Why sociologists abandoned the sick role concept

The rise and fall of the sick role

The example for which I now offer a post-mortem, the sick role, was introduced formally by Harvard sociologist Talcott Parsons in 1951 in two publications. Parsons (1951a, 1951b) there described a social process by which, when people felt ill or had an injury, they took on a new role that was standard in their societies, the sick role. That is, they were unable to function in their usual roles, such as worker, housekeeper, parent or student, and deviated from that norm. They communicated the possibility of this shift in role to their immediate associates, who then legitimated the new role, in which the sick person was held not to be responsible for his or her disabilities and could be excused from the duties of his or her normal roles. Moreover, the sick person had new responsibilities: to try to get well enough to resume her or his accustomed role, and to turn to social figures for help in returning to normal functioning. Indeed, the sick role required that one cooperate with caregivers and healers to try to regain customary functioning. All of these social behaviors were familiar in the mid-20th century when western institutions supported this role and when anthropologists could report observing similar role-playing in other cultures. ²

The concept of the sick role appeared just as the subdiscipline of medical sociology was materializing seriously in the years after the Second World War (one account is Bloom, 2002). The concept was particularly conspicuous as a standard element in the discipline of sociology in the 1960s and 1970s. ³ As participant-observer Alexander Segall reported in 1976, ‘The concept of the sick role has been widely (and often uncritically) accepted among medical sociologists’ (Segall, 1976: 165). Sometimes the idea was explicit or sometimes, as in some discussions of psychosomatics, implicit (for example, Simmons and Wolff, 1954: 75; King, 1963: 111–14; Croog, 1963: 249–55; Wilson, 1970; King, 1962: ch. 4, 208–10). And the fact was that some people in medical care – doctors and nurses – found the idea continually practical and useful. ⁴

As late as 2005, British sociologist Simon J. Williams testified: ‘Parsons’ analysis of illness as social deviance, and the sick role as a socially prescribed mechanism for channelling and controlling this deviance, is a key point of reference in the history of medical sociology, and a staple part of the diet that students of medical sociology (or sociology of health and illness as it is now more commonly known) are fed, year in and year out, on both sides of the Atlantic’ (2005: 123). ⁵ Even though few sociologists published original work on the subject after the 1980s, as Williams indicated, the sick role did remain a standard item in textbooks and reference books on medical sociology – albeit often in a distorted form, a fact that will become more significant below (for example, White, 2002: 111–14; and Cockerham and Ritchey, 1997: 117–18).

Altogether, considering how important the sick role was 40 years ago, it is astonishing how quickly sociologists ceased to publish on it or even to discuss it. Perhaps the best indication of the marginalization of the sick role idea is the fact that Samuel W. Bloom, in his 2002 history of medical sociology, does not even mention the sick role concept. ⁶

One scholar, Uta Gerhardt, writing in 1989 reviewed the history of medical sociology, inquiring why sociologists turned away from Parsons. Her account deals with sociological theory, beginning with Parsons’ structural functionalism, and traces the history of ideas and political ideology that led many sociologists, particularly in the 1960s and 1970s, to account for illness and the working of society in ways different from Parsons. ⁷

My inquiry is more concrete. I shall focus on the sick role and the professional and disciplinary functions of medical sociologists in the 1980s and 1990s. I would like therefore to trace the rise of the concept and then suggest another narrative, in addition to Gerhardt’s, of what happened that the sick role faded out of medical sociology.

The origins of the idea

For Parsons, the role of a patient, or someone who came to a physician as ill, was at first a secondary consideration, and so Parsons came to the sick role only indirectly. His basic interest, as scholars have shown in detail, was in the profession of medicine. In the 1930s, he spent much time observing medical practice. Although he did not publish his findings from those observations, he slowly developed ideas of social structure, in which the profession of medicine was an important paradigmatic element. ⁸

The idea of social role as such was classic in at least US sociology (Gordon, 1966: ch. 1). But Parsons himself did not trace his inspiration to George Herbert Mead or other predecessor sociologists. Rather Parsons cited an odd paper by a Harvard colleague, L. J. Henderson, an MD who was professor of chemistry and taught physiology. Henderson was also a translator and advocate of the social theorist Vilfredo Pareto. In 1935, Henderson wrote an essay about physician conduct in which he briefly described his ‘theory of the relation between physician and patient’ as ‘a social system’. Parsons saw the potential in the title, if not the essay, and in introducing the structure of a social system into a functional sociology, he hit upon the doctor–patient relationship as a major model for what became known as ‘structural functionalism’ (Parsons, 1951b; Brick, 2000).

