Bury, M. (1986) Social Constructionism and the Development of Medical Sociology, Sociology of Health...

7/22/2019 Bury, M. (1986) Social Constructionism and the Development of Medical Sociology, Sociology of Health and Illness

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M. R. BurySocial constmctioiiisiii and the developmentoi

Abstract U tis paper offers a review of recent approaches in the 'socialconstnictionism ' of medical knowledge. It argues that'coitstructiotiist' propositiom offer a bold attempt to resolvesome of the p roblem s in earlier formulations of the sociology ofmedical know ledge, particularly those of Eliot Freidson.Ho wever, the paper goes on to argue that social constructionismhas failed to tackle the inherent relativism in its stance and tha tit frequently rests on contradictory intellectua l and valueprem ises. The pap er concludes that both policy considerationsand theoretical consistency require a critical appraisal of socialcon tnictionism and its future ro le in medical sociology.

IntroductioBIn recent years a growing number of articles and books haveappeared within medical sociology bearing the mark of a 'socialconstructionist' approach . Though the forms and em p h a^s of suchwriting have varied they have carried the same basic message:medicai knowledge no less than medical practice is sociallyconstructed. In tum, it is argued, medical knowledge contributes tothe shaping of social relations. Further, the objects of medicalscience are not what they appear to be; the stable realities of thehuman bo3y and disease are in fact 'fabrications', or 'inventions'rather than discoveries. Rationality as a force for good is itselfbrought into question and made 'problematic'.

H ie purpose of the presen t paper is to examine these propositionsin some detail and to assess their contribution to medical sociologyas a field of study. While the ntunber of writings infiuenced byconstmctionist precepts has undoubtedly grown in recent yearsthere have been few, if any , attempts to provide a criticalassessment of its argument or implications. It may be, of course,


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138 M . R. Burythat such a trend is developing in medical sociology and that connects with important developments in the broader field of socithought as well as in sub-disciplines such as the history of medicinand the sodology of science. Tlius a more critical debate concem inconstructionism's strengths and weaknesses may be both timely anuseful.There are four main parts to the present discussion. First, I briefsketch in the background to the developm ent of social constructionism. Identifying the context in which it has developed should help unravelling some of the connections it has with existing issues imedical sociology, as well as indicating where it departs from themSecond, I identify and describe constructionism's main themes.\piethod here is to outline some of the key propositions to be founin the literature. Third, I offer an appraisal of constructionismstrengths and weaknesses. In spite of important and challenginaspects of the constructionist argument this assessment highlighsome key difficulties. It pays particular a ttention to the problem s orelativism raised by constructionism's view of medical knowledge a social product, and the issues of the putative medicalisation, no t say mystification, of contemporary social and political structures b(medical) science and rationality.

In the last part of the paper I go on to identify importandifferences in constmctionist writings, particiUarly in the variousodal processes they describe. These tum out to rest on differelevels of analysis, in spite of some shared common featuredisctissed earlier in the paper. Thus, different constmctionists semedical knowledge as an objective discursive process, as a criticmediation of cultural forms and social interests (for some especialdass interests) or as part of a proce^ of professional boundarmaintainance and exclusion. Each of these petitions varies in iemphasis on the supposed 'sodal control' function of medidne anmedical knowledge. Finally, the discussion identifies the differenand at times incompatible, intellectual smd ideological purees owhich these constmctionist arguments call.The paper concludes with a plea for a more critical view of sodconstmctionism within medical sociology and a rejection of i


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Soda l constnu^tionism and the develqpment of medical sodotogy 139interested in medidne had worked under the latter's umbrella(albeit frequently in its more 'smaal' forms, for example in publichealth and general practice) sharing many of its assumptions andgoals. In the nineteen sixties and seventies social sdentists wereincreasingly infiuenced by the appearance of distinctly theoreticalapproaches, espedally those emerging from American sodology,rather than simply adding empirical 'sodal factors' to epidemi-ological and other medical research. Parsons (1951) and thenFreidson (1970) in particular, m apped out a coherent and independ-ent view of both illness and the practice of medidne. Freidson'sapproach in particular brought together a view of illness experiencein terms of the 'social constm ctionism' of Berger & Luckman (1%7)and a critical view of the medical profession's 'monopoly' indictating the terms of such experience.

In spite, however, of the development of a general sociologicalview of medidne much of Freidson's argument rested on thedistinction between disease and illness. As he put it: 'While illnessas a biophysical sta te exists independently of human knowledge andevaluation, illness as a sodal sta te is created and shaped by hum anknowledge and evaluation . . .' (Freidson 1970: 212). Medicine'sclaim to have access to the neutral world and language of diseasewas certainly challenged by Freidson. He saw such claims assignificant and powerful sodal processes. But while Freidson'sanalysis viewed the application of medical knowledge as a socialevent it stopped short of a constructionist account of the content ofthat knowledge.

At the same time other influences were affecting workers in themedical sodology field, and I mention them just in outline at thispoint. First is Marxian-influenced 'critical theory' with its origins inthe Frankfurt school. This has been in part concerned with the roleof the technical in modem society. Far from treating technical areasof modem life as neu tral it has emphasised the ideological as well aspractical role that they play in the shaping of modem socialrelations. Medicine can be portrayed as a frequent and importantpoint of contact for m odem populations with this scientific/technicalrealm.Second has been the influence of other critical social philosophy,


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140 M. R. Buryusedto explain theirownmethodsandobjectsof enquiry. Thisitu m has connected with major challengestoliberal-rationalist viewof sdentific knowledgeand its development.Th ird, there has beenadeveloping deba te within the medical fieitself, and among wider 'publics' con(%ming medidne's effectiveness and efficiency. Thus intellectual debate has coindded witapparent 'crises' in the impact of medical practice on mtxlempopulations.Ifthe efficacyofm edidne wasindoubt then surelythknowledgeonwhichitwas based shouldbeopentoscmtiny as welAll these developments have infli^nced whatonemight call postFreidsonian m edical sodo logy.Insum they have providedthebasiforthedevelopmentofthe sodal constmctionist argument, namelythat medical knowledgeaswellasmedical practiceissusceptibletsodological scmtiny. I now go on, therefore, to flesh out thargument byprovidingan outlineof the main propositionsof th(X}nstmctionist case, before addressing what I take to be itimplications.

