[the book] offers specific analysis of how the medical model has been used in the social construction of the reality of social problems. ..."Sickness" has a cognitive, a moral, and an institutional dimension. To define people who behave "strangely"...as "sick people" changes their role in society and their status as deviants. "Illness" puts the object of concern under a different moral light than does "sin" or "preference." It introduces an element of compulsion into the cognitive reality of the phenomenon. ...The "sick" are neither criminal nor morally responsible for their "disease." However, as sick people, they are both obligated and entitled to be helped. Defined as having medical problems, they are fit objects of treatment by medical institutions. They can be cured and helped by technical knowledge.
...The transformation of problems from ones of badness to ones of sickness has a ring of humanitarian concern. ..It makes it less possible for morally upright people to ignore these people's "problems" and makes feasible develoment of institutional and public facilities for their care.
...three new issues raise significant questions... The concpet of compulsive behavior suggests helplessness and loss of control that is itself an unflattering self-portrait to which many object. Better to be thought a sinner, but responsible for myself, than to be a victim of the fates! There is a moral connotation to sickness... With the attribution of disease, the individual is delivered up to a body of institutional experts--psychiatrists, child guidance counselors, physicians, alchol treatment practitioners, social workers--who seek the person's rehabilitation. In becoming technical objects, the deviants give rise to a new group of control agents and agencies whose power is suspect.
...the medicalization of social problems depoliticizes them and diminishes the recognition of differences in moral choices they represent..R.D. Laing and Thomas Szasz have given clear recognition of this...It puts the responsibility for the problem on individual causes and the solution to social problems on individual treatment. The face-to-face model of the physician-patient is considered the model of how to deal with the cases... The psychologizing of social problems leads away from the analyses of the social structure of the culture..
The intervention of science into human affairs has carried the hope that human problmes might be susceptible to solution by technical knowledge and skill as some problems of nature have been. ...
The positivist approach assumes that deviance is real, that it exists in the objective experience of the people who commit deviant acts and those who respond to them. This view of deviance rests on a second important assumption--that deviance is definable in a straightforward manner as behavior not within permissible conformity to social norms. These norms are believed part of a moral or value consensus in society that is both widely known and shared. Positivists devote much of their study of deviance to a search for causes of deviant behavior. ...In medicine, for example, this search is called etiology. The major questions about deviants the positivist might ask are, Why do they do it? and How can we make them stop?
...by the middle of the 19th century. There had been a considerable reduction in the incidence and mortality of certain dread diseases. The plague and leprosy had nearly disappeared. Smallpox, malaria, and cholera were less devastating than ever before. These improvements in health engendered optimism and increased people's faith in medical practice. Yet these dramatic "conquests of disease" were by and large not the result of new medical knowledge or improved clinical practice. Rather, they resulted from changes in social conditions: a rising standard of living, better nutrition and houseing, and public health innovations like sanitation. With the lone exception of vaccination for smallpox, the decline of these diseases had nearly nothing to do with clinical medicine. But despite the lack of effective treatments, medicine was the beneficiary of much popular credit for improved health. ...the last three decades of the century saw significant "breakthroughs" in medical knowledge and treatment. ...Anesthesia and antisepsis made possible great strides in surgical medicine and improvements in hospital care. The bacteriological research of Koch and Pasteur developed the "germ theory of disease"
..With the emergence of scientific medicine, a unified paradigm, or model, of medical practice developed. It was based, most fundamentally, on viewing the body as a macine (e.g., organ malfunctioning) and on the germ theory of disease. The "doctrine of specific etioloty" became predominant: each disease was caused by a specific germ or gatent. Medicine focused solely on the internal environment (the body), largely ignoring the external environment (society). ...It set the stage for the achievment of a medical monopoly by the AMA regulars. ..."Once scientific medicine offered sufficient guarantees of its superior effectiveness in dealing with disease, the state willingly contributed to the creation of a monopoly by means of registration and licensing."
...In securing a monopoly, the AMA regulars achieved a unique professional state. ..The medical profession was functionally autonomous. Physicians were insulated from external evaluation and were by and large free to regulate their own performance. Medicine could define its own territory and set its own standards.
The domain of medicine has expanded in the past century. The is due to the presstige medicine has accrued and its place as thesteward of the 'sacred' value of life... expansion of medince, especiall into the realm of social problems and human behavior, frequently has taken medicine beyond its proven technical competence...
The medical sector of society has grown enormously in the 20th century. It has become the second largest industry in America. There are about 350,000 physicians and over 5 million pople employed in the medical field. The "medical industries," including the pharmaceutical, medical technology, and health insurance industries, are among the most profitable in our economy. Yearly drug sales alone are over $4.5 billion. There are more than 7000 hospitals in the United States with 1.5 million beds and 33 million inpatient and 200 million outpatient visits a year (1976). ..today physicians are increasingly in large corporate practices or empolyed by hospitals or bureaucratic organizations. ...Medicine in modern sssociety is becoming bureaucratized. The power in medicine has become diffused, especially since World War II...to include the organizations that represent the bureaucratic medicine: the health insurance industry, the medical schools, and the American Hostpial Association. ..Medicine has become both ore specialized and more dependent on technology...
medicine has always operated on a "fee-for-services" basis, that is, each service rendered is charged and paid for separately. Simply put, in a capitalist medical system, the more services provided, the more fees collected. This not only creates an incentive to provide more services but also to expand those medical services to new markets...
The method by which medical care is paid for has changed greatly in the post half-century. In 1920 nearly all health care was paid for directly by the patient-consumer. Since the 1930s an increasing amount of medical care has been paid for through "third-party" payments, mainly thorugh health insurance and the government. ..the ascendancy of third-party payments has effected the expansion of medicine in another way: more and more human problems become defined as "medical problems" (sickiness) because that is the only way insurance programs will "cover" the costs of services.