Читать книгу The Wiley Blackwell Companion to Medical Sociology - Группа авторов - Страница 29

The term critical theory has a long history but in sociology has come to be associated with a group of philosophers and social theorists pre-eminent in a “culture critique” in Frankfurt in the interwar years and later, with the advent of Nazism, in California. Under the inspiration of Max Horkheimer and Theodor Adorno, and in the 1960s in the USA with Marcuse, the classical contributions of Marx and Weber were reworked and framed in response to fascism, Stalinism, and managerial capitalism (Outhwaite 1996). The name of Adorno, in particular, came to be linked with a profound and remorseless cultural pessimism: the logic of the twentieth century, even of modernity, was seen as one of ineluctable decline. The influential Dialectic of Enlightenment, written with Horkheimer during World War II and published in 1947, epitomizes this inexorable sense of decay. One of Adorno’s assistants, Jürgen Habermas, did not share the gloom of his mentor and it is his contribution that came to dominate critical theory during the last decades of the twentieth century. Some medical sociologists turned to his work for theoretical inspiration. It was Habermas’ concept of rationality that differentiated his theories from those of predecessors like Marx, Weber, Adorno, and Horkheimer. He rejected any suggestion that rationality be subsumed by Weber’s Zweckrationalität, or instrumental rationality. In other words, rationality is more than that which governs the choice of means to given, usually material, ends. He developed the notion of what he came to call “communicative rationality,” which refers to the activity of reflecting on our taken-for-granted assumptions about the world, bringing basic norms to the fore to be interrogated and negotiated. Not only does instrumental rationality bypass these norms, but it is on its own insufficient to capture the nature of either “cultural evolution” or even the economy and state, which are too complex to be seen merely as its product.

Basic to his early work is a distinction between work and interaction. Marx, Weber, and his Frankfurt predecessors had, he felt, fixated on the former and neglected the latter. In the case of Marxian theory, what Habermas understands as the reduction of interaction, or “communicative action,” to work, instrumental or “strategic action,” dramatically limited its scope both to account for modernity and to ground a project of human emancipation. The two-volume Theory of Communicative Action, published in Germany in 1981, took this analysis to a new level of subtlety and comprehensiveness (Habermas 1984; 1987). Locating his theories within the orbit of a “reconstructed” Enlightenment project, Habermas sought to bring together two long-standing, “rival” approaches to social theory. The first analyzes society as a meaningful whole for its participants (Verstehen theory); and the second analyzes society as a system that is stabilized behind the backs of the participants (system theory) (Sitton 1996). This goal gave rise to the celebrated distinction between the lifeworld, based on social integration, and the system, based on system integration.

The lifeworld is characterized by communicative action and has two aspects or sub-systems: the private sphere comprises the rapidly changing unit of the house-hold, while the public sphere represents the domain of popular communication, discussion, and debate. The system operates through strategic action and it too has its sub-systems, the economy and the state. These four sub-systems are interdependent: each is specialized in terms of what it produces but is dependent on the others for what it does not produce. The private sphere of the lifeworld produces “commitment” and the public sphere “influence;” the economy produces “money” and the state “power.” These products or “media” are traded between sub-systems. Thus the economy relies on the state to set up appropriate legal institutions such as private property and contract, on the public sphere of the lifeworld to influence consumption patterns, and on the private sphere to provide a committed labor force, and itself sends money into each other sub-system. Habermas argued that in the modern era, system and lifeworld have become “decoupled.” Moreover, the system has come increasingly to dominate or “colonize” the lifeworld. Thus decision making across many areas owes more to money and power than to rational debate and consensus.

This notion of system penetration and colonization of the lifeworld has been taken up in medical sociology (Scambler 2001). It has been suggested that “expert systems” like medicine have become more answerable to system imperatives than to the lifeworlds of patients. Using Mishler’s (1984) terms, the “voice of medicine” has grown in authority over the “voice of the lifeworld.” Independently of the motivations and aspirations, and sometimes the reflexivity, of individual physicians, they have become less responsive to patient-defined needs, nothwithstanding ubiquitous rhetorics to the contrary. Habermas’ framework of system and lifeworld, strategic and communicative action, continues to be used in the twenty-first century to analyze and explain macro-level changes to health care organization and delivery and micro-level changes to physician–patient interaction and communication.

Under the influence of Axel Honneth (Hazeldine 2017), contemporary critical theory has taken a different turn. Honneth has developed the concept of “recognition,” seeking in doing so to acknowledge the false optimism of many critical theorists who anticipated progressive change and under-estimated the elasticity and durability of capitalism. Attention is switched in “recognition theory” away from distribution and towards identity. In this way feminist and post-colonialist movements are interpreted as rejecting “misrecognition” and in pursuit of active autonomy. For all that “identity politics” has proved controversial in both mainstream and medical sociology, with some regarding it as compromising critical theory’s Marxian heritage, there is no doubt that notions of identity have gained significantly in salience in studies of health and health care (Scambler 2018).