Critical Theory and Health

This is another longish blog adapted from a piece on critical theory and health that I contributed to Bill Cokcerham’s Encyclopaedia of Medical Sociology. Critical theory, I suggested, serves as an umbrella term to encompass a range of oppositional standpoints inside and outside of sociology. Marx, Marcuse, Foucault, Habermas and Deleuze and Guattari have for example all been labeled critical theorists, notwithstanding their philosophical, theoretical and political differences. In this summary piece the term refers to members of the Institute for Social Research, or the ‘Frankfurt School’. Founding protagonists were Theodor Adorno, a philosopher with a specialist knowledge of music; Erich Fromm, a psychologist; Herbert Marcuse, a philosopher with ride-ranging interests; Walter Benjamin, an astonishingly fertile and creative thinker who remained on the periphery of the Institute; and Jurgen Habermas, the leading representative post-1968 and most prolific thinker. It was Max Horkheimer, however, who was the main catalyst, bringing together these unusually gifted colleagues to forge an interdisciplinary critical theory of society.

The early works of the Frankfurt School were premised on what were widely seen as very real prospects of revolutionary action leading to social transformation: they comprised a kind of intellectual arm of the proletariat. As the 1930s unfolded, however, this ‘optimism’ gradually diminished as the revolution in the Soviet Union failed either to inspire support or to transmit its energies elsewhere. Fascism emerged to call into question the spirit and meaning of modernity. Members of the Frankfurt School switched their critical attention to longstanding ‘left’ presumptions concerning the progressive character of science and technology, popular education and mass politics (Bronner, 2011).

Perhaps the most influential text to come out of the Frankfurt School during this period of ‘pessimism’ was Horkheimer and Adorno’s (1982) ‘Dialectic of Enlightenment’, which was written during the war and published in 1947. Set in the shadow of the Holocaust, it is a book that heralded the arrival of a ‘barbaric’ and bureaucratically administered mass society, epitomizing its authors’ sense of the irreversible decay of modernity. Auschwitz was the culmination and incarnation of (1) ‘alienation’, or the psychological impact of exploitation and the division of labour, and (2) ‘reification’, or the instrumental treatment of people as ‘things’. After Auschwitz there seemed no possibility of modernity’s redemption.

It is Habermas who has made most impact on sociology in general, and the sociology health and health care in particular, over the last generation. He did not share the deep and abiding pessimism of his mentors, Horkheimer and Adorno. He rejected what he interpreted as their conflation of rationality with Weber’s Zweckrationalit or ‘instrumental rationality’. Instrumental rationality refers to the rationality that governs the choice of means to given – and often material – ends. Habermas contrasted instrumental rationality with ‘communicative rationality’, which refers to the activity of reflecting on our background assumptions about the world so as to expose our ‘basic norms’ and make them available for (re-)negotiation. Instrumental rationality takes these norms for granted. Moreover, Habermas went on to argue, instrumental rationality is insufficient on its own to capture the nature of either ‘cultural evolution’, which is not governed by means-ends reason alone, or economic and administrative systems, which are too complex to be regarded merely as its products. These themes were to be elaborated in detail in his later work.

Habermas has contributed voluminously to scholarship and debate over the years, so there is a need to be selective (Scambler, 2015). The principal criteria for coverage here are: (1) which of his theories and concepts have most engaged medical sociologists to date, and (2) which of them might yet deepen our understanding of issues of health, illness and health care (Scambler, 2001). Three contributions will be explored under (1) and/or (2). They are:

  1. his elaboration of the concept of a public sphere;
  2. his notion of a legitimation crisis;
  3. his theory of communicative action.
  1. The public sphere

The investigation of the idea of a ‘bourgeois’ public sphere, and of its early potential and later decline, goes back to Habermas’ fledgling years of intellectual development (Habermas, 1989). His analysis was rehearsed in an ‘Habilitation’ thesis rejected initially by Adorno but subsequently accepted by Abendroth at Marburg. In it Habermas traced the concept of ‘public opinion’ back to its historical roots in a bourgeois public sphere emergent in late eighteenth-century Europe. It was in the clubs, coffee houses and salons maturing in this era, complemented by a free press, he maintained, that provided a ‘critical forum’ for the gentlemen of the day to meet and talk over political affairs on a basis of relative equality. A crucial precipitant was the need for these bourgeois gentlemen to grasp state policy-making, which was of growing salience for them and their interests.