Parsons began, as I have noted, by arguing that being ill constituted a deviance from social norms, in which a person was unable to function normally as one should in his or her society. Parsons laid out four aspects of the sick role, known for at least a generation as ‘Parsons’ postulates’ (Osmond, 1980: 556). First, the ill person is exempted from ‘normal social obligations’. Second, the person is ‘also exempted from … responsibility for his own state’, an infection or other illness or accident. Third, one has to take the responsibility to get out of the sick state as expeditiously as possible. And, fourth, one should seek help to get out of the deviant sick state, including applying to caregivers and doctors, with whom one must cooperate. Parsons went on to describe how ‘the phenomenon of physical and mental illness and their counteraction are more intimately connected with the general equilibrium of the social system than is generally supposed’, and for that reason the physician–patient dyad is a fundamental social relationship. Thus the physician ‘stands at a strategic point in the general balance of forces in the society of which he is a part’. ⁹

By starting with the physician–patient dyad as an institutionalized social system, Parsons created a narrative in which it was the obvious doctor role that made the patient role discernible. But instead of seeing the sick person as a mere object in doctor–patient relations, Parsons creatively separated the ill person out and made that role into an independent entity. Indeed, in the sick role, the doctor or healer does not appear until the very last stage in falling ill – a point that many later writers missed.

The story is not so simple, however. The term ‘sick role’ and a first-hand description of how deviants in a small group used that role had appeared clearly in a paper published already in 1947 by David M. Schneider. He worked up the idea from observing events in his army units before he was discharged in 1946. He saw clearly that those who pleaded sickness had a recognized place in the group. Schneider not only had written but had published his paper before he became a graduate student at Harvard, where Parsons became well acquainted with him and with his published paper. At that time, Parsons was developing his general theory, and he discussed his ideas with other Harvard faculty members who also knew Schneider’s work. Schneider, who was flattered by Parsons’ recognition of his work, at the time did not object when Parsons took Schneider’s material and used it without acknowledgment. In 1953, Schneider implicitly received some recognition when his paper was reprinted along with two of Parsons’ papers in a collection that made the sequence of publication obvious (Kluckhohn and Murray, 1953). Schneider later did not recall how he came to devise the term ‘sick role’ beyond what he spontaneously observed among his army comrades. ¹⁰

It is only fair to Parsons to point out that he added greatly to the idea by putting the sick role into the major theoretical context that he was developing. He not only put the deviancy–sick role connection into a general social system, but in the process he expanded the idea of the sick role, especially adding the obligation of the sick person to seek help and get well. It was for good reason, then, that subsequent writers on the sick role cited Parsons, not Schneider.

Moreover, one might argue that the primordial source for the idea of the sick role was cultural anthropology. Before he went into the army, Schneider had done some postgraduate study in anthropology at Yale with G. P. Murdock and Geoffrey Gorer, and Gorer counseled Schneider to act as a participant observer and record his observations in his radically displaced situation. Indeed, Schneider even acknowledged Gorer for criticisms and suggestions in revising the paper (Schneider, 1947: 323 n.; Schneider, 1995). ¹¹

Parsons, although a sociologist, in fact was himself well acquainted with the cultural anthropology of the 1920s and 1930s, and historians contend that he adopted the functionalism in his structural functionalist theory from British anthropological thinkers of that time. Parsons did in one place in 1951 refer to the sick role in ‘other’ societies, but he was not explicit. A number of anthropologists, however, in their turn, took up the idea of the sick role. They, too, were already using the idea of social roles, and many were intrigued by the shaman or witch doctor figure and the way in which his role was produced by the local society. As one might expect, they seamlessly wove the socio-cultural sick role into their discussions. In 1978, George M. Foster and Barbara Gallatin Anderson wrote: ‘Anthropologists are beginning to make use of the concepts of illness behavior, the sick role, and the patient role; the terms, certainly, are as applicable to one society as to another.’ ¹² As late as 2001, a medical sociologist (Gallagher, 2001: 398) raised the question: ‘Should the sick role be understood as a universal, impervious to cultural modification – or is it significantly shaped into variant forms by cultural values?’ His own view was ‘that the sick role is indeed universal within broad limits’, that is, in detail adapted to each culture. ¹³

Perhaps the most influential figure contributing to the cultural anthropology of medicine was psychiatrist Arthur Kleinman. In 1980, he reported that he found the sick role being played out in China – in appropriate local forms that he characterized as the ‘cultural shaping of symptoms’. But by that year, Kleinman did not bother any longer to cite Parsons, and he extended the sick role to show the interrelations of the sick role with medical, clinical, social and psychiatric/psychological factors. Kleinman then and later showed a special concern with the subjective (as opposed to the social) experience of illness, and he at one point stated explicitly that he was dealing with ‘illness experience and sick role’. In succeeding years he tended to write of ‘identity’, using Kai Erikson’s term (see below), rather than social role as such (Kleinman, 1980: esp. 77, 119, 194–5; Kleinman, 1988: esp. 159–61). ¹⁴

