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A Critical Theory of Medical Discourse: Ideology, Social Control, and the Processing of Social Context in Medical Encounters Author(s): Howard Waitzkin Source: Journal of Health and Social Behavior, Vol. 30, No. 2 (Jun., 1989), pp. 220-239 Published by: American Sociological Association Stable URL: . Accessed: 19/08/2011 16:39Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]

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A Critical Theory MedicalDiscourse: of Ideology, Social Control, the and Processing Social Context MedicalEncounters* of inHOWARD WAITZKINIrvine University California, of

Journal Healthand Social Behavior1989, Vol. 30 (June):220-239 of

thatpatientsbringto doctorsoften The personaltroubles have roots in social issues beyond medicine. While medical encountersinvolve "micro-level" between theseinterpersonal interactions individuals, processesoccur in a social structures society. in context shapedby "macro-level" Examining priortheories to pertinent medical discourse leads to the propositions:(a) that medical tendto conveyideologicmessagessupportive the current social encounters of haverepercussions social control; (c) that theseencounters and order;(b) that for a excludes critical medical The languagegenerally appraisalofthesocial context. as seen by health technicalstructure the medical encounter, traditionally of that may have littleto do with the masks a deeper structure professionals, aboutwhatthey saying are and doing.Similar conscious thoughts professionals of betweenclients and membersof other patternsmay appear in encounters or "helping" professions. Expressed marginally conveyed absenceof criticism by and social control medicaldiscourse in remain aboutcontextual issues,ideology consent. unintentional mechanisms achieving largely for froma Why look at medical encounters theoretical pointof view?* Directall correspondence HowardWaitzto Community Clinic, kin,UCI/North Orange County CA 300 WestRomneya Drive,Anaheim, 92801. This article one of a seriesof papersfrom is an ongoingresearchprojecton medical discourse. has in The research been supported partby grants fromthe National Center for Health Services Research(HS-02100), the RobertWood Johnson the Clinical Scholars ProFoundation (through gram), the FulbrightProgram, the National on Institute Aging (1-F32-AG05438), and the of AcademicSenateof theUniversity California, Irvine (Honorary FacultyResearchFellowship). Elliot a John Stoeckle, During spanofmany years, of care Mishler, Sam Bloom,members theprimary of researchdiscussiongroup at the University in California, Irvine,and participants the Society of General InternalMedicine have given me abouttheproject.Stephconstructive suggestions J. any Borges,TheronBritt, Hillis Miller,Mark CarlosRowe have Poster, Leslie Rabine,andJohn of to the helpedin my attempts negotiate terrain critical in are My theory thehumanities. errors no fault theirs. of

Morethan quarter a century C. Wright ago, Mills analyzed the relationships between "personal troubles" and "social issues." Mills pointed a out thatthe troubles person experiences arise in the context broader of social problems. Accordingto Mills, an individual'sdifficulties almost always are in interconnected with structures society, although theselinksmay not be obviouson the surface.Mills arguedthatan important withsocial probgoal forpeople concerned lems-those withwhathe called the "socio-is logical imagination" to clarify how perand sonal troubles social issues relateto one another (1959, pp. 3-24). In the intimacy the medicalencounter, of to doctors variety a of patients present their personaltroubles.From Mills' perspective, often in these troubles haveroots socialissues thatgo beyondthe individual level. Yet the tendnot to receive social issues themselves in critical attention conversation between and doctors.In trying help their to patients doctors often find patients, waysthat patients can adjustto troubling social conditions.'