Habermas accepted that this European prototype of what he came to term the ‘public use of reason’ was compromised from the outset: it was class and gender-specific for example. He also incorporated in his analysis a trajectory of decline consequent upon enhanced commercialization. Referring to the ‘re-feudalization’ of the public sphere, he showed how this realm of ‘critical publicity’ was progressively undermined by the expanding role of the state (culminating in ‘welfare statism’) and the growth of private businesses and of the mass media. While once the media merely ‘mediated’ public reasoning, they came over time to actively to shape it. Public opinion nowadays, he contends, is a social-psychological variable to be factored in and manipulated by career politicians and the like. Publics become less engaged and more passive as part of this process. Outhwaite (1996) asks whether this is not merely a revisiting of Horkheimer and Adorno’s negativity, another narrative of decay. But Habermas’ pronouncements are characterized by caution, an interpretation revisited below.

  1. Legitimation Crisis

Published in Germany in 1974, ‘Legitimation Crisis’ posits a multiplicity of possible crises in relation to capitalism. Reflecting on the increased salience and steering capacities of the state in capitalism, Habermas anticipated a number of possible ‘crisis tendencies’. The state, he maintained, self-consciously acts to avoid dysfunctions, a strategy he terms ‘reactive crisis avoidance’. More precisely, the state acts to ‘iron out’ the peaks and troughs of the business cycle and to mediate between wage labour and capital to arrive at a ‘partial class compromise’. But it is a strategy with costs.

Habermas contends that the potential economic crises of late capitalism are not expelled from the social system but rather displaced into other spheres. Thus economic crises might be resolved by state intervention, but only by displacing them into the political domain. The state’s two fundamental tasks are: (1) raising and utilizing taxes to avoid crisis-ridden disturbances of growth, and (2) raising and utilizing taxes in such a way that needs for legitimation can be met as and when required. Failure in the former leads to a rationality crisis, and failure in the latter to a legitimation crisis. A legitimation crisis is the more threatening for government. It is as if ‘by intervening’ the government accepts final responsibility for managing the economy.

For Habermas, writing as a self-confessed Marxist, there can be no ‘authentic legitimation’ of late capitalism because of its enduring class structure. Even in the presence of continuous growth, the fundamental ‘contradiction’ of the capitalist system – between the social process of production and the private appropriation and use of the product – remains. State policy is ultimately driven by a class structure that is kept latent. It is class structure that is the source of any legitimation deficit.

A legitimation crisis is contingent on a motivation crisis. This refers to a discrepancy between the need for motives declared and underwritten by the state and the educational and occupational systems on the one hand, and the motivation supplied by the ‘socio-cultural system’ on the other. A motivation crisis occurs when changes in the socio-cultural system become dysfunctional for the state and the system of social labour. The motivations most relevant for late capitalism are epitomized for Habermas by the term ‘civil and familial-vocational privatism’. This refers to (1) the mass, diffuse loyalty associated with formal or parliamentary democracy, and (2) family and career orientations suitable to status competition.

The threat of a legitimation crisis along the lines spelled out by Habermas has been much discussed in the aftermath of the ‘global financial crisis’ of 2008-9, and medical sociologists have made links between the renewed salience of this threat and the health of populations and health inequality and equity.

  1. System and Lifeworld

As part of his early coming to terms with Marx and Marxism, Habermas distinguished between ‘work’ and ‘interaction’. He suggested that Marx failed to attend properly to the latter, as a result reducing communicative action to instrumental action. This ‘oversight’ on Marx’s part led to a ‘misrepresentation’ of his theory in terms of a mechanistic relationship between forces and relations of production. Liberation from hunger and misery, he went on to say, does not necessarily converge with liberation from servitude and degradation. In other words, there is no automatic or developmental relation between labour and interaction.

In his classic volumes on the theory of communicative action, published in Germany in 1981, Habermas (1984, 1987) built significantly on his earlier work. Only the central themes can be addressed here.

  • Habermas argued for a ‘reconstruction’ of Enlightenment philosophy or the ‘project of modernity’, committing sociology in the process to a revisiting and renewal of its classic heritage against agents of counter-Enlightenment like Nietzsche, Heidegger and others.
  • Weber, he contended, conflated concepts of rationality and of rationalization better kept distinct. The lifeworld, is characterized by ‘communicative action’, or action oriented to consensus, the system by instrumental or ‘strategic action’, or action oriented to outcome. The lifeworld here is the medium or symbolic space within which culture, social integration and personality are sustained and reproduced: it consists of private and public spheres (respectively, households and mediated arenas of open discussion and debate). The system has to do with material rather than symbolic reproduction; it comprises the economy and state.
  • Lifeworld and system have over time got out of sink. More precisely, they have (1) become ‘de-coupled’, and (2) the system has increasingly come to ‘colonize’ the lifeworld. Expressed different, the ‘steering media’ of the system (economy = ‘money’, and state = ‘power’) have come to dominate those of the lifeworld (private sphere = ‘commitment’, and public sphere = ‘influence’). Thus, pace Weber, the lifeworld has increasingly come to be bureaucratized, and, pace Marx, it has come to be increasingly commodified.
  • Habermas does not share either Weber’s or Horkheimer and Adorno’s pessimism. While it is true that ‘system rationalization’ has proceeded at a greater pace than ‘lifeworld rationalization’, and that this has led to an extended reach for and scope for strategic rationality, there is nothing inevitable about this. Further lifeworld rationalization, representing communicative rationality, might yet trigger a ‘de-colonization’ of the lifeworld, most notably through a reconstitution of its public sphere.
  • We can no longer expect class-based politics to be the agency of lifeworld de-colonization. Instead Habermas focuses on the potential of ‘new social movements’ like feminism, that is, movements oriented to identity-formation. It is through these that anticipates a challenge to system rationalization.

Habermas switched his attention in his later work to discourse ethics, the law and issues of governance, and these have yet to be mined by medical sociologists.

Applications of Habermasian thought to issues of health, illness and healing to date can be discussed under discrete rubrics: (1) doctor-patient interaction; (2) medicine and social control; (3) lifeworld resistance; and (4) health inequalities and inequities.

(1) Doctor-patient Interaction

In his critique of Parsons’ functionalist account of modern medicine, Freidson (1970) insisted that patients as well as doctors are typically ‘active’ before, during and after their encounters. He was not saying that patients enjoy either the authority or self-confidence of doctors, rather than the ‘voice of the lifeworld’ has been under-researched compared with the ‘voice of medicine’ (Mishler, 1984). Habermas’ detailed discussion of communicative versus strategic action has been used to address this ‘intermingling of voices’ around doctor-patient interaction. Communicative action occurs when doctor and patient are dealing with each other on a reciprocal basis: each is open to challenge and requests for clarification and evidence. Strategic action can take several different forms. Open strategic action occurs when a doctor makes explicit mention and use of his or her authority: ‘I am the expert and my judgement is …’. Concealed strategic action involves more subtle modes of exchange. Conscious deception or manipulation is when a doctor gets his or her way by, for example, deploying arcane medical terminology to put patients in their place. Unconscious deception or systematically distorted communication occurs when neither doctor nor patient is aware that, for example, a suspect evidence-base in being drawn upon to counsel a particular option. It has been suggested that the simplistic and essentially erroneous assumption that a hospital birth is always ‘safer’ or ‘less risky’ than a home birth provides a ready instance of systematically distorted communication: obstetrician and pregnant patient might alike accept this (‘simplistic and essentially erroneous’) assumption ‘in good faith’, oblivious to the fact that it is a assumption that may directly serve the interests of the former (Scambler, 1987). It is a conceptual frame increasingly being put to use.

Barry et al (2000) investigated Mishler’s claim that the dominating voice of medicine is equated with inhumane and ineffective care. They found four principal ‘communication patterns’ across 35 general practice case studies:

  1. Strictly medicine: when both doctor and patient relied heavily on the voice of medicine (worked well for ‘simple unitary problems’);
  2. Mutual lifeworld: when both doctor and patient engaged with the liefworld (more relaxed consultations, more common with a combination of psychological and physical problems);
  3. Lifeworld ignored: when the patient’s use of the lifeworld was simply ignored (most common with chronic physical complaints);
  4. Lifeworld blocked: when the patient’s use of the lifeworld was overridden by the voice of medicine (again, most common with chronic physical complaints).

4 and 5 were associated with the poorest outcomes, measured in terms of patient-centred endpoints such as ‘information/reassurance that was required’ and ‘self-reported adherence’. Another example of a Habermasian framework is Greenhalgh et al’s (2006) study of the role of interpreters in general practice in London.

(2) Lifeworld Resistance

Kelleher (2001) has argued that some self-help groups, especially those run by or comprising only lay members, can be important agents of lifeworld rationalization and de-colonization. He explicates this notion via an analysis of self-help groups around diabetes. In a later paper, a more general case is made that self-help groups, in combination, might constitute a ‘culture of challenge’ to the authoritative and sometimes strident voice of medicine (Scambler & Kelleher, 2006). They note the growing volume of complaints against doctors, increasingly legal, even outside the USA, and the public’s access to the Internet and other ‘rival’ sources of data on their conditions and modes of therapy. People as patients, it seems, are more willing to question experts than hitherto. They go on to posit a new concept of civil society, arguing that the seeds of resistance and mobilizing are planted in what they call the ‘enabling sector’ of civil society, which is located in the private sector of the lifeworld. It is in causal meetings in ‘third places’ like shops, cafes and so on that early decisive conversations occur. The ‘protest sector’ of civil society is located in the public sphere of the lifeworld: it is here that the impulse to resist turns into coordinated action.

Scambler and Kelleher list five types of ‘mobilizing potential’ for the contemporary era. These are:

  • rights: epitomized by the disability movement, initiatives here are centred on the extension of cultural and civil rights;
  • user: illustrated with reference to mental health users in the UK, these arise out of dissatisfaction with local or national treatment options;
  • campaigning: like anti-smoking or anti-pollution campaigns, this potential revolves around specific or highly focused interventions in civil society and the public sphere;
  • identity: as in the case of ‘third-wave’ feminism for example, this form of activism focuses on consumerist celebrations of difference and identity formation, privileging ‘choice’;
  • politics: the ecology movement is representative here, the thrust of this potential being lifeworld resistance to system intrusion, whether via economy or state.

This account of mobilizing potentials owes much to Habermas’ analysis of ‘new social movements’, acknowledging that in the era of high, late or financial capitalism mobilization around relations of class has become less likely. The authors note, however, that the potential for class action should not be written off and are critical of Habermas for too readily implying as much (see Edwards, 2004). The threat of a legitimation crisis is more severe after the ‘global financial crisis’ of 2008-9 than it was previously.

(3) Health Inequalities and Inequities

Some recent contributions to the sociology of health inequalities have used Habermas’ system/lifeworld distinction as a framework within which the rapid growth of material and health inequality and inequity in and between nations since the 1970s might be explained (inequity here refers to inequality which is unnecessary in the sense that it could be eliminated given the political will to do so). For some, this growing inequality/inequity is a function of resurgent neo-liberal (or neo-conservative) colonizations of the lifeworld.

At an increasing pace since the mid-1970s western healthcare systems have been ‘reformed’ to permit more market competition. From a Marxian or Habermasian perspective, this amounts to a progressive ‘commodification’ or ‘re-commodification’ of healthcare. The failure of Clinton’s, and latterly the opposition mounted against Obama’s, healthcare reforms in the USA fall into this category, as does the 2012 Health and Social Care Act in England. There have been no noteworthy exceptions to this neo-liberal trend. There is clear evidence that these reforms are regressive rather than progressive; but there is evidence also that the nature of delivery of healthcare is not pivotal for health inequality or inequity. More important are people’s standards of living, behaviours and orientations to the world (Scambler, 2002, 2011).

Notwithstanding rival sociological explanations for the growing rate of inter- and intra-national health inequalities/inequities, the causal contribution of dimensions of stratification like social class is for some indisputable (Coburn, 2009). There is a strong case that income inequality is causally as well as statistically associated with health inequality, for all the continuing dispute about the ‘mechanisms’ that account for this. Scambler (2011) maintains that health inequalities/inequities in the west and beyond have deep and increasingly global structural roots in western relations of class (of the economy) and command (of the state). He argues that the era of financial capitalism has witnessed a new class/command dynamic in the west. His argument is that objectively class relations have been resurgent, holding more sway over the power elites and command relations of states, even though subjectively they have become less salient for identity formation. The resultant, enhanced colonization of lifeworlds is at the core of the growing rate of inter- and intra-national health inequalities/inequities. He admits, however, that sociological analyses remain overly informed by western theories and perspectives.

Germond and Cochrane (2010) introduce the concept of ‘healthworlds’ in an attempt to add specificity to discussions of health and healthcare deriving from Habermas’ work. The healthworld, they contend, mirrors the lifeworld generally and enters into people’s consciousness as a kind of ‘horizon of action’. It is a ‘region’ of the lifeworld linked to agency governed by an interest in restoring, maintaining or enhancing health: it directs health-seeking behaviour. Thus it is characterized by a telos. Departing from Habermas, they insist that it is also about corporeality, about expressing meaning through bodily existence.

What these authors offer is a refinement of the Habermasian frame, allowing for a more focused conceptualization and study of behaviours around health and healing. But Habermas is not the only critical theorist to emerge from the Frankfurt School. Sociologists are not alone in investing undue resources and effort in reinventing wheels. If Habermas has been adopted, and critiqued, by medical sociologists, there remains an argument that others apprenticed in the Frankfurt circle – not just Horkheimer and Adorno, but Marcuse, Fromm, Benjamin and so on – might yet prove fertile sources in the future.


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