The main strandsofconstnictionisniThe 'problematising'ofreality As will already be clear, thefirsand main proposition of social constmctionismis to treat medicaknowledge as problematic and as a central issue in analysis. IWrightandTreacher's words:

Sodal constmctionists beginbytakingasproblematicthe very issueswhich appeared self-evident and uninterestingto theearlierwriters.They, therefore, insistonenquiringhow itshouldbethat certain areasof human life come - or


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Sodal consttucdoiuaR ^ id the develf^nnent of nw dka l sodcdogy 141the Body (1%3) prefaces Ms work with a description of tow heexperienc d th e process of 'prob lem atisation' in a^ntrast t o anearlier outlook which took medical realities for granted . H e states:

I doubt ifitever occurred tomeormyfellow medical students that thehumanbody which wedirectedandexaminedwasotherthan astableexperience. It w ^ thereforewithconsiderable surprise thatyearslater Ilearned that itwas only since theend of the eighteenth century thatdisease had been localisedtospecificorgansand tissues, and that bodieshadbeen subjectedtotherigoursof clinicalexamination.(Armstrong1983:xi)It now seems to be a tenet of modem thought that a range ofrealities, including medical ones, became 'possibilities', in theEuropean context, during and since the late eighteenth century.Dreyfus and Rabinow (1982), foiiowing Foucauit, maintain diat thehuman sdences took on a new impetus in this period, one whichstressed both human subjectivity and the development of humanityand human sodety as objects of study. This historical perspectivesuggests that the human sdences, including medicine, have playedan essential par t in the sh ap ii^ of modern culture and society, but ina way which is inherently problematic, as the subject-objectrelationship simultaneously opens and closes our vision, l^usobjects come into view (e.g. the stmctures of the human body) andare given meaning by human subjects - yet the very process ofdiscovering meaning creates an illusory context, for it is part of thedevelopment of new forms of power and social organisation - whichbecomes even more complex when human subjectivity itselfemerges as an object of enquiry. The layering of social practices,including the production of knowledge, are deeply compromisedfrom this viewpoint, as they are part of the growth of sodaiorganisation and the increasing disposal of power. An attempt tocome to terms with this legacy inevitably involves the 'problem atisa-tion' of the apparently stable reahties which the 'sdences of man'have created.

For Foucault knowledge and the 'conditions of its possibility' arecaught up in forms of power which are highly abstract and diffuse.


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142 M . R . Burying. In this muse Foucault may be seen combining elements M aDurkheimian view of stmcture, or 'collective representations(Armstrong 1%S) with several other intellectual sources, abouwhich I shall have m ore to say. B ut it is im{X)rtant to no te here thapower itself is 'problematised' in Foucault's work while others areprepared to link the 'fabrication' or 'con stmction' of knowledge to amore straightforward view of sodal interests and professionapurposes.

American writers such as Amey and Bergen (1983, 1984), foexample, strongly Foucauldian in flavour, wish to make medicarealities problematic in order to show their dir^:t involvement inpattems of sodal control. Issues such as the medical treatment ofpain in childbirth, sexuality and teenage pregnancy or the 'anomalies'of disability (Am ey & Neill 1 ^ , Am ey & Bergen 1984,1983are shown as effectively colonising experiences, robbing them oftheir authentidty, immediacy, even transcendent qualities. There islittle reticence here in spelling out the political message of theapproach, highlighting the point that different constmctionisarguments vary considerably in their emphasis on medidne'srelationship to forms of power and social control.Mediating Social Relations This trea tm ent of knowle(%e productand the interaction of social relations and the hum an sde nc es, bringmedidne into a new focus. The second proposition which constnKtionism advances, therefore, is that rathe r than standing ou t^de osodal relations, medidne, not only in its practice, but also in itknowledge base 'm ed iates' scK al reiati


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So da l constructionism and the development of medical sod olog y 143depending on which social class was being addressed. Thus the claimthat chlorosis was a natural phenomenon itself became a force inshaping and mediating a class based sodal stmcture.Indeed, Figlio went on to show that a disease such as 'minersnystagmus' was influenced by and expressed the dynamics andchanges of a class society, not just their configuration (Figlio 1982).The reality of nystagmus as a disease mediated early twentiethcentury battles over malingering and workmen's compensation onthe one hand, whilst giving expression for medidne's growingconcern with the environment and psycho-somatic aspects of illnesson the other.

In a similar vein Lawrence's (1979) work on eighteenth centuryEdinburgh medical thought shows how it was caught up in the'improving' ideology of tha t period . The em phasis on physiologicaland espedally 'n ervo us ' mechanisms reflected, and (x>ntributed to , agrowing 'civilising process'. An emphasis on 'refinement, delicacyand moderation' found its expression in a 'physiology of dviiizedman', which helped to 'legitimate the controlling ambitions of thelowland elite ' (Lawrence 1979: 23). A s in Figlio's case,mcialclassfigures strongly here. Lawrence maintains that physiologicaltheories could easily IK adapted depending on the audience: the'sensible' upper classes and the 'insensible savages' or labouringclasses could all be dep icted in terms of the new physiology, albeit ascontrasting cases.

As with C ooter (1978 ,1982) and to a lesser extent Jewson (1974)medical knowledge is seen to mediatechangingsocial relations, notjust their contours or conflicts. Cooter, in particular, emphasises the'flexibility' of sdentific knowledge under conditions of markedsocial change. In this way formal similarities can be found inconceptions of both society and nature. Medicai knowledge is seenas interacting with prevaihng ideologies though different writersvary in how much they are prepared to concede to an instrumentalview of knowledge and its use. Certainly, Lawrence (1979), forexample, does see an 'instrumentality' in Edinburgh 's physiologicalknowledge despite his materialistic view of class relations andscience. Other sociologists and historians working with similar


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144 M. R. Buryview of human agency, knowledge products and thefunctions they may perform.

Medidrte and the neutredity of technique The third propositiowhich flows from the above in spite of some limited qualificationsm ade to it, is that the technical realm cannot be regarded as neutralWright (1979) for example, argues for an incorporation of thetechnical into the analysis of m ed idn e's ro le. Indeed, he argues tha'the distinction between the technical and the non-technical shoiildbe treated as prob lem atic' (Wright 1979 p 101). Traditionasodological approaches which fail to tackle this issue surest adegree of inconsistency whch weakens their impact. Wright arguesthat the world of the technical cannotbeleft to itself in view of t l ^incorporation of significant sodal and political issues (e.g. abortionand child-rearing) into its realm. As we have seen in the case ofA m ey and B ergen's approa ch, the increasingly sophisticated natureof teduiique and the wider scope of instrumental rationality in humanaffairs is linked with important aspects of the spedalisation ofknowledge and the growth of its abstract character. Technicasolutions are advanced to a wider range of sodal problems, aprocess of m edicalisation which, it is claimed, can only contribute toa growing alienation from genuine social and political debateConstructionism in medical sodology asks for renewed attention tosuch powerful issues.

