MAX WEBER
None of the classical theorists – Comte, Spencer, Simmel, Marx, Durkheim, and Weber – concerned themselves with medical sociology. The canonized trio of Marx, Durkheim, and Weber did occasionally refer to health in their writings (Collyer 2010), but they did not establish medical sociology as a subdiscipline of sociology nor indicate they were even aware of it. Weber, nevertheless, had a major influence on the field. Among his most important contributions are his concepts of formal rationality and lifestyles. Weber ([1922] 1978) distinguished between two major types of rationality: formal and substantive. Formal rationality is the purposeful calculation of the most efficient means and procedures to realize goals, while substantive rationality is the realization of values and ideals based on tradition, custom, piety, or personal devotion. Weber described how, in Western society, formal rationality became dominant over its substantive counterpart as people sought to achieve specific ends by employing the most efficient means and, in the process, tended to disregard substantive rationality because it was often cumbersome, time-consuming, inefficient, and stifled progress. This form of rationality led to the rise of the West and the spread of capitalism. It is also linked to the development of scientific medicine and modern social structure through bureaucratic forms of authority and social organization that includes hospitals. The rational goal-oriented action that takes place in hospitals tends to be a flexible form of social order based on the requirements of patient care, rather than the rigid organization portrayed in Weber’s concept of bureaucracy (Strauss et al. 1963). But his perspective on bureaucracy nevertheless captures the manner in which authority and control are exercised hierarchically and the importance of organizational goals in hospital work (Cockerham 2015).
Weber’s notion of formal rationality has likewise been applied to the “deprofessionalization” of physicians. Deprofessionalization means a decline in power resulting in a decline in the degree to which a profession maintains its professional characteristics. Freidson’s (1970a; 1970b) seminal work on the medical profession in the 1970s had depicted American medicine’s professional dominance in its relations with patients and external organizations. Medicine was the model of professionalism, with physicians having absolute authority over their work and ranked at or near the top of society in status. However, George Ritzer and David Walczak (1988) noted the loss of absolute authority by physicians as their treatment decisions came under increasing scrutiny in the late twentieth century by patients, health care organizations, insurance companies, and government agencies.
Ritzer and Walczak found that government policies emphasizing greater control over health care costs and the rise of the profit motive in medicine identified a trend in medical practice away from substantive rationality (stressing ideals like serving the patient) to formal rationality (stressing rules, regulations, and efficiency). Government and insurance company oversight in reviewing and approving patient care decisions, and the rise of private health care business corporations, decreased the autonomy of medical doctors by increasingly hiring them as employees and monitoring their work. This, joined with greater consumerism on the part of patients, reduced the professional power and status of physicians. Thus, the “golden age” of medical power and prestige ended, as medicine’s efforts to avoid regulation left open an unregulated medical market that invited corporate control and public demands for government control to contain costs.
Weber’s work also provides the theoretical background for the study of health lifestyles. Weber ([1922] 1978) identified life conduct (Lebensführung) and life chances (Lebenschancen) as the two central components of lifestyles (Lebensstil). Life conduct refers to choice or self-direction in behavior. Weber was ambiguous about what he meant by life chances, but Ralf Dahrendorf (1979: 73) analyzed Weber’s writings and found that the most comprehensive concept of life chances in his terminology is that of “class position” and that he associated the term with a person’s probability of finding satisfaction for interests, wants, and needs. He did not consider life chances to be a matter of pure chance; rather, they are the chances that people have in life because of their social situation.
Weber’s most important contribution to conceptualizing lifestyles is to identify the dialectical interplay between choices and chances as each works off the other to shape lifestyle outcomes (Abel and Cockerham 1993; Cockerham, Abel, and Lüschen 1993). That is, people choose their lifestyle and the activities that characterize it, but their choices are constrained by their social circumstances. Through his concept of Verstehen or interpretive understanding, Weber seems to favor the role of choice as a proxy for agency over chance as representative of structure in lifestyle selection, although both are important. Weber also made the observation that lifestyles are based not so much on what people produce, but what they consume. By connecting lifestyles to status, Weber suggests that the means of consumption not only expresses differences in social and cultural practices between groups, but establishes them as social boundaries (Bourdieu 1984).
Health lifestyles are collective patterns of health-related behavior based on choices from options available to people according to their life chances (Cockerham 2005, 2013b, 2021b; Cockerham et al. 1997). These life chances include class, age, gender, ethnicity, and other relevant structural variables that shape lifestyle choices. The choices typically involve decisions about smoking, alcohol use, diet, exercise, and the like. The behaviors resulting from the interplay of choices and chances can have either positive or negative consequences for health, but nevertheless form a pattern of health practices that constitute a lifestyle. Although positive health lifestyles are intended to produce good health, the ultimate aim of such lifestyles is to be healthy in order to use (consume) it for something, such as the capability to work, feel and look good, participate in sports and leisure activities, and enjoy life.
Health lifestyles originated in the upper middle class, yet have spread across class boundaries in varying degrees of quality (Cockerham, Kunz, and Lüschen 1988). While Weber did not consider the health aspects of lifestyles, his concepts allow us to view them as (1) associated with status groups and principally a collective, rather than individual, phenomenon; (2) patterns of consumption, not production; and (3) formed by the dialectical interplay between choices and chances. His conceptualization of lifestyles provides the foundation for current theorizing on health-related lifestyles (Cockerham 2005, 2013b, 2021a, 2021b).
CRITICAL THEORY AND JÜRGEN HABERMAS
The term critical theory has a long history but in sociology has come to be associated with a group of philosophers and social theorists pre-eminent in a “culture critique” in Frankfurt in the interwar years and later, with the advent of Nazism, in California. Under the inspiration of Max Horkheimer and Theodor Adorno, and in the 1960s in the USA with Marcuse, the classical contributions of Marx and Weber were reworked and framed in response to fascism, Stalinism, and managerial capitalism (Outhwaite 1996). The name of Adorno, in particular, came to be linked with a profound and remorseless cultural pessimism: the logic of the twentieth century, even of modernity, was seen as one of ineluctable decline. The influential Dialectic of Enlightenment, written with Horkheimer during World War II and published in 1947, epitomizes this inexorable sense of decay. One of Adorno’s assistants, Jürgen Habermas, did not share the gloom of his mentor and it is his contribution that came to dominate critical theory during the last decades of the twentieth century. Some medical sociologists turned to his work for theoretical inspiration. It was Habermas’ concept of rationality that differentiated his