probably occurin thecommunication Seen from this vantage point, medical patterns clients members other and of are helping encounters "microlevel"processesthat between such as law, psychology, of These professions, involvethe interaction individuals. and however, occurin a social work. Clarifying interpersonal processes, these patternsin whichis shapedby "macro- medicine therefore shedslight professionalon social context, in moregenerally. exploring In level" structures society. For example, clientdiscourse discussproblems the interconnections at betweenpersonaltrouwhenpatients doctors and work, they take their bearings from the bles and social issues,and between micro the organizationof work in society, social and macrolevels,I first buildon theworkof to socialclassrelations prior theorists deal with the issue of expectations aboutwork, to Similarly, medical ideology. I then examine social pertaining work,and so forth. to life in whenproblems pertaining family arise control professionals theirencounters by I in medicalencounters, conversation the must with clients. Afterward, ask how the pertains to deal in some way with such issues as languageof medical encounters women's and men's roles in the family, thesocial context medicine. of and the expectationsabout reproduction and social patmaintenance households, of ternsaffecting children, elderly people, and MEDICAL IDEOLOGY stages of the life individualsat different kindsof social Ideology,while difficult define,is in also to cycle.Patients raiseother whentheytalk withtheir doctors, general an interlocking of ideas and problems set in structures thesociety that the andmacrolevel shape doctrines form distinctive perspective as of a social group.Throughsuch ideas and thecontext thoseproblems well. of has for ideology One challenge socialtheory beento doctrines, represents-on imagian social structures and nary level-individuals' relationship the how macrolevel clarify to microlevel processes affect one another. real conditionsof theirexistence(cf. Al have dealtwiththis thusser1971, pp. 162-165; a criticalapManyschoolsof thought have praisal of Althusser'scontribution theoretical challenge. Some theorists follows of quality of argued for the importance macrolevel laterin thispaper).This imaginary how individuals like power ideology, which patterns structures socialclass andpolitical in in determining happens interpersonalperceiveand interpret experience, what their conprocesses at the micro level. Othershave tributesto ideology's impact in society. claimed that microlevelprocesses are pri- Because ithelpsshapea population's percepand and thatmacrolevel structures emerge tions interpretations, can mary, ideology achieve effect social life. on (similartermsinclude a mostprofound only as a reflection gloss, repetition, As a macrolevel structure society, in integration, aggregation, of and transformation) microlevel processes ideology impinges patients doctors on and as of occurringroutinelyin everyday life. A partof thesocial context medicalencouncompromise positionholds that macrolevel ters. At the micro level of interpersonal structures influence interpersonalinteraction, elements ideologyappear in of profoundly processes, but that microlevel processes doctor-patient communication. Whatpatients reinforce social structures the and doctorssay when theymeet reinforces at cumulatively macrolevel as well (fora critical review,see theirparticular about ideologic conceptions and Knorr-Cetina Cicourel1981). social life. Although ideologyhas received In thispaper,I do nothope to resolvethis wide attentionin social theory, several to theoretical theoretical debate,butrather explorehow previous are contributions helpful themacroand microlevels impinge each for clarifyingideology in medicine. In on theseperspectives ideology,I otherin the single institutional on sphere of presenting medicine.When patientsand doctorstalk emphasize thosetheoretical strands shed that their light on ideologic processes in medical witheach other aboutsocial problems, wordshave muchto do withthesocial order encounters. of around them. Structures society help Ideology,work,and thefamily: perspecin the social context which tivesfromearly Marxisttheory.In classic generate specific The and find patients doctors themselves. talk Marxist theory,ideology is an important thatoccursin medicalencounters also may though inconsistently developednotion.Acbroadersocial structures. Similar cording theprinciple economic to of reinforce determi-



nacy, the eventsof history emergechiefly idleness. When people become sick, they fromeconomic forces and the conflicting often stopworking, doctors involved and get relations socialclass. Fromthisviewpoint, in this processin severalways. Frequently of economicforcesaffect the ideologiesof a doctorscertify that a patientis physically specific historical period.Despitetheprimacy disabled and thus unable to work. By the of economicforces,ideologyis crucial in certification disability, doctorin effect of a sustaining reproducing socialrelations decideswhena patient and the must return thejob. to of production, especially patterns domina- Whenjudgingthe seriousness a patient's of of tion.Marxcalledattention themechanisms c