In addition to Foucauldian, social interests and class analysis theproposition that the technical is itself a sodal construct di^ws onW eberian, and more generally 'critical' aj^ro ach es in contemporarysodo logy (Sm art 1983). W right (1979) in particular has been keen toshow the relevance of the Fr^ikftirt s c h o ^ to the analysis of mo demmedidne aicmgside polemicists such as IUich (1975). And Berline(1984) in a more openly political form a tt e m p t to dem m ^trate therole of technology in 'medical dom inan ce', forexamf in thevseofoetal monitors, which, he alleges, is the direct cau^ oi morbidityand escalating costs in obstetrics. From this viewpoint medidne isseen to be a central 'carrier' of the tendency towards rationalisationin the modem world; that is, the intensification and deployment o


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Sodal amstmcdonism and the development of medical sodology 145rationalisation prcKess and the increasing deployment of powerfultechnique tmder the guise of research and analysis. Sociology, andmedical sociology in particular, will in Foucaldian terms becomepartly responsible for the trend towards 'the organisation ofeverything' (Dreyfus and Rabinow 1982: xxxii).The Social Construction of Nature: abolishing 'discovery' Fromthese propositions flows a fourth, namely that disease categoriesshould not be regarded as signalling the discovery of naturalphenomena by the application of neutral and rational methods. Or,to put it another way, claims to the discovery of disease arethemselves scMaal events and take place in social contexts. Hieboundaries between what is to count as legitimate knowled^ andwhat is not are, again, not given states of affairs. They have to htachieved, and c^nflic:t takes place on the margins of science as towhat is to be incorporated and what rejected (Wallis 1979). W hat istaken to be a ciefinitive picture of the natural world tcxlay may notbe so in years to come. Thus a fixed and stable natural world,increasingly revealed through the application of rational methods ofenquiry (particularly by the effort of the individual sdentist) is takento be a myth. Put bluntly, in the words of the late Peter Sedgwick:'There are no illnesses or diseases in nature' (Sedgwick 1982: 30:).Though I shall have more to say about it below, the assaulton the liberal-rational myth of science, mounted by Kuhn inparticular, deserves mention at this point especially in its influenceon the scKiology of science, notably in the work of Barnes (1982),and in the frequent reference made to it by a variety of 'critical' andconstmctionist approaches to medidne.

Bames' treatment of Kuhn's argument leads him to a majorassault on the idea of the autonomy of the natural world. For B am esthere can really be no such thing as sdentific 'discovery '. Only at thepoint when a measure of agreement is achieved among scientificcommunities as to the 'reality' of a given finding or phenomenon,carrying the necessary degree of authority, can that reality beregarded as existing. Thu s methods, within specified soda l contexts,constitute their own objects. Bam es gives the example of the planet


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146 M .R . Burysurround the production of leptimate knowledge. Untess this isrea)gnised, disease, it is held, becomes 'reified', and takes on areality which disguises the conditions ofitspossibility. Constructicmism seeks to m ake these hidden conditions visible.

From this viewpoint m edid ne and sde nc etnmy be better i^en asymbolic sjrstems within society, not as autonomous realms outsideit (Com aroff 1982, ShafMn 1979). The tecSmical/scientific woridsthey inhabit are esentially 'modes of di^x)urse' or 'life worlds' andthey cannot be separated from historical and sodal practices. Infact, Bames argues for the elimination of the distinc:tion betweenthe discovery and c:cMistmction of objects in nature, and also for theelimination of the distinction between sdence and ideology, aconsistent position once one takes the technical/non-technicarelationship to be inherently suspect. Bames' constructionist argument leads him to conducle that if science is a symbolic systemwithin sodety, and not a means of independent enquiry anddiscovery, no distinction between science and ideology will hold. Aradical version ofthisproposition is expressed in the title of Young 'paper: 'Sdence ts Scxjal Relations' (Young 1977).

The questioning of medical progress The emphasis here ondiscourse, the cx}nventional character of knowledge and its sociallycontingent nature, leads to a fifth and final constmctionist proposition, namely that linear or 'narrative' prcx;esses in the history ofmedidne and in medical progress must be abandoned. Theemphasis by Foucault, in particular, on discursive practices and theconditions of their possibility in spedfic historical settings, continually suggest a fundamental message: things could have beenotherwise. Knowledge and the present state of affairs is thus noonly superfidally stable but is also the outcom e of prcxesses we onlydimly perceive. While I have noted that some writers are able toaccept the instmmental and even incremental value of medicaknowledge, the basic constmctionist approach certainly places aquestion mark over regarding changing scientific knowledge asprogressive.


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So da l constnictionism and the developm ent of medical sod olo gy 147issue and as a more important determ inant of sdentific thought thanhistorical 'pro gress ' (W right 1979b). This also suggests that objectsnot conventionally thought of as proper items of enquiry c:an bebrought into view. Those objects lost in the historical mists or keptbeyond the bounds of orthodoxy can be reintroduced to the light ofday (for example Figlio's chlorosis (1978)).More generally, wholeareas of enquiry, can, it is argued, create new awareness bybreaking the hold of the present and its systems of theorising.Foucault's work on the human body, and on discipline are obviouscases in point (1976, 1979).If the terms in which health and illness are set are dictated bymodern medicine, and if medicine's own self-image is then treatedas problematic, we can remain hopeful that new ways of thinkingand acting in the face of human affliction can be sught. R ather thansimply adding to the 'reproduction of conventional knowledge', forexample, by objectifying and reifying such notions as 'stress'(Young 1980), the sodal constructionist approach hopes to breakout from the straight-jacket of the definitions and assumptions ofmedical historiography and medicine's own self-image. Such aproject is given particular urgency in relation to the putativeineffectiveness of much modern medicine, and yet its paradoxicallycentral role in organising our affairs and thoughts.

However, the task for some is not simply to account for thisparadox, but to understand present conflicts within medicine (e.g.between curative and preventive approaches) and between ortho-dox ahd 'altemative' practices (Salmon 1984). As with previousexamples American academic writers have, perhaps, been quickerto identify themselves more closely with altemative practices andknowledge than their British counterparts. Berliner (1982,1984) forexample, has located the development of medical orthodoxy in theU.S. after the publication of the Flexner report in 1910. Thissignalled, he argu es, a strong realignm ent of medical knowledge andpractice and the eventual ascendancy of scientific medicine overrival thought and therapy. Both Salmon and Berliner are clearlydoing more, however, than mapping historical development.Compared with Bames and even Wright they are less concemed


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148 M. R. BinyTht importaiK^vi thecaastrue^tmMHaving establishedinoutline,theccmsmictionist case,how are wto evaluatethepropositionsIhave enum eratedand how are we tjudge their merits?Intryingtoprovideanasse^men tofconstructionism, I want to examine someof the difficulties raised by thapproach,butfirstIwanttoemphasize whatItaketo beimportanabouttheconstmctionists' case.AsIhave indicated, sodal constmctionism extends,and tosomextent restates, sodological approachestomedical knowledgeanpractice. However, contemporary constructionism seeksto tacklwhatittakesto be important inconsistendesinprevious positionInsoifaraslabellinganddeviancy theoryhadbeen em ployedin thmedical field before Freidson, it was [ychiatry that providedthmain target. Muchof this earlier work (exemf^ified by SzaszanScheff I960., 1966) based its arguments not on the problematicharacter of medical knowledge and pracrtice as such,but on i'mistaken' application to psycho-scxnal disturbance and distresIndeed, Szasz (1960) argued that medicinewasappropriate and this sense legitimate and non-problematic) where organic lesionwere evident.The constmctionist position, however,has notbeecontenttoleaveitthere,but hasfollowedtheargument t h r o u ^ tconsiderthesodalandideological ramific:ationsofmedical thoughasawhole.

