suicide). A fourth type, fatalistic suicide, was never fully conceptualized. The merit of his approach is that it shows the capability of the larger society to create stressful situations where people are forced to respond to conditions not of their own choosing. Thus, Durkheim helps us not only to understand the social facets of suicide, but also to recognize that macro-level social events (like economic downturns) can affect health in a variety of ways through stress and that the effects of stress can be mitigated through social support.
SYMBOLIC INTERACTION
The first major theoretical perspective to challenge Parsons and structural-functionalist theory in medical sociology was symbolic interaction, based largely on the work of George Herbert Mead (1934) and Herbert Blumer (1969). Symbolic interaction maintained that social reality is constructed on a micro-level by individuals interacting with one another on the basis of shared symbolic meanings. Human beings were seen to possess the capacity to think, define situations, and construct their behavior on the basis of their definitions and interpretations. “It is the position of symbolic interaction,” states Blumer (1969: 55), “that the social action of the actor is constructed by him [or her]; it is not a mere release of activity brought about by the play of initiating factors on his [or her] organization.” Social life was therefore produced by interacting agents choosing their own behavior and acting accordingly, not by large-scale social processes and structures channeling behavior down optionless pathways. Symbolic interaction had not only its particular (micro-level) orientation toward theory construction, but also its own qualitative research methodologies of participant observation focus groups, unobtrusive measures such as biographies and life histories, and situational analysis consisting of mapping the positions, situations, and social worlds of those being studied (Clarke et al. 2018; Denzin 2017; Denzin and Lincoln 2018). These methodologies focused on small group interaction in natural social settings. A related approach was ethnomethodology, which featured descriptions of taken-for-granted meanings in natural settings, rather than analysis.
The major figures in early medical sociology working in the symbolic interactionist tradition were Anselm Strauss and Erving Goffman. Strauss joined with Howard Becker and others in their now classic study of medical school socialization, Boys in White (Becker et al. 1961). Strauss made his own contributions to theory and methods in a number of areas, including seminal work on the social process of death and dying (Glaser and Strauss 1965, 1968); observation of the “negotiated order” of hospital routine featuring a minimum of “hard and fast” regulations and a maximum of “innovation and improvization” in patient care, especially in emergency treatment (Strauss et al. 1963); and formulation of grounded theory methodology featuring the development of hypotheses from data during analysis, rather than before (Glaser and Strauss 1967).
Goffman, who became a major theorist in sociology generally, began his research career in medical sociology by using participant observation to study the life of mental hospital patients. His classic work in this area, Asylums (1961), presented the concept of “total institutions” that emerged as an important sociological statement on the social situation of people confined by institutions. His observations also led to the development of his notions of impression management and the dramaturgical perspective in sociology that views “life as a theatre” and “people as actors on a stage,” as well as his concept of stigma (Goffman 1959; 1967).
With the introduction of symbolic interactionist research into an area previously dominated by structural-functionalism, medical sociology became an arena of debate between two of sociology’s major theoretical schools. By the mid-1960s, symbolic interaction came to dominate a significant portion of the literature in the field. One feature of this domination was the numerous studies conducted in reference to labeling theory, a variant of symbolic interaction, and the controversy it provoked. Labeling theory held that deviant behavior is not a quality of the act a person commits but rather is a consequence of the definition applied to that act by others (Becker 1973). That is, whether or not an act is considered deviant depends upon how other people react to it. Although labeling theory pertained to deviance generally, the primary center of argument was focused on the mental patient experience, with Thomas Scheff (1999) the principal proponent of the labeling approach. Labeling theory was also employed in studies of the medical profession as seen in Eliot Freidson’s (1970b) alternative concept of the sick role.
By the 1980s, however, symbolic interaction entered a period of decline in medical sociology. Many of its adherents had been “rebels” intentionally subverting the dominant paradigm of structural-functionalism and giving voices to women and marginal social groups like mental patients, the physically handicapped, and the aged and their caretakers by entering their social world and observing it. Yet, as Norman Denzin (1991) points out, between 1981 and 1990, the canonical texts in the field had shifted from Mead to Blumer and Blumer himself was under attack on several methodological and substantive issues – but most importantly for not advancing the field to meet his own early criticisms; moreover, practitioners of the perspective were getting older (“the graying of interactionism”), the number of students espousing interactionism was decreasing, and the old enemy (structural- functionalism) had been largely vanquished. Elsewhere, in Britain, where interactionism had been the dominant theoretical perspective in medical sociology in the majority of published studies in the past (Annandale 2014), a related theoretical perspective – social constructionism – has now largely displaced it (Nettleton 2020; Seale 2008).
Unfortunately, symbolic interaction had taken on the image of a “fixed doctrine” and, except for Mead’s (1934) concept of the “generalized other,” was unable to satisfactorily link small group processes with social phenomena reflecting the behavioral influences of the larger social entities. It was particularly unable to account for interaction between institutions or societal – level processes that affect each other, not just individuals or groups. In addition, labeling theory, despite its merits in accounting for the powerful behavioral effects of “labels” placed on people, had not been able to explain the causes of deviance (other than the reaction of people to it), nor whether deviants themselves share common characteristics like poverty, stress, family, or class background.
But it would be a mistake to relegate symbolic interaction to history, as its methodologies remain the primary forms of qualitative research in medical sociology. Observed patterns of behavior and first-person accounts of social situations bring a sense of “real life” to studies that quantitative research is unable to capture. While symbolic interaction theory has not moved far beyond the original concepts of Mead and Blumer, it persists as an important theoretical approach to the study and explanation of social behavior among small groups of people interacting in ways that are relevant for health.
CONFLICT THEORY
Conflict theory, with its roots in the work of Karl Marx and Max Weber, joined symbolic interaction in significantly reducing the influence of structural-functionalism, but did not achieve a dominant position in medical sociology. Conflict theory is based on the assumption that society is composed of various groups struggling for advantage, that inequality is a basic feature of social life, and conflict is the major cause of social change. Marx’s perspective in conflict theory is seen in the rejection of the view expressed by structural-functionalism that society is held together by shared norms and values. Conflict theory claims that true consensus does not exist; rather, society’s norms and values are those of the dominant elite and imposed by them on the less privileged to maintain their advantaged position. Weber adds, however, that social inequality is not based on just money, property, and relationships to the means of production, but also on status and political influence. Since all social systems contain such inequality, conflict inevitably results and conflict, in turn, is responsible for social change.
Whereas the Marxian-oriented features of conflict theory have emphasized systemic exploitation and class struggle, other theorists have moved toward emphasizing conflicts that occur between interest groups and the unequal distribution of political power (Dahrendorf 1959). According to Bryan Turner (1988), modern societies
