A WEEK ago, this column featured two related paradigms that explained illness in sociological terms: structural-functionalism, which views illness as the inability to discharge one’s social function; and the political economy perspective that sees illness as the consequence of capitalistic economy while being modulated by the social structure of medicine.
By and far, perhaps the most contentious paradigm in explaining illness is the “symbolic interactionism”: health and illness are both socially-constructed. It explains that various physical and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are defined as such by a society and its members.
Simply put, it rejects the notion that illness is the direct consequence of disease but rather a product of social definition.
“People may have a serious disease but this does not automatically result in defining themselves as ill”, writes sociologist Stephen Moore in his contributed essay in the ‘Health, Medicine and the Body”.
Symbolic interactionism has its roots from intellectual thinkers like: George Herbert Mead, Charles Horton Cooley, W. I. Thomas, Herbert Blumer, and Erving Goffman.
These thinkers have their own slightly varying versions of viewing health and illness within such paradigm. But for the sake of brevity, this article will only limit itself to the most influential and with practical utility in health and illness.
One prominent sociologist is George Herbert Mead, who pioneered this thought to begin with. In his book “Mind, Self and Society”, which was published posthumously by his students in 1934, he identified that the “self” as having two aspects or phases- the “I” and “Me”- that shape social interaction or socialization.
Mead pointed out that the “I” is the incalculable, unpredictable and creative aspect of the self. Simply put, it is the immediate response of self to others’ attitudes and is seen as impulses. It is how the person himself or herself relates to others.
On the other hand, “Me” is the organized set of attitudes by others. It is how others see the self that in turn, may force the individual to act or behave in accordance to the expectations of others.
As applied to health, the subjective experience of “illness” lies in the “I” while the objective diagnosis of the disease by the physician addresses the “Me”.
Mead argues that the “I” reacts against the “Me”, which demands conformity and social control. In the context of medicine, requires the patient “me” institutionalization and compliance to medical interventions.
Using these premises, it can be deduced that the “I” may or may not consider himself as “ill” contrary to what the doctor may diagnose “me” to be sick.
Likewise, illness can be seen dependent on how the “I” is overpowered by the “me”. For instance, a person who has been diagnosed with terminal-stage cancer by the oncologist but is still in denial to make lifestyle modifications and continue to discharge social functions refusing to conform to therapies whether curative or palliative is guilty of an overdeveloped “I”.
On the contrary, if the said cancer patient complies with all the chemotherapeutic interventions and make lifestyle modifications has developed a stable “Me” over “I”.
The sociologist Erving Goffman furthered the work of Mead, who was his late professor.
In his published work, “Dramaturgical Account of Human Interaction”, Goffman, an American-Canadian sociologist argued that we display a series of “masks” to others in acting out roles, controlling and staging how we appear, ever concerned with how we are coming across, constantly trying to set ourselves in the best light.
“Dramaturgy,” as what he had named it, refers to the basic idea that interacting people put on a “show” for each other, stage-managing the impressions that others receive.
According to Goffman, we play a range of different parts determined by the situations we take ourselves in. Furthermore, he pointed out that we adapt what we are depending on who we are interacting with. This is most apparent when we are in awkward situations when we find ourselves trying to play two contrasting roles.
In these situations, we tend to joggle “masks.” In Goffman’s radical view, there is no true self; no identifiable performer behind the roles. The roles, for him, just are the performers. He challenged the idea that each of us has a more or less fixed character or psychological identity. Simply put, social situations, predict the masks we put on that defines our behavior.
For instance, once a person is diagnosed with a particular disease, this person assumes the expected behaviors or “roles” of having such pathology-weak, does less physical activity and always on bed rest.
A Maranaw male patient who is in agonizing post-surgery pain, for instance, may act “numb” because it is the culturally accepted behaviour to display a high-level of tolerance to pain equating it to bravery, manhood and machismo. In short, he is using a mask to put up a “show”.
A professional nurse may not really have authentic intentions to serve humanity but is rather lured into the profession for the potential greener pasteur overseas. Yet is forced to appear caring and concerned to her patients because these are the behaviors expected of her profession.
Another way to approach his thought lies in the patient-doctor relationship (PDR). In such interaction, the doctor wears the “mask” of a professional and thus behaves in the way society expects him for his medical profession. In white coat and stethoscope within his reach, these are, for Goffman, costume and prop for his role. The patient, likewise wears a “mask” expected of him. As such, he readily submits himself to the “doctor’s orders” and grants him the liberty to examine his body like a dysfunctional machine and void of personality.
In a similar example of PDR, nurse-sociologist Mae A. Biggs gives us a glimpse of how the physician and the patient joggle masks in an interaction, specifically in the physical examination between two opposite sexes that requires touching private anatomy.
In her study, she has conducted a total of 14, 000 vaginal examinations together with a male obstetrician that, with the help of sociologist James Henslin, were able to generate the following conclusions consistent with Goffman’s thoughts: (1) the patient transforms into a “non-person state” like a dysfunctional machine and the physician freely examines her “parts”.
During such examination, taboo is suspended; (2) the sterile gloves and whatever other instrument the physician uses to examine her vagina is considered not an extension of himself.
For instance, the sterile gloves is believed primarily to be used to prevent direct finger-to-vagina contact and not really to prevent cross infection; (3) a third party, preferably a lady nurse, should be present to tell society that nothing malicious is transpiring in the examination room during ‘fingering’; and (4) the patient then returns to her previous “human state” and the physician removes gloves and both return to the physician office for prescriptions and other related orders.
In the said vaginal examination, both the patient and doctor played different roles that cut through taboos but was considered acceptable all in the name of health, which can be subjective as the cited example is a Western practice.
Probably, one plausible explanation why this paradigm is contentious is that the applicability of this view influences most research studies as to health-seeking behaviours or when decisions to consult the physician is involved.
When was the last time you ever experienced this: “I” being not ‘ILL’ and you [the medical professional] labelling “me” to be “SICK”?
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The writer is a medical professional and has been writing as a health columnist of this paper since 2008. He is an alumnus of Xavier University Ateneo de Cagayan from Elementary to Graduate School. Currently he is a faculty member of the Medical Education Unit for the Doctor of Medicine Program of Southwestern University Phinma, where he is likewise finishing his Master of Public Health.