the principles of democratic politics (emphasizing equality and universal rights) and the organization of their economic systems (involving the production, exchange, and consumption of goods and services, about which there is considerable inequality). Therefore, while people have political equality, they lack social equality. This unresolved contradiction is relatively permanent and a major source of conflict. Ideologies of fairness are constantly challenged by the realities of inequalities, and they influence governments to try to resolve the situation through politics and welfare benefits.
This situation represents one of conflict theory’s most important assets for medical sociology; namely, the capacity to explain the politics associated with health reform. Conflict theory allows us to chart the maneuvers of various entities, like the medical profession, insurance companies, pharmaceutical companies, the business community, and the public, as they struggle to acquire, protect, or expand their interests against existing government regulations and programs and those under consideration. Other conflict approaches are connected more directly to classical Marxism by relying on class struggle to explain health policy outcomes and the disadvantages of the lower and working classes in capitalist medical systems where the emphasis is on profit (De Maio 2010; Muntaner et al. 2014; Scambler 2018). This view does not consider political struggles between interest groups as a sufficient strategy for understanding health inequalities and instead emphasizes class conflict and exploitation as the most complete explanation for the poor health of disadvantaged groups.
While versions of conflict theory emanating from the writings of Marx undoubtedly lost salience in the last quarter of the twentieth century, the global financial crisis of 2008–2009 and its aftermath have triggered a resurgence of interest. As material inequalities have increased in a politically uncertain and volatile world some medical sociologists have returned to mainstream Marxian analyses of capitalism’s inherent contradictions to explain health inequalities (Scambler 2018). In this context Fredrich Engels too is often cited, not least because of his studies of Manchester in nineteenth-century England and the differential impact of rapid processes of industrialization on workers’ health. For him, capitalist exploitation amounted to a murderous assault on the working classes. Unsurprisingly, explanations based on the theories of Marx and Engels emphasize the macro-sociology of social structure, sometimes at the expense of culture, interaction, and agency. As with most other theorists who have gained the attention of medical sociology, the contributions of conflict theorists throw light on limited aspects of health and healthcare. Their strength is a focus on the causal inputs of system and structure on institutions and individual behavior, their weakness a tendency to gloss over non-conflictual phenomena and the minutiae of everyday interactions through which individuals forge their projects and negotiate their way in the world.
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
