Sociology and the hospital


At the centre of health sociology is the analysis of medical organisations and institutions. In particular, the hospital has been of key interest to sociologists studying how the practices of the medical profession operate within the organisational system of health care. One example of this lies in the work of British sociologist Anselm Strauss, who researched the relationships between different sectors of the psychiatric profession in hospitals. Strauss was interested in how ideological differences between specialist groups within the hospital affected the conduct and relationships within the hospital, as well as relationships with other people and groups outside the hospital. He found that the hospital’s social structure is primarily based, first, on the number and kinds of professionals who work in the hospital. Second, on the treatment ideologies and professional identities of these professionals. Third, on the relationships of the institution and its professionals to outside communities. One of Strauss’s key contributions was his development of the concept of the ‘negotiated order’, which refers to the idea that while hospital affairs are orderly, they did not follow the strict structure set by the hospital. Instead, the structure of hospital life is constantly being modified on the fly by medical employees, depending on what needed to be done and when, because the nature of work in hospitals is unpredictable and can’t always follow the official institutional structure. The distribution of work in the hospital is always being negotiated, and the hospital as a social institution is best understood through an analysis of the on-going relationships that occur within it. As one of the primary healthcare institutions in society, the hospital is also a useful place for learning about the exercise of power in medical settings. Nicholas Jewson’s work is a useful starting point to understanding how medical knowledge and its power dynamics have come to be regarded as a defining feature of modern health care systems. Jewson argues that the production of medical knowledge is rooted in society, and not within a purely objective science. He identifies three ‘medical cosmologies’, which are paradigms describing how medical developments have been linked with the surrounding social relations and dominant ideas. The first cosmology is ‘person-orientated’, and required the physician to recognise the patient as a holistic entity. Medical judgements about the health or illness of the patient were made in terms of the personal attributes of the sick person, such as their personality and general disposition. The doctor-patient relationship during this period was one in which the power-balance was tilted towards the patient. If the doctor didn’t cultivate a good relationship with the patient and treat them for their illness with regard to their personhood as a whole, they would lose their patient’s patronage and their own income with it. The spread of industrialisation, capitalism, urbanisation and the increasing dominance of scientific knowledge led to the emergence of a specialist scientific medical knowledge, described by Jewson as an ‘object-orientated’ cosmology. Jewson argues that this is the period where the doctor-patient balance of power began to change, as the medical elite were no longer dependent upon patronage and the control of medical knowledge passed from the patient to the clinician. Hospitals became training centres for the new profession of medicine, as well as sites for medical research. The third cosmology, ‘laboratory medicine,’ emerged in the late 19th century. This was when the patient as the object of medical practice actually moves out of the frame almost entirely. In other words, rather than seeing the patient as a holistic person, medical professions break the patient up into smaller and smaller parts – first large body parts, then organs, and finally cells. This cosmology is characterised by the emergence of what Michel Foucault termed the new ‘clinical gaze’, reflecting the changing social relationship of power between doctors and their patients. Foucault described the clinical gaze as the power that comes with the everyday rational-scientific practices associated with the work of doctors in the hospital. These practices contribute to the construction and reproduction of what has been termed the ‘biomedical discourse’. For Foucault, institutions such as medicine exercise power not through overt coercion, but through the moral authority over patients associated with having greater specialised knowledge. This allows medical professionals to be able to identify problems, diseases and illnesses, and then provide solutions and treatment for them. In this way, medical experts play a mediating role between authorities and individuals. Power in this context is relational, rather than a ‘thing’ possessed by individual doctors or the medical profession as a social group. A key concern in the sociology of medicine and health, then, is exactly how the power dynamics of hospitals and other health settings operate, and how they gradually change over time.

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