# Section 7: Social and structural iatrogenisis

We are currently in the process of updating this chapter and we appreciate your patience whilst this is being completed.

### Concepts of health, wellbeing and illness, and the aetiology of illness: Section 7.  Social and structural iatrogenesis

This section covers:

1. The historical development of medical knowledge

2. Power and knowledge: Constructing the biomedal discourse

3. The Medicalisation thesis

Science in general, and biomedical science in particular, can be seen at one level as a proven, reliable, and valid method for developing our understanding of the natural world, including human health and illness. However, such constructions never exist at a purely conceptual level; they are always applied through sets of material practices. The biomedical understanding of human illness and suffering is reflected in the material practices of the medical profession, which for over a period of two centuries has been able to establish its dominance within the evolving organisational system of health care. It is through such practices that the power of the biomedical discourse of health and illness has become socially embedded. In this sense, medical knowledge and power has long been regarded as a defining feature of modern health care systems.

Reflecting the distinct sociological perspectives outlined in Section 1, there are several approaches to the subject of the social basis of medical knowledge and power found within the medical sociological literature; these are outlined below. Beginning with an outline of Jewson's (1976) now classic work on 'medical cosmologies', this section will also examine Foucault's social constructionist analysis of medical discourse as well as Illich's equally influential notion of 'medicalisation'.

1.  The historical development of medical knowledge

Jewsons (1976) classic work on the historical development and production of medical knowledge defines what he termed ‘medical cosmologies'. These frameworks describe the way in which historically, developments in medicine have been intimately linked with the particular social relations and dominant ideas that existed within the society at the time. That is, the production of medical knowledge is rooted within social contexts, rather than the popular notion of a progressive march of science towards ever greater knowledge of the functioning of the human body.

The first 'cosmology' identified by Jewson is what he terms ‘person-orientated'. This existed prior to industrialisation and the ‘age of enlightenment', and required the physician to recognise the patient as a holistic entity. Medical judgements were made in terms of the personal attributes of the sick person, if they were not, then the physician would lose that person's business!

The early development of hospital-based medicine in the late eighteenth / early nineteenth centuries is seen as being associated with the broader social changes occurring within British society at that time. That is, the rise of capitalist forms of production, industrialisation, the growth of towns and cities, and the increasing dominance of scientific knowledge and explanation. The emergence at this time of a specialist scientific medical knowledge, described by Jewson as that of an ‘object-orientated' cosmology, reflects a period in which the doctor-patient balance of power begins to change. Here the medical elite were no longer dependent upon patronage and the control of medical knowledge passed from the patient to the clinician. The hospitals now became training centres for the new profession of medicine and sites for scientific research.

The late nineteenth century saw the emergence of Jewsons third medical cosmology, ‘laboratory medicine'. This is when the patient as the object of medal practice moved out of the frame, and disease became a ‘physio-chemical process'. This medical practice is characterised by the emergence of what Foucault (1973) termed, the new ‘clinical gaze', reflecting the changing social relationship of power between doctors and their patients.

2.  Power and Knowledge:  Constructing the Biomedical Discourse

Foucault's work conceptualises power as the property not of any particular social group, or as something exercised through a structural instrument such as the state, rather: 'It is a relationship which was localised, dispersed, diffused and typically disguised through the social system, operating at a micro, local and covert level through sets of specific [discursive] practices ' (Turner:1997:xii). Power is a 'strategy' or set of discursive practices that characterise the working of modern social systems, summed up by Foucault's much-quoted statement that 'power is a machine that no one owns'. Hence, for Foucauldians, traditional forms of governmentality (a conception of which focuses attention on the ways in which power is present at all levels of society, serving to regulate the activities of the population) depend on systems of knowledge and truths that constitute the object of its activity, and here the roles of experts and their expertise are central.