Parsons’ own writings were so difficult to read that they commanded a limited audience, even in sociology. He was, therefore, not the best advocate of his own ideas. The wife of one of his colleagues complained that ‘his sentences took fifteen minutes to pass any given point’ (see especially Owens, 2010; Gerhardt, 2006: 234). ¹⁵ For some years, a sometimes more commonly cited description of the sick role was that published in 1957 by a young sociologist, Kai Erikson. Erikson brought together three streams. The first was the pre-existing, substantial discussion of social roles in mental hospitals. The second was Parsons’ idea of the doctor–patient social system. The third was the idea of social identity or ‘ego identity’ suggested by psychoanalyst Erik Erikson. Kai Erikson was concerned about how mental patients assumed and left the sick role identity, but in the course of his exposition, he gave a clear description of the sick role, particularly in the chronic diseases that were gaining much more attention in medicine and society after the Second World War. Because his empirical work was based on patients who were taking roles in theater productions they put on for therapeutic purposes, his use of the concept of role was very clear and easily understood. ¹⁶ That clarity probably accounts for why Kai Erikson’s article was what a number of other writers cited for their discussions of the sick role in the 1960s and after, particularly those in the field of mental health, where the idea had by far the most practical application (e.g. Polgar, 1963: 399).

These sociological approaches to the ways in which the sick role functioned in society implied that social structures caused people to fall into the role – especially when they were unable to carry out their accustomed or normal social roles. That is, the person who fell ill adapted by using an institutionalized role available by custom (see especially Parsons, 1951b: 292–3).

Sociologists’ use of the idea of the sick role was understandable. As sociologist Gerald Gordon (1966: [unpaginated] introduction and passim) explained as early as 1966, the sick role ‘has become one of the more central concepts in medical sociology … it has been accepted because of its prima facie reasonableness’. For one thing, the idea of a sick role contained familiar elements. Social role theory, as I have noted, was well established even before Parsons published. Anthropologist A. Irving Hallowell in 1953 quoted the eminent biologist Herbert S. Jennings’ discussion of social organization among infra-human animals, noting that ‘only if the individuals play different functional roles is there social organization’ (Hallowell, 1953: 601). At other times, other scholars (e.g. Osmond, 1980: 556) described how elephants and dolphins responded to and looked after another member of the group who became dysfunctional and distressed. Even the idea of social deviance was already in the literature in 1950. ¹⁷ In many of the culture and personality writings that were so standard in the mid-century decades, social roles were the cultural means by which a person learned to function in his or her society (Sarbin, 1954: 223–9; King, 1962: 208–10). In 1981, Stuart T. Hauser in a book for clinicians explained how the sick role worked:

… cultural roles applying to this new, usually temporary role have … been internalized during the course of development. Learning to assume the future patient role occurs within the family setting, as the child and young adult observes various relatives moving in and out of this status during different points in their life cycles. This learning continues even after one becomes a patient. There are many cues, for instance, within medical interviews and in hospitals or clinics as to what is appropriate ‘patient behavior’. (Hauser, 1981: 125) ¹⁸

A number of Parsons’ colleagues in sociology did understand and explore the idea of the sick role and showed how it could be applied and expanded. Perhaps the most successful was Edward A. Suchman (1965), who spelled out a series of stages through which a person went, from feeling ill to taking on the sick role, to receiving medical care, to resuming a normal role. His description and the chart with which another colleague illustrated it were still being repeated in textbooks almost half a century after 1965 when Suchman first published. ¹⁹

As late as 1981, Andrew C. Twaddle presented a systematic evaluation of the various writings on the sick role. Despite all of the criticisms, which he reviewed, his conclusion was surprisingly positive, and he found ‘that the sick role is an analytically useful concept’. The one area in which he found growing lack of support and validity was the finding that various social groups held different standards and bases for responding to a person’s perception of when, why and how he or she might take up a sick role – such as feelings of pain versus inability to perform tasks. But already the language in medical sociology was beginning to include not the sick role but ‘illness behavior’, which would soon turn into ‘health behavior’, as will be noted below (Twaddle, 1981: quoting 179).

Competing theories in sociology

The fact remains that, although the idea had become a commonplace, leading medical sociologists did eventually stop writing about the sick role, and it is at that point where this article takes up the story. Many investigators just assumed that everyone knew about the sick role, and they moved on. What they moved on to – at least at first – were new theories and frameworks that generated discussion and research beginning especially in the 1960s and after.

From one point of view, as Uta Gerhardt (1989) shows in her detailed intellectual history, Parsons’ idea of a social system in general and the sick role in particular ran into a buzz-saw of criticism from some of his colleagues. In part the critics, who particularly targeted Parsons, were just anti-Establishment, typically younger people who accused Parsons of being a conservative who advocated conformity and passivity and denied the importance of individual agency. In part, however, the critics represented major alternative viewpoints, particularly not only neo-Marxism and phenomenology but more generally symbolic interactionism. ²⁰

The advocates of alternative approaches typically subscribed to the then-new idea that illnesses were social constructions. They also generally subscribed to labeling theories, that is, that variance or deviation of any kind did not come from nature but was just a label humans applied to other humans. In those alternative schemes, professionals, especially physicians, were power and control figures, and therapy was a way of reducing a deviant to an inferior social status. Finally, alternative authors implicitly rejected ideas of unconscious irrational motives, particularly those of Freