IJE Advance Access originally published online on May 11, 2009
International Journal of Epidemiology 2009 38(3):642-645; doi:10.1093/ije/dyp184
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Commentary: Indeterminate sick-men—a commentary on Jewson's ‘Disappearance of the sick-man from medical cosmology’
Department of General Practice, School of Medicine, King's College London 5 Lambeth Walk, London SE11 6SP, UK.
E-mail: david.armstrong@kcl.ac.uk
Accepted 7 October 2008
Jewson's seminal paper of 19761 explored the causes and repercussions of a radical change in medical knowledge some two centuries ago. Given the close connections between medical knowledge and clinical practice, this cognitive revolution was closely associated with changes in the organization and status of the medical profession. It was this dyadic relationship—of medical knowledge and the medical profession—that formed the underpinning for Jewson's analysis.
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The sociology of the medical profession |
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The sociology of the professions only began in the 1950s when, reflecting contemporary concerns with understanding social stability, professions (and medicine was always the archetypal profession) were seen as exemplars of social virtue and their history a model for how other occupations could aspire to higher ideals.2 In 1970, however, Freidson3 advanced the claim that the medical profession was simply a competitive ploy in the occupational marketplace and had achieved its high occupational status (and concomitant rewards) by establishing a monopoly over the definition of illness. A more historically nuanced study by Johnson4 a couple of years later started with two premises. The first was that a profession is simply one way of controlling an occupation; the second that all producer–consumer interactions contain an element of uncertainty or indeterminacy that either party might try and control. This led Johnson to identify three historical phases of how the medical profession was organized. The first, that dominated the eighteenth century and earlier, he labelled as ‘Patronage’, when indeterminacy was controlled by the high-status patients (only the latter being able to afford care from the limited number of physicians). Then, in the nineteenth century, medicine seized control of the indeterminacy and ushered in a period of ‘Collegiate’ control of the profession. Finally, the advent of post-Second World War government intervention in health care brought another player to the medical encounter that increasingly tried to control indeterminacy (‘State-mediation’ as Johnson called it). In this analysis, therefore, the nature of the profession varied according to who controlled the uncertainty in the identification and management of illness; more importantly, mid-twentieth century ideals of the nature of a profession represented a brief flowering of a celebration of a Collegiate form of governance that in retrospect can be seen as only a transient arrangement.
Jewson, who was Johnson's colleague at Leicester University, took this argument further by examining in more detail how the medical profession succeeded in controlling indeterminacy and shifting to a system of Collegiate governance. The key was his identification of a new ‘system’ of medical knowledge that emerged at the end of the eighteenth century, but this part of his analysis had only been made possible by contemporary work in the sociology of knowledge and science.
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The sociology of science |
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The sociology of science had emerged as an area of specialist study after the Second World War. It believed that the ‘truth’ science produced was not susceptible to sociological analysis and so restricted itself to examining the social factors that facilitated or impeded the progress of science. Research was therefore focussed on revealing the social conditions allowing the emergence of scientific ideas as shown; for example, in the many examples of parallel but independent discoveries in science (the independent co-discovery of a theory of evolution by Darwin and Wallace being perhaps the best known example).5
In 1962, however, the sociology of science (and indeed the history and philosophy of science) was transformed by the appearance of Kuhn's ‘The Structure of Scientific Revolutions’6 in which he identified social processes at the very heart of science. Kuhn argued that far from adopting a disinterested objectivity, scientists defended and maintained scientific paradigms which allowed them to ‘puzzle-solve’ within a framework that was based on untested and unstated assumptions. These paradigms dominated scientific thinking for centuries but eventually, as unexplained anomalies accumulated, the paradigm collapsed and a new one emerged from its ashes. The history of science was therefore not one of incremental progress but rather one characterized by periodic major upheavals. Kuhn's examples were largely drawn from the history of physics and chemistry but the analysis, it seemed, could equally well be applied to other areas of scientific knowledge.
For Kuhn, successive paradigms were ‘incommensurable’, that is they could not be directly compared as extra-paradigmatic evaluation criteria did not exist, the paradigm defining as part of its core assumptions what was to count as success. Astrological medicine of the seventeenth century, for example, that tried to predict a person's future prosperity cannot be directly compared with modern medicine, which would make no such claim. Accordingly, there seemed no way in which to judge that one paradigm was ‘better’ than another as each defined different problems to solve, used different methods and applied different outcome criteria. Though Kuhn was later to deny the relativism that others read into his work was part of his original intention, it became possible to imagine that perhaps contemporary medical knowledge was not the outcome of a long process of getting closer to a better understanding of illness but simply the triumph of one way, neither the first nor the last, of ‘seeing’ illness. Indeed, this very possibility was advanced by Michel Foucault in his ‘Birth of the clinic’,7 first published in French in 1963 though only accessible to an English readership from 1972.
A post-Kuhnian perspective fitted well with the earlier work of medical historians who recognized that a major revolution centred on Parisian hospitals had occurred in medicine around the closing decades of the eighteenth century. In those radical years, older humoral theories of medicine had given way to a new pathological medicine in which illness was seen to be located in an intra-corporal lesion that could be identified/diagnosed with a clinical examination of the body (and confirmed at a later post-mortem). Here, then, was the outline of a paradigm shift (or new cosmology as Jewson called it) in which the theories and practices of clinical medicine were fundamentally reformulated; a world that ushered in a new way of seeing and thinking about illness that, in broad outline, has continued to the current day. The rise of the Collegiate medical profession seemed to map closely on to this emergence of Pathological or Hospital Medicine—but what exactly was the relationship between a revolution in medical knowledge and the ascendency of the medical profession? For an answer, Jewson turned to the Marxist idea of ‘social relations of production’.
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Marxist influence |
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For Marx, a key characteristic of any economic system was the ‘social relations of production’; that is the way in which people had to work together to transform the natural world. In feudalism, serfs offered service and a tithe to their lord in return for protection. Feudalism was replaced by capitalism in which a few people held ‘capital’ such as factories, etc., which produced the goods people needed and the rest of the population simply sold their labour power to work in those factories. Capitalism was therefore characterized by a means or mode of production represented by the factory and two groups of people, the capitalists and labourers. Thus the ‘social relations of production’ of capitalism was constituted by this critical dyad, those who owned the means of production and those who simply sold their labour. This relationship imbued contemporary thinking about what was ‘natural’ in social and economic relationships (consider the ‘hidden’ message in the popular nineteenth century hymn: ‘The rich man in his castle/the poor man at his gate/God made them high or lowly/and ordered their estate.’). This core idea, that the social means of production underpinned both human relationships and whatever was produced, was a powerful one that could potentially be applied to any output of capitalist or late capitalist society.
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Synthesis |
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Jewson's originality was the way in which he applied this Marxist analysis to the periodization of medical history that had begun to emerge from medical historians and had received strong impetus following Kuhn's work. Medicine itself was a productive process involving the fashioning of illness definitions and provision of health care. In that sense, as Johnson had earlier identified, the historically changing relationship between doctor and patient could be seen to be associated with changing forms of medical knowledge. In other words, and this was Jewson's striking insight, the particular relationship between doctor and patient could be ‘encoded’ in the contemporary system of medical knowledge. In his earlier 1974 paper8 he applied this logic to the eighteenth-century system of patronage. Patients of high social status had to be heard by their socially inferior physicians so discussion of symptoms dominated their interaction and medical knowledge was based around an elaborate classification system for all the variations of symptom that a patient might present.
In Paris in the late-eighteenth century, poor people were provided with access to health care through new public hospitals. This changed the relationship between doctor and patient to one in which the doctor was dominant. At this point, clinical medicine became focussed on a new way of thinking about illness that located it in a pathological lesion inside the patient's body. In this model, the patient's symptoms were only preliminaries; the real task was to apply the newly developed skills of the clinical examination in an attempt to uncover the ‘signs’ of the underlying lesion.
The emergence of pathological medicine was not therefore the result of ‘scientific progress’ or advancement, but rather the direct expression of a doctor–patient relationship that placed the doctor centre-stage. The patient might feel ill and experience all sorts of symptoms but it was only the trained physician who was able to look beyond these outward manifestations of illness to identify the real disease of which the patient had no necessary awareness. This new-found medical dominance also found expression in the Collegiate form of professional identity that accompanied the rise of this new medical theory. Yet, Jewson went further. This new medical paradigm, or cosmology as he called it, had meant the disappearance of the ‘sick-man’ in that the patient's voice was now relegated to a minor role in the clinical task, a role further reduced with the beginnings of medical investigations (or Laboratory Medicine) later in the nineteenth century. In the latter, the role of the patient was further reduced as in many cases it was simply a tissue sample, a few of the patient's cells, taken to a distant laboratory that provided all medicine needed for an accurate diagnosis and choice of relevant treatment. For all its claimed benefits, medical ‘progress’ has resulted in the subjugation of the patient and a loss of their status as ‘person’.
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Alternatives |
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Jewson's linking together of social relations with a form of knowledge was not original in itself but in its application to medicine it was a first. This was—and remains—an important paper. His analysis provided a context for understanding medical history (Jewson's paper is widely cited by medical historians) especially that fertile period of revolution around the end of the eighteenth century. It also provided a context for understanding the emphasis on and limits to patient autonomy. Medicine has been successful but in so doing has excluded the patient. Bringing the patient ‘back in’, however, is always constrained by a medicine rooted in a pathological model in which patients have no direct access to the basis of their own illness.