To this extent cx)nstmc:tionism also challenges the restrictecharacterofmedical sociologyitself. Farfrom being contentto ad'social factors'tomedic:alorepidemioiogical enquiry ,or restricrtiitselfto adesignated areaof sodal experience, often on medidneown terrain for example, the doctor-patient relationship), it hasought to penetrate the dtadel of medidne, medical knowledgitself. This is not so much a retum to the 'trait' theory oprofessionalisation (Saks 1983) but an attempt to show thorganising and powerful role which medic:al knowledge plays icontemporary scxnal relationsandsocial stmctures. Inthis sensemaybeseenas aneffort toovercome both conspiratorial viewsothe medical profession and traditional Marxist positions whic


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So da l constnictionism and the developm ent of medical so do log y 149for a degree of reflective thought often absent in the medicalsociology field.As a brief illustration of this argument consider for example thecase of modem general practice in Britain. This might be seen notsimply as providing a range of socially neutral 'services' for specificclient or patient groups, but as a significant form of social pracrticewith definite consequences in shaping our experiences and acrtions.Armstrong (1983,1985) for exam ple, attempts to show that m odemgeneral practice, both in its organisational form and in its emphasison patient subjectivity and patient biography plays a cmcial role inthe surveillance of modern com munities. In doing so its organisationand their effects are seen to be more than just a product of sodalcircumstances: they help constmct the social fabric and mediate theforms of authority and order characteristic of post-war Britain. Thedevelopment of health centres and clinics are thus portrayed asimportant linkages in the surveillance of modem populations,particularly in emphasising subjective needs and individual meaningin health care. Viewed from this angle, meeting needs has to recastas involving important forms of scxnal control. In Dreyfus andRabinow's words, 'Bio-power is increasing ordering in all realmsunder the guise of improving welfare of individuals and thepopulation' (Dreyfus and Rabinow 1982: xxii).These tendende s areheld to be even more effective where mechanical medicine issuperseded by humanistic medicine (Armstrong 1979). Constmc-tionism repre sents, in sh ort, a strong counter-intuitive thm st inmedical sodology, and suggests renewed attention to familiarobjects of enquiry. Its promise, as noted, is also to bring into therealms of enquiry hidden objects of historical prcKesses in an act ofrecovery, or 'archaeology', to use one of Foucault's terms.Foucault's work itself has hinged on showing the development of'genealogy' of ideas and practices in historical contexts, though notas part of some overriding 'history'. Counter-intuitive views of thebody or sexuality provide, it is hoped, the basis for a form ofanalysis different from the schem es of traditional historiography. Inthis way the central m essage that 'things could have been otherw ise'is examined and cx>nfirmed at one and the same time.


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150 M .R . BuryBritain (Kouiedy 1981) and Susan Sontag's essays on the metaphorical character of cancer in American sodety (Sontag 1979) arecases in point, if such ideas are gaining popukr attention then iseems d e a r the premises and traditiom of thought on v/Mckthey arbased require serious attention. The medical arena is not singly afocus of inquiry to which the human sdences might be attracted(Figlio 1977). In a Foucauldian view these latter forms of enquiryare themselves caught up in, and part of, the very proces^s whicdmedidne may be thought to represent. It is nothing less than thesubtle observation and ordering of the human body and somrelationships under modem conditions; the constitution and c^mstmction of human beings as 'meaningfiil subject and docileobjects' (Dreyftis & Rabinow 1982: xxiii). Constmctionism therefore suggests a form of double reflection, both about ite sub j^^matter and about its part in creating it. There is here anunderstandable reluctance to issue ill-thou^t out prescriptionswhich will only add to the catalogue of worthy if mi^laced'solutions', an argument echcjed elsewhere in contemporary sodological thought (e.g. Berger 1983). Some constructionist arguments imply a 'reflexive' message but leave open the direction oftheir argument.

For others, however, espedally those with an explidt Marxisor ientatio n, the aim of constmc-tionism is to investigate new ways orelating social structures to experience, of showing social aetiologyin disease and illness (Sedgwick 1982, Figlio 1979). And asI haveshown even some of those following Foucault wish to argue anopenly 'radical' case. I hasten to add, here, that many nonconstmctionists working in the health field are , of cx>urse, cxtncemedto tackle what are perceived as the limitations of traditionaapproaches in medical knowledge, medical treatments and theieffects, whether at the level of the susceptibility of social groups tomortality and morbidity or in a closer appredation of the outcomeof interventions including the dangers of 'medicalisation' in healthservices research (Blaxter 1983). Constmctionism is not alone inchallenging taken-for-granted individualistic ievels of explanation inconnecting ill hea lth and scxrial stru ctu re . My point here is simply to


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So da l constnictionism and the devei ^xment of medical sodology 151T h eRationality and relativism in constmctionism In offering anaccount of modes of knowledge, especiaUy medical knowl^e andthe part they play in modem sodal relations, social constmctionismimplicitly r a i^ s the issue ofitsown knowledge base. I say implicitly,for, apart from passing references little is said in the constm ctionistliterature which faces the problem of accx^unting for its ownperspective and methods. The issue which arises c:an be simply put:if all forms of knowledge are part of 'discourees' where does thatleave constmctionism? If the claim is to a form of 'cnitic-al' enquiry,in what way is this claim any more valid, reasonable or tm e than anyother, including that which it seeks to critidze? This problem,common of course to sociology as a whole, becomes particularlyintense when knowledge, and its alleged conventional characterbecomes the focasof a ttention.

The issue is sharpened by a denial of an independent court ofappeal to rationality or the scientific method. Constructionismprecisely sets out to challenge the neutral character of the scientificenterprise and of rationality in medical thought and prac tice, and byimplication in the human sciences more generally. Far from beingmeans by which we c:an better understand nature (and, through thehuman sciences, the individual subject and social forms) rationalityand objectivity become themselves the fod of enquiry. Thus the'discovery' of the tubercle bacillus is not to be regarded as the resultof applying rational procedures to a passive nature, though, as Ihave noted some authors are prepared to draw back from acompletely non-instmmental view of knowledge (e.g. Lawrence1979). In general, however, the whole idea of scientific dis-covery is part of the matter in hand. From this point on, socialpractices replace rationality, sodal contexts are the foundations ofknowledge and power s t m ^ e s replace progress in accounting forchange.

But such is the relativistic nature of the app roach, in its insistencethat scientific and medical categories are relative only to a giventime, place and social configuration, that its own prem ises are pu t in


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152 M. R. BuryFar from medical knowledge about asthma having consisted of proven,timeless, objective facts, it has appeared under scrutiny to be composedof liinited interpretations of the complex phenom ena of illness. Thenatu re of those interpretationsisformed by the w orld, a soda l world, iwhich the physician and patient happen to live; it also contributes to thformation of that worid (Gabbay 1982:43).

In saying this, however, Gabbay is aware that a similar argumencould, of course, be levelled athimself.A thesis might then develosuggesting that constmctionism reflects and contributes to tensionand dilemm as of late twentieth century social life, and so on . Not ffrom here is the abyss of relativism, into which ail argumenconceming the conventional character of knowledge, and thconstitution of objects through the methods of their enquirthreaten to fall. G abbay finally concedes that there are no groundfor aceeptinghis accx)unt of asthma as opposed to any other . Finalland paradoxically, we are left to choose between accounts on thbasis of intuition, offering us a form of construcrtionism morcx)ncemed with epistemologic:al puzzles than with drawing stroncx>nclusions concem ing m ed idne's role as ideology or social contro

For most working in this area, however, the problem of relativisis neither recognised nor taken seriously. Wallis (1979) for examplin introdudng a c-ollection of essays about the history of rejectescientific and medical knowledge, which draws heavily on constmtionist ideas, simply tums the problem aside with the comment th'sodologists and historians have developed a more methodologicall'agnostic' view of the tmth claims of sdence' (Wallis 1979: 5(Though a recent paper by Wallis (1985) indicates an interestinchange of position , partly through a consideration of the 'temperarationalism' of Newton-Smith (1981)). Constmctionism attempts tabsorb ail claims to rational or objective knowledge under thmantle ofitsown perspective, o r at the very least, to neutralise succlaims. By claiming a central, if not privileged, position for thsodal dimension in accounting for forms of knowledge it assumethat relativism has been overcome. It contends that sodal interesand contexts are both necessary and suffident to explain forms o


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Sodal constmctionism and the develt^ment of medical sodology 153methods of enquiry are held to constmct rather than disclose realitywe are bound (as Foucault recognises) to include the humansciences, including 'critical' thought in the process as well. Thisplaces us in a drcle from which there appears to be no escape. Ifrationality cannot be treated as extemal to social forms, as a meansof understanding reality or adjudicating acxounts, what methods areavailable to evaluate the books, articles and arguments which putthis view forward? If all distinctions a re to be treated as problem atic(e.g. science/ideology, discovery/construction) how can any form ofargumentation proceed? Specifically, on what grounds are we tojudge Gabbay's view of asthma, Figlio's view of chlorosis orArmstrong's view of the body, as compared with those offered bythe physicians and scientists in the respective fields? Are theybetter, more adequate or more true, or are we left with a choicedepending only on our social interests?

As Jarvie (1983) has recently pointed out in a discussion ofrelativism in modem serial thought it is not enough to take a furtherstep by trying to incorporate questions of this kind as furtherevidence of the relativist (and I would argue, constmctionist) case.To avoid the dilemm as of relativism by incorporating its rejection asfurther evidence for it, simply twists the spiral round once more . Infact, Jarvie argues that while tendencies towards relativism havebeen important and in some ways welcome in twentieth centurythought, particularly in challenging fundamentalist (and in anthro-pology, ethnocentric) attitudes, the abandonment of any claim torationality or reason as a means of evaluating alternative explana-tions, threatens both the status of scientific/empirical enquiry andfinally of discourse itself. In contrast, Jarvie maintains forms ofknowledge which reject relativism must be taken seriously and notas further evidence of the relativist case. By the same token thegenerative stm ctures of what Jarvie calls 'world historic forces', andfor that matter those of nature, cannot totally be incorpiorated intoconstmctionist accounts. Such forces act as constraints over whatconstmctions are possible and what are not. (As Thompson puts it'The wood imposes its properties and its "logic" upon the joiner asthe joiner imposes his tools, ^ U s and his ideal conception of tables


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134 M. R . Burya result. It has been quick to absorb the relativism of Kuhn andsurprisingly slow to discuss the defence of rationalism (even in its'moderate' forms) by writers such as Newton-Smith 1981) andJarvie (1984).Beyond relativism: theinfluenceof Foucault In particular, the mofar reaching relativistic tenor in a}nstmctionist thought stems fromFoucault's influence. For those who advocate a more Marxistinfluenced version of cx)nstmctionism the problem may not apf^ato be so acute , though 'mediation' theories clearly reduce the impacof materialism as a causal approach. Few of those drawing onMarxism and critical theory have adciressed the fact that \K^terssuch as Habermas have emphasised the distortion of rationalityunder modem conditions and thus offered a defence of it (Habermas 1971).

In the last analysis, however, some residue may be available froma consideration of material or class forces not entirely encapsulatedin the constmctionist argum ent, and of use, therefore, as means ofexplaining forms of knowledge and their development. But Foucault has broken with all such frameworks. If discourse creates itown objecrts and is created by them, then any 'extemal' or generalevel of explanation is suspect. The only methods entertained byFoucault are described as 'archeology' and latterly 'genealogy' inwhich a kind of descriptive chronicle is produced, the status ofwhich is left ambiguous. In other words, the tmth value ofFoucault's arguments is left unanswered and unanswerable. At thecost of a further twist of the relativist spiral, Foucault hc^es to avoidthe problem of appearing to have access to a privileged version ofreality, but in so doing undermines his own position. Dreyfus &Rabinow (1982) quote Foucault in this connection:

For the m oment and as far ahead as I can see my discourse far fromdetermining the locus in which it speal is avoiding the ground on whichit could find support (Dreyfus & R abinow , 1982:85).In Foucault's work there is an attempt to pass beyond relativismwithout recourse to conventional methods or the 'grounds' oexisting theoretical approaches. It tums out, however, that far from


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So da l constructionism and the developm ent of medical sod olo gy 155a deeper nihilism here threaten s to follow relativism. The attem pt tooperate outside all forms of conventional enquiry, untainted by theculture of which one is a part, can be both spectacular andthreatened with disaster. In this connection N ietzsche's influence onFoucault is important, and should be recognised. Nietzche's attackon the 'fabrication' of ideals and the need to re-evaluate all values(Nietzsche 1979) is clearly echoed in Foucault's writings, amongmany other themes (see Smart 1983 for a fuller discussion). In thissense Foucault's work offers no basis for 'constmctionism' or anyother perspective but a thoroughgoing demolition of all suchenterprises. Again, a discussion of this intellectual project as awhole is beyond the scope of this paper. What is surprising, andworth highlighting, however, is that those developing a constmc-tionist view in m edical sodo logy , especially those taking Fouc^ault asa point of reference, have largely failed to tack le any of the criticalissues in so doing and have failed to engage with the debatessurrounding the status of Foucault's work in the wider scx:iologicaland philosophical literature.

If social determination or causal pathways are expunged fromsocial enquiry then the resulting chronicle or argument has to bevery convincing if an atmosphere of arbitrariness is not to develop.If the dictum 'things could have been otherwise' is to hold then thelevel of argum entation has to be highly developed, o therwise realityispotrayed as a contingent and haphazard affair. For exam ple, if thedevelopment of modern medicine is portrayed without reference tosuch issues as changing demographic and mortality patterns, or theeffectiveness of treatments, and if these are to be treated as'fabrications' or as social constm ctions then the argum ent, to say theleast, becomes an ambitious one. In fact, it seems that unlesssociology (and, for that matter, medical sociology) can claim accessat some point to 'generative structures ' little of what it says is likelyto appear valid. Even in the case of work in the phenomenologicaltradition, which attempts to 'bracket' such analytic claims as amethodological device, the organisation of a hospital or thediscrepancy in the power relations between doctor and patient areseen to exercise a powerful effect on the constmction of reality.


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156 M.R. Buryvalue is suspect and is incapable of progress, suggests that categoriein use are cUspensable. O the rs can jttstaseasily serve so da l interestor the d i s p e l of pow er. The dispensability of categories arisedirectly from c3nstmctionism's relativistic stance, for why shouldone interpretation or constmction prevail over any other, if theydisclose or discover no aspect of an independent reality? In sp ite oa cx}mmitment to demonstrate the 'c;onditions of possibility' ocategories constmctionism singularly fails adequately to understandthe organising role of categories which are believed not to bfabrications.

Indeed, a belief in the stable nature of reality may infuriate opuzzle sodologists and philosophers, but it is a precondition of alsodal life (Baumann 1978). To point out that current knowledgewas once different or does not hold somewhere else, or does norepresen t trans-historic tm th , may certainly challenge fundamentalist or rigid views, but it does not by itself alter the place it plays inscKial life. This problem bedevils constmctionist accounts. Hirst &WcxjUey (1982) discuss this issue in a recent review of labellingapproadies to psychiatry. Even when categories are shown to bscxdally variable and value laden this does not necessarily destabili^ their legitimacy. They state:

If the category insanitywerenothing more thanajdugement of socialcompetency, if it involvednorecognition of suffering ortheneed tooffer care, then it would still haveadefinite sociallegitimacy:certainconducts and incapadtiesarean unacceptable disability in modemscK alrelations. It issociallyirrelevant that they mightbe lessorsoanadvantageinother social relations (Hirst Woolley 1982:203).The same point can be made about the methods of science andmedicine as a whole, as well as about specific categories. Bame(1982) for example , begins to recognise this difficulty at the end ohis essay on the nature of the scientific enterprise. Again, thpurpose of his enquiry is to challenge the potentially stultifyingeven dangerous, character of an unreflexive 'liberal-rational' sciencin the m odem world. But, B am es realises that it is easier to say thathings could have been otherwise than to show how. He states:


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con^nicticmism and the development of medicai so d c rt (^ 157categories have no foundation in MIobjective reality and scientificmethods are 'reifying metaf^ysics' then an arbitrary qualitypervades the sociological view. A s Room (1984) has recently pu t it:'This paticular set of emperor's clothes (i.e. medicine's belief in acorrespondence between categories and reality) seems to have theability to bring out the nom inalist small boy in most sodologis ts'. Ifsodal interests explain the production of knowledge then th e actualproducts have no firm foundation outside specific and relativecontexts.Theexaggeration of medicalisathn The problems of relativism,and the implic:ation of the dispensibility of c^ategories stem, I think,from a more frmdamental difficulty, namely a tendency to exagger-ate the hold which medidne has over contemporary experieiue. Ihave shown that some forms of cx>nstmctionism find themselves onsimilar ground to arguments which allege a thorough going'medicalisation of everyciay life', a 'victim blaming' ideology and acentral social control role for modern medidne. In particular,constructionism contends that the presentation of disease as'natural' by medicine, contributes to a 'reification' of categories andeven a 'fetishism' of disease in a commodity form (Taussig 1980,Figlio 1979). ITiis feeds into the idea that modern medicine is acentral 'carder' of rationalising proces^s in the modem world;central to a form of power which is pervasive, ubiquitous andhidden.

Armstrong (1983) for exam ple, sees this developm ent exemplifiedmost clearly by the modern clinic which, he argues, documents,orders and surveys modem populations. As a case in point,Armstrong examines the Peckham Experiment, an exercise incommunity and scientific medicine in South London in the nineteenthirties, (for an account see Pearse and CrcKker 1943), which mightbe seen as the precursor of the modem health centre. Far fromseeing this initiative as a 'progressive' reform - its own self-imageand its official history - Arm strong sees it as symbolic of the overalldevelopment of medicine which was to acxelerate after the Secx>ndWorld War. Rather than meeting community or individual needsand expressing the positive contribution of biological and medical


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158 M . R. Burydevelopment of the clinic which claims that it meets needs andprovides welfare, and another which argues that this is merely acover for the disposal of power.Could we, for example, have recourse to empirical evidenceabout how far the alleged disposal of power and ideologicpervasiveness is acxurate, and what the experiences of thcê werepassing through the Peckham Experiment? In particular, ciid theyexperience surveillance, social cx)ntrol or an 'ideology of healthpromotion'? Lewis (1982) in a paper on the Peckham Exf^dmentsuêsts in fact that there is little evidence for these contentions.Most people in this case, andf^rhaf more generally, experienceservices in a far more mundane way. Lewis's paper suggests thatpeople may well be far more resistant to the 'sinister' effects ofmedidne than is frequently supposed. In spite of the repetition ofthe 'medicalisation of life' thesis, there is inc^reasing empidcalevidence to show that modem populations do not totally rely ontechnical or medical explanations in accounting for the causes ofdisease (Pill Stott 1982) or in the management of illness it^lf(Bury 1982 Com well 1984). Indeed , som e 'radical' au thors find suchevidence qu ite a pro blem , even when they find it in their own work.Thus,Crawford for example, in a study of Amedcan health beliefsstates: 'Given the ex tent of medicalisation in Amedcan Society it isrem arkable that in an everyday context so vaded a discourse exists'.(1984:65). The problem from a constmctionist viewpoint is how toentertain such empidcal complexities, and checks on its arguments.In general the fact that people may notexperiencethe processes thatare alleged to be taking place is either ignored or not taken asto the constmctionist case.

Similarly, allegations that diseases are reifications, fetishisedcômmcxlities and the like, are often expressed in such abstract term sthat the possibility of refutation is avoided. Indeed, alleging thatparticular objects are reified a ppears to be a self-'fulfilling argum ent.David Silverman (1983) in a recent review of essays on 'reification'expresses hisfrîstration( and mine)mth this type of argument. Hestates:Reification, of an objective orderis,forseriousphenomenologists an


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So da l coiffitmctioiiism and t t e (te ve k^ n^n t ^ imdScalsocioif 159edge, without empidcal chicks m evaiilaicm as to its ciegree ofnegativity (or reification) is simply to perpetuate an argiinwntwithout the possibility of refritaticm. At its furthciist point theargument gives die impression that aU forms of sodal instituticms,espedally tho% which are cxnnnuniiy thought to amtdbute tohuman and socid progress, are forms of oppression. Reading, forexample, the final chap ter of A rm stro i^'s Pîticai Armtomy oftheBodyone gains a glum picture of virtually all human enquiry. Notonly is medicine inciic:ated, but so tcx) are other cdtic:al studies.ofmedicine, ^ d a l {^ychiatiy and m uch of medieval sociology i^ l f .Under modem conciitions all such endeavours, it %ems, arecompromi^d and caught up in the proceês of surveillance andrationalisation. This , it seems to m e, casts a gloomy dcnid over tibesocial îentific enterpdse, indeed all interpretation or evaluation,as all acxxxunts are contextualised and, in the final analysis, 'merefabrications'. Th at this condusion m ay be the deliberate intentionofconstructionist wdters is open to some doubt (though there can belittle doubt of a strong trend in this direction in work influenced byFoucault) but m uc^ constructionism as currently argued can be readin this way.

Such is the wide x>pe of the constmctionist perspective thattotalising and general statements (about medidne, sdence, knowl-edge) becomes inevitable. In ackiition, the 'broad brush' effects ofthe approach cx>nceal disparate intellectual and ideolc^câl issues.Most sedously, constmctionism's 'cdtical' af^roach to medidneand medical sden ce is not shared by many of the sources it relies on.It also has difficulty in re flec t of the very different ideolo^ca ltraditicHis inherent in 'critical' soda l though t, and I wish to round offthis assessment by briefly addressing these two problems.