In the case of medicine, power is embodied in and comes with the day-to-day rational-scientific practices associated with the work of doctors in the hospital or clinic, which Foucault (1973) termed the 'clinical gaze'. Such everyday practices contribute to the (social) construction and reproduction of what has been termed the 'biomedical discourse'. For Foucault, the relationship between power and knowledge is an inevitable and inextricable one (he in fact uses the single term 'power/knowledge'): any extension of power involves an increase in knowledge. Specific forms of power require highly specific formations of knowledge. In this sense, institutions such as medicine (also the law and organised religions) exercise power not through overt coercion but through the moral authority over patients associated with being able to explain individual problems (such as an illness) and then provide solutions (i.e. treatment) for them. As Miller and Rose phrase it, medical 'experts' play a mediating role between 'authorities' and individuals, 'shaping conduct not through compulsion but through the power of truth, the potency of rationality and the alluring promises of effectivity' (Miller and Rose:1993:93). In this conceptualisation of medical practice, power is essentially relational rather than something that is possessed by individual doctors or the medical profession as a social group. This moral or disciplinary approach means that power is exercised most effectively as the subject of the discourse 'interiorises' this gaze, 'to the point that he is his own overseer, each individual thus exercising this surveillance over, and against, himself' (Foucault:1980:155).

It is in this context that Foucault discusses the place of medicine in the monitoring and administration ('surveillance') of populations and their bodies. This disciplinary form of power is not seen as openly coercive; rather, it might be thought of 'as a facilitating capacity or resource, a means of bringing into being the subjects 'doctor' and 'patient' and the phenomenon of the patient's 'illness' ' (Lupton:1997:99). Thus, whilst there is a recognition of the role of the state in the reproduction of this medical dominance, it does not then follow that the medical profession simply serves the interests of the capitalist state. For example, Armstrong's (1993) work on the 'New Public Health', argues that public health strategies are purely a contemporary example of medical power exercised through the surveillance of a population's health behaviour. Such an approach would deny that health promotion strategies have emerged directly from a policy process instigated by the British State, which has its own particular sets of interests and goals.

A central criticism of Foucault's theorisation of medicine as discursive practice is that it is overly deterministic. It focuses attention almost exclusively on the ways in which the discourse of medicine (as represented in official texts, medical notes, etc.) both subjects and subjugates patients. This is the 'docile body' view of the patient, subject to the clinical gaze; there is very little discussion of the ways in which this discourse might be resisted by patients. As Lupton argues, this approach tends to 'present a consonant vision of a world in which individuals' lives are profoundly experienced and understood through the discourses and practices of medicine and its allied professions' (Lupton:1997:94). What follows for Lupton is a tendency to neglect examination of the ways in which medical discursive practice is 'negotiated' by the lay population in their avoidance of suffering and in 'maximising their health status'.

3.  The Medicalisation thesis

Illich's (1976) 'medicalisation of life' thesis is a radical critique of biomedicine and the medical profession which went on to become highly influential in the 1980s. Unlike the Foucauldian social constructionist approach, it does not question the basis of medical knowledge but rather it seeks to challenge its application. The theory asserts that more and more aspects of daily life have been brought into the biomedical sphere of influence. Illich is referring to those experiences that were once seen as a normal part of the human condition, such as pregnancy, childhood, ageing and dying.

Medicalisation is associated with a social process that Illich termed 'iatrogenesis'. This concept refers to the detrimental consequences of medical interventions (clinical iatrogenesis), such as adverse drug reactions and hospital acquired infections. However, this concept goes beyond doctors inflicting direct clinical harm, it also involves the social and cultural spheres of life. Cultural iatrogenesis refers to the way in which medicine is seen to have undermined people's ability to manage their own health, and cope with pain, suffering, and death. Illich recognised that within industrialised societies an institutionalised system for the 'containment' of death and dying, run by health professionals, had emerged. The major function of such institutions (the modern hospital) was the management of the `technical aspects' of symptom control.

These two strands of the medicalisation thesis reflect the influence of both interactionist and Marxist approaches to health and illness in that definitions of illness are perceived to derive from social interactions / negotiations that are built upon social inequalities.