Where Jewson's thesis can be challenged, however, is in its Marxist framework. In an important essay Lukes9 compared and contrasted the Marxist notion of alienation with the idea of anomie from the French sociologist Durkheim. Both alienation and anomie had many similarities—both emerged with industrialization, both would be experienced as similar psychological feelings of disenchantment and unease—but their origins and social implications could not have been more different. For Marx, capitalist production meant labourers were alienated not only from what they produced but also from their ‘species-being’. The problem would disappear once capitalism was removed and people could live freely without the oppressive force of capitalist production.
For Durkheim, anomie also emerged with industrialization and increased with occupational specialization as people shared fewer and fewer workplace experiences. The latter meant that people became separated from their traditional communities, which gave them identity and purpose. What was needed to remove anomie, however, was not less ‘structure’ as the Marxists wanted, but more. It was only by being given a sense of identity and purpose through new forms of socialization that people would not feel lost and normless.
The basis for this difference of perspective between Marx and Durkheim was their very differing views of human nature. There are two ‘great traditions’. One is to see Man as inherently good, who, when able to exercise free choices unencumbered by restraints, would choose a decent and sociable life. Rousseau's noble savage is very much in this mould: even uncivilized life has its nobility as it is the very processes of socialization and control that threaten Man's inherent positive nature. In contrast, Durkheim belongs to a tradition that included Hobbes and Freud, which believed that Man needed society simply to be human; without social regulation and restraint life could at worst be ‘brutish and short’ or at best the unrealized potential of a tabula rasa.
The process of objectification that Jewson claimed accompanied the application of Hospital and Laboratory Medicine can be seen to derive from the Marxist concept of alienation: just as in the human relations of the factory system, a medicine based on pathology meant that humanity was being lost (hence ‘disappearance of the sick-man’). But, following a Durkheimian perspective, there is a different interpretation of these events that would claim that the objectification was not a negative process but a positive one as the ‘object’ of the analysable human body was established. It was precisely the ‘objectification’ of the sick-man that established the possibility of an analysable and plastic body that has become an integral part of modern social life from physical education to rehabilitation and from tattoos to body piercing. Indeed, this objectification of the human body can be traced through the institutions and practices of other transformative disciplines such as prisons, schools and workplaces.10
The objectification of the patient, which Jewson identified as being a consequence of Hospital Medicine, can therefore be read in two ways. On the one hand, as Jewson argued, it could represent the loss of a subjective identity that had always been the hallmark of human nature, and on the other hand, it could mark the very crystallization of a new form of ‘modern’ identity, albeit initially in an anatomical form. Was the sick-man lost or was a new identity being forged that, in retrospect, would enable the construction of a genealogy that involved a distant lineage and a past golden age?
Jewson's paper remains a powerful contribution to the sociology of the medical profession as it brought contemporary thinking in the sociology of science into an understanding of modern medicine; where it now looks contentious is in its Marxist assumptions. Certainly, many sociologists will still see much of clinical practice as objectifying ‘real’ people, but there is now a sufficiently strong alternative interpretation to realize that Jewson's paper represented just one pole of an on-going debate about the nature of that very sick-man whom he declared as lost. If the task is to liberate the experience of the sick-man then Jewson provides the blue-print; but if it is better to understand the processes through which the analysable body of the sick-man has been constructed, Jewson provides only a stepping stone, albeit an important one.
Conflict of interest: None declared.
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1 Jewson ND. The disappearance of the sick-man from medical cosmology, 1770-1870. Sociology (1976) 10:225–44. (Reprinted in Int J Epidemiol 2009;38:622–33).[Abstract]
2 Goode WJ. Community within a community: the professions. Am Sociol Rev (1957) 22:194–200.[CrossRef][Web of Science]
3 Freidson E. Profession of Medicine. (1970) New York: Dodd Mead.
4 Johnson T. Professions and Power. (1972) London: MacMillan.
5 Merton RK. Singletons and multiples in scientific discovery. Proc Am Philos Soc (1961) 105:470–485.[Web of Science]
6 Kuhn TS. The Structure of Scientific Revolutions. (1962) Chicago: Chicago University Press.
7 Foucault M. The Birth of the Clinic: An Archaeology of Medical Perception. (1973) London: Tavistock.
8 Jewson ND. Medical knowledge and the patronage system in eighteenth century England. Sociology (1974) 8:369–85.
9 Lukes S. Essays in Social Theory. (1977) Basingstoke: Macmillan.
10 Foucault M. Discipline and Punish: The Birth of the Prison. (1977) Harmondsworth: Penguin.
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