The intdlectuid aiMl ideirfogical sources of constructHHiisiiiIntellectual cross-currents Throughout this discussion I havesought to identify some of the different forms which contemporaryconstmctionism takes. Summarising, I have distinguished a 'sodai


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160 M R . Butytive of social relations as inter-subjectivity in sdence as a culture or'life-world' to the Marxian emphasis on class power and its effec;tson ideas; and from the radical cdtique of the power of professionaland technological elites to the view of power and knowledge asobjective and subtie processes of ordedng in Foucault, in whichhuman agency is all but absent. I have shown that each of theseforms of constmctionism differs in its political and epistemologicalimplications, and I have also shown that individual wdters, of(xmrst,sometimes stray across the vadous boundades. I now wantto look more clcwely at the intellectual sources on which thesecx^nstmctionist arguments ciraw.

First, let me retum to the constmc:tionist view of medicane andsdence as enterpdses in the modem wodd. In arguing for a cdticaland counter-intuitive view of m edid ne, W dght and Treacher (1 ^ 3 )for example, draw attention to the arguments of wdters such asMcKeown and Coch rane, which have questioned the sdentific basisof much medical practice and contdbuted to a more general cdticalappraisal of medidne's efficacy. At the same time Wdght andTreacher engage Kuhn's anti-rationalist acxount of sdence to thesame task. Hieir argument conveys a cdtical view of medicalknowledge and medical practice which assumes them to b e, at best,marginally effective and, at worse, a thinly veiled ideology.

Take, for example, the very different work of Cochrane andKuhn in this cx)nnection. While it is tme that Cochrane's work,especially hisEffectiveness and Efficiency(Cochrane 1972) deliver-ed a major challenge to medicine's complacent self-image concem-ing its role in the improvem ent of hea lth, it can in no way be thoughtto offer a radical or cdtical view of science or scientific method.O uite the reverse, Cochrane's answer to the difficulties fadngmodern medidne is that it should be ever more scientific. Indeveloping his argument on the applicability of randomised c:ontroltrials he argues for a strongly scientific, if not positivistic solution form od em medicine's dilemmas. A s Wallis (1985) notes it is difficult toaddress this example sedously and not accept that such methods ofevaluating medical treatment are a marked improvement onprevious ones. While it is possible to draw attention to thewiderquestioning of m edidn e which Coch rane' work, a m o n ^t others, has


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constnictionism and the develo^mient of metfical x^>logy 161belief in the sdentific methcxl. It is mtical of medidne's lackofscientific standards and dgour, and, in essence, stands at dieopposite intellectual pole to constrwîcmism.Similarly, if we tu m to th e b roader sexual and phiicôpMcal basisof sdentific cliange and scientific fn'ocedure exemplified in Kuhn'swork, this has also been c-opted by sodologic:al wdters with astrongly cdtical, if not anti-sdentific flavour and this is echc}ed inmany constmctionist accounts. In fact, Kuhn's work has little ornothing in cmmon with such views. T l ^ challenge whicdi Kuhnoffers to the contem porary self-image of a liberal-rational ^ e n c e isone which emphasises the paradigmatic or conventional natifre ofscientific know ledge. W hile this seems to be m eat for the constmc-tionist cê it is important to note that Kuhn's aim was not tocontdbute to a disillusionment with sdence or to demonstrate itsputative negative effects - again, quite the reverse. As Barnes(19SZ) has recently argued, Kuhn's wdtings are designed tocomm end science, and it is clear that for Kuhn sdence representsone of the great achievements of human encteavour.

These views, I contend, exist uneasily within constmctionistperspectives. Rath er than clarifying their own position reg ardii^ thenature of science in mcxlem sodety, and the sodological apprciachto which they are trying to con tdb ute , they have, to da te, rested ona loose amalgam of argum ents. Unless t h e ^ are clarified they carrypersistent contradictory connotatiom. Containing Fowâult andKuhn, for instance, under the sam e rcK>f is quite a t a ^ , and it iseven more difficult to shelter Foucault and medical wdters likeCochrane and McKeown who stand poles apart. Yet this is whatsome constmctionkts offer m. Whilst tiie^ difft[:ulti^ may bereccîsed, little attempt has been made to addre^ them inconstmcticmist work.Ideological cross-currents A similar problem adses over theideological direction of 'cdtical' thought and sodal constmctionism.When constmctionism is presented as a general approach it issometimes emphasised that it does not represent a single orcoherent political viewpoint, and we have seen that the political


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1 2 , M. R . BuryOpposition to the liberal-rational view of sdentific enquiry, forexam ple, those of community, consensus and convention are hardlyradical sounding terms. Bames (1984) in fact places Kuhn, in spiteof his concem with scientific change and revolution, in a longtradition of conservative thought, and as part of a conservtivereaction to liberal-rational trends.Similarly, Foucault presents a difficult case for constmctionism, inthat while the odgins of some of his works are in Frenchstructuralism and Marxism, cx)mmentators have increasingly foundhis political out]cx>k to be either cx>nfused or cx)nfusing. As G eertz isquoted as saying: 'Whoever he is, or whatever, he is what anyFrench savant seems to need to be these days: elusive' (Dreyfus &Rabinow 1982: xiv). TTius, for some, radical or 'Hberationist'messages are not read off from Foucault's woit (e.g. Amistrraig1985) yet taken to be its implications by others (e.g. Amey andBergen 1983, 1984). A concem with the exerdse of power canclearly lead in many directions, yet Foucault's abiding concemavoids direct reference to human agency or the social interests atwork. Who instigates or who benefits from forms of surveillance orcontrol seems lost in the mode of discx>urse. This is reflected in anelliptical style of wdting, in which descriptive vignettes are followedby broad generalisations (for example, Armstrong's shock atdiscovedng the 'instability' of the human body is retold as if itclearly demonstrates something profound about reality constmc-tion). Assumptions are thus disguised by stylistic devices makingassessment of evidence or analysis particularly difficult.

In this sense, constmclionism shares a problem with othe r cdticalviews of medidne in modem contexts. Blaxter (1983) for example,notes that constant cd tidsm s of m edidn e and the supposed negativeeffects of health care systems in the nineteen sixties and seventieshave provided much useful ammunition for those with very differentinterests in the nineteen eighties. The attacks on the power ofmedidne and its supposed monopoly in defining disease and illnessand the disposal of scarce resources , take on a very different hue ina ped od of recession and conservative govem ments. Today it is the'New Right' which attacks medical autcmomy and clinical freedomas a part ofageneral argum ent in favour of individualism and choice


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So da l constructionism and the developm ent of medical sodcriogy 163A similar picture of ideological cross current exists over thearguments concerning the 'rationalisation' process in sodety, inwhich m edidn e is portrayed as deeply implicated, and which I haveahready discussed. Constmctionism, as was noted, draws lai^ely on

the Frankfurt school in this connection , particularly in its challengeto the neutrality of technique. This latter is seen to be a keylegitimation of power, a means of realising it and an ideologicalcover for it. Expertise, scientific know ledge and appeals to technicalsolutions are, from this point of view, insiciious aspects ofcontemporary social relations. The result, in terms of alienation,becomes a dominant aspect of scx:ial expedence. Here, again, theargument speaks (in the voices of Wdght 1979, Figlio 1979 andSedgwick 1982, for example) in an anti-capitalist or Neo-Marxisttone.

