Paper presented at the Fourth International Aiki Extensions Conference. University of Augsburg.

Levine, D. (2003). The many dimensions of Aiki Extensions. Paper presented at the Fifth International Aiki Extensions Conference. University of Augsburg.

Levine, D. (2006). Powers of the mind. Chicago: Chicago University Press.

Levine, D. (2007a). The Aiki way to therapeutic and creative human interaction. Paper presented at the "Living Aikido: Bewegungs-Und Lebenskunst" Conference, Schweinfurt.

Markens, S. (2013). “It just becomes much more complicated”: Genetic counselors' views on genetics and prenatal testing. New Genetics & Society, 32, 302-321. Retrieved November 1, 2013, from EBSCO Online Database SocIndex with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=89946056

Nye, R. (1985). The bio-medical origins of urban sociology. Journal of Comparative History 20: 659 - 675.

Ross, J. S., Gross, C. P., & Krumholz, H. M. (2012). Promoting transparency in pharmaceutical industry-sponsored research. American Journal of Public Health, 102, 72-80. Retrieved November 1, 2013, from EBSCO Online Database SocIndex with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=70453878

Wirth, L. (1931). Clinical sociology. American Journal of Sociology, 37:49-66.