Basic to his early work is a distinction between work and interaction. Marx, Weber, and his Frankfurt predecessors had, he felt, fixated on the former and neglected the latter. In the case of Marxian theory, what Habermas understands as the reduction of interaction, or “communicative action,” to work, instrumental or “strategic action,” dramatically limited its scope both to account for modernity and to ground a project of human emancipation. The two-volume Theory of Communicative Action, published in Germany in 1981, took this analysis to a new level of subtlety and comprehensiveness (Habermas 1984; 1987). Locating his theories within the orbit of a “reconstructed” Enlightenment project, Habermas sought to bring together two long-standing, “rival” approaches to social theory. The first analyzes society as a meaningful whole for its participants (Verstehen theory); and the second analyzes society as a system that is stabilized behind the backs of the participants (system theory) (Sitton 1996). This goal gave rise to the celebrated distinction between the lifeworld, based on social integration, and the system, based on system integration.
The lifeworld is characterized by communicative action and has two aspects or sub-systems: the private sphere comprises the rapidly changing unit of the house-hold, while the public sphere represents the domain of popular communication, discussion, and debate. The system operates through strategic action and it too has its sub-systems, the economy and the state. These four sub-systems are interdependent: each is specialized in terms of what it produces but is dependent on the others for what it does not produce. The private sphere of the lifeworld produces “commitment” and the public sphere “influence;” the economy produces “money” and the state “power.” These products or “media” are traded between sub-systems. Thus the economy relies on the state to set up appropriate legal institutions such as private property and contract, on the public sphere of the lifeworld to influence consumption patterns, and on the private sphere to provide a committed labor force, and itself sends money into each other sub-system. Habermas argued that in the modern era, system and lifeworld have become “decoupled.” Moreover, the system has come increasingly to dominate or “colonize” the lifeworld. Thus decision making across many areas owes more to money and power than to rational debate and consensus.
This notion of system penetration and colonization of the lifeworld has been taken up in medical sociology (Scambler 2001). It has been suggested that “expert systems” like medicine have become more answerable to system imperatives than to the lifeworlds of patients. Using Mishler’s (1984) terms, the “voice of medicine” has grown in authority over the “voice of the lifeworld.” Independently of the motivations and aspirations, and sometimes the reflexivity, of individual physicians, they have become less responsive to patient-defined needs, nothwithstanding ubiquitous rhetorics to the contrary. Habermas’ framework of system and lifeworld, strategic and communicative action, continues to be used in the twenty-first century to analyze and explain macro-level changes to health care organization and delivery and micro-level changes to physician–patient interaction and communication.
Under the influence of Axel Honneth (Hazeldine 2017), contemporary critical theory has taken a different turn. Honneth has developed the concept of “recognition,” seeking in doing so to acknowledge the false optimism of many critical theorists who anticipated progressive change and under-estimated the elasticity and durability of capitalism. Attention is switched in “recognition theory” away from distribution and towards identity. In this way feminist and post-colonialist movements are interpreted as rejecting “misrecognition” and in pursuit of active autonomy. For all that “identity politics” has proved controversial in both mainstream and medical sociology, with some regarding it as compromising critical theory’s Marxian heritage, there is no doubt that notions of identity have gained significantly in salience in studies of health and health care (Scambler 2018).
OTHER THEORIES IN THE TWENTY-FIRST CENTURY
The twentieth century ended with new social realities causing both sociology and medical sociology to adjust and consider new theoretical orientations, as well as adapt older ones to account for the changes. At the beginning of the twenty-first century, sociology’s three once dominant theoretical perspectives – structural, functionalism, conflict theory, and symbolic interaction – were dead or on life support as “zombie theories” with a minimum of life (Ritzer and Yagatich 2012:105). The new theories and concepts in medical sociology that emerged in medical sociology suggest a shift away from a past focus on methodological individualism (in which the individual is the primary focus of analysis) toward a growing utilization of theories with a structural orientation as seen in (Cockerham 2013a, 2013b). Some built on the work of the classical theorists, such as health lifestyle theory and critical theory, while others take a different direction.
Michel Foucault
French theorist Michel Foucault, who focused on the relationship between knowledge and power, provided social histories of the manner in which knowledge produced expertise that was used by professions and institutions, including medicine, to shape social behavior. Knowledge and power were depicted as being so closely connected that an extension of one meant a simultaneous expansion of the other. In fact, Foucault often used the term “knowledge/power” to express this unity (Turner 1995). The knowledge/power link is not only repressive, but also productive and enabling, as it is a decisive basis upon which people are allocated to positions in society. A major contribution of Foucault to medical sociology is his analysis of the social functions of the medical profession, including the use of medical knowledge as a means of social control and regulation, as he studied madness, clinics, and sexuality. Foucault (1973) found two distinct trends emerging in the history of medical practice: “medicine of the species” (the classification, diagnosis, and treatment of disease) and “medicine of social spaces” (the prevention of disease). The former defined the human body as an object of study subject to medical intervention and control, while the latter made the public’s health subject to medical and civil regulation. The surveillance of human sexuality by the state, church, and medicine subjected the most intimate bodily activities to institutional discourse and monitoring. Thus, bodies themselves came under the jurisdiction of experts on behalf of society.
Foucault’s approach to the study of the body also influenced the development of a new specialty, the sociology of the body, with Bryan Turner’s book The Body and Society (2008, originally published in 1984) the seminal work in this area. Theoretical developments concerning the sociological understanding of the control, use, and the phenomenological experience of the body, including emotions, have been most pronounced in Britain. One area of inquiry is directed toward understanding the dialectical relationship between the physical body and human subjectivity or the “lived” or phenomenological experience of both having and being in a body.
Foucault has his critics. Some suggest that Foucault’s perspective on knowledge/power does not take limits on power into account, nor explain relations between macro-level power structures other than dwell on their mechanisms for reproduction; moreover, there is a disregard of agency in poststructural concepts. Giddens (1987: 98), for example, noted that Foucault’s history tends to have no active subjects at all and concludes: “It is history with the agency removed.” And he (Giddens 1987: 98) goes on to say that the “individuals who appear in Foucault’s analyses seem impotent to determine their own destinies.” Yet Foucault’s knowledge/power equation, applied to the medical profession, remains a useful analysis of their role as “experts” in the social control of the body.
Social Constructionism
Social