At the same time, however, the trend towards the rationalisationof soda l relations and the ro le of the technical is part of an argumentwith a more cxinservative intent, especially in an emphasis on themoral cdsis of modem sodal systems. Berger, among others, hasbeen documenting in recent years the 'disenchantment' of themodem world (to use the Webedan term), the growth of 'com-ponential' forms of consciousness (in which the components ofmodem industdal techniques spill over into mcxlem consciusness)and more generally the problems raised by modernity (Berger 1979,Berger, Berger and Kellner 1974). This line of enquiry, in tum,stems directly from Weber and is influenced by the conservativethought of wdters such as Gehlen (1980) which is concerned in partwith increasingly abstract character of scientific thought, andZijderveld (1979) who documents the impoverishment of scKialrelations dominated by functional forms. This approach differssharply from both Marxian 'critique ' and the discussion of particularrationalities in Foucault, for whom depicting general historicaltrends was increasingly an anathema.

In short, cdtic:al and cxjnstructionist views of science and medicineare oceurdng in an intellectual and ideological climate of somecomplexity. Of course, it is quite possible to regard this as awelcome environm ent and even one in which more 'elusive' and less


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164 M. R . Buryprescdbe a particular solution to the difficulties whicii construction-ist approaches to science and m ed idneencountet. What does seemcalled for, however, is a clearer appredation of these cx}mplexitii^and difficrulties by advocates of constructionism . As it is, c^ntraciic-tory assumptions remain unexamined and conclusions dificmlt toreconcile. A general counter-intuitive message of greater reflexive-ness and cudosity conceming taken-for-granted realities may be achallenging starting point, but it seems less than adequate as acx}ndusion. In the absence of further debate on these issues theconstmctionist challenge to the assumptions of conventional ap-proaches (in m ed idn e and sociology) must necessarily remain weak.

cmclwiing rem arksIn many respects it is too early to draw up a final balance sheet onthe contdbution of sodal constructionism. At any rate, there is noreal point in doing so. Constmctionism remains a loc^e trend insocial thought which though it shares some common themes andpropositions is sedously cross-cut by logical and ideological am-biguity. I have also shown that there are several quite distinct t j ^ sof constructionism, with varying degrees of friendliness towardseach other. Certainly the attitude towards Marxist influences byvery different wdters such as Barnes and Amstrong is inc^reasinglyhostile. In addition, constructionism faces the same fundamentaldifficulty shared by other approaches to the scx;iology of knowledge,namely, how to depict the cultural production of knowledge withoutunderm ining, by the same tok en , the validity of its own statements.At best, constmctionism's challenge to conventional wisdom isilluminating and its matedals intriguing, but I have also argued thatit can be unconvincing and contradictory. The attempt to incor-porate and explain other forms of knowledge tends towards an'inclusive' form of cdtica l analysis, from which only constmctionismis apparently exempt. Paradoxically, as Philp (1984) has recentlypointed out even Foucault's strenuous efforts at exemption havefailed. Foucault, the opponent of intellectual systems and grandtheory, has created adherents and a distincrtive school of thought,


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Social (xjnstructionism arai t t e (tewlcqniieat (rf medkid s o d ^ > ^ 165re-formulation, or re-assertion,(d ihe s o c M o ^ a l emterpme, withits strengths and its limits, would stiU seem to offer a way forward.In their recent arpunent Berger & Kellner (1983), for eisample,openly admit the limited ami mcxtest character of scxaoiogy's'relevance stmctives'. Hiis accepts that multiple realities, differentmodes of thought are characteristic of modem sodal systems, bethey psychological, sodological or those erf the natural and medicalsdences. Horobin (1985) has recently and persuasively a m ^ d for adirection,in medical sodology that gcjes beyond the traditionaldivide of a scKiology 'in ' or 'o f medicine. A sociology 'withmedidne' suggests a modest but confident self-im^e for socio-logical work. From this viewpoint constmcrtionism suffers fromexcessive reflecrtion and an over-reaching of the 'relevance stm c-tures' of sodo logy, in a form of incorporation that su ^ e s ts that iteown position is pdvileged. When it does face these difficulties (aswas shown in the exam ple of Gabb ay's essay on asthma (1982)) theargument becom es circular, and we are left with no way of judgingone account of reality as better than another.

The difficulties I have identified in this paper go scmieway, Ibelieve, to explain som e of the less than sympathetic reactions to theconstructionist case, which find broad generalisations about medi-cine unconvindng (e.g. Skultans 1983, Porter 1984). Further, if allforms of knowledge about disease and illness are inherently suspect,interdisdplinary work and collaborative studies become difficult ifnot impossible. Tak en to the extrem e constmctionism finds all othermodes of enquiry wanting.The value of the cnstmctionist case lies in its renewed attentionto, and emphasis on, the frequently unrecognised and problematicnature of science (particularly medical science) and rationality inmodem sode ty. Bu t, as I have been at pains to argue , demonstrat-ing the problematic character of medicine is not the same asdemonstrating its dispensibility, and it does not necessadly helpmatters much to know that things could have been otherwise.Insofar, therefore, as constmctionism is taken to be a part ofmedical scxnology, it may have the effect of narrowing its audienceand reducing its impact. As with anti-psychiatry in the sixties and


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166 M. R. Burysuffedngs which human expedence entails, and with which ali formsof society must deal. Constructionism too readily conveys theimpression that care and welfare are mere facades for the interestsof powerful groups. In its preoccupation with medicine's supposedrole in sodal surveillance and control it frequently exaggerates theprocesses at work. Unless these issues are recx>gnised and tackled infuture constmctionist work its cd tique of medicine and its contdbu-tion to sociology will diminish.

I would like to acknowledge the helpful comments of RayFitzpatdck on an earlier version of this paper as well as useftildiscussions with David KeUeher and Jon Gabe. David Armstronghas encouraged my efforts to tackle 'sodal constmctionism' eventhough this has involved a cmtical view ofhisown w ork. N eedless tosay I alone acxept responsibility for the views expresised.Dept. Social Policy and Social Sdence

Royal Holloway and Bedford NewCollegUniversity of Londo11 Bedford SquareLondon WCIB 3RAU.K.

ReferracesArmstrong, D . (1979 ), The Em andp adon of Biographical M edid ne,Social Science

& M edicine, ISA, 1,1-8.Armstrong, D , (1983), Political Anatom y of the Body, Cambridge: Cambridge

University Press.Armstrong, D . (1 984), The Patients's View,Social Science & M edicine, 1 8 , 9 ,737-744 .Armstrong, D . (19 85), The Subject and the Sodal in M edidn e: an appredation of

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Bury, M. (1986) Social Constructionism and the Development of Medical Sociology, Sociology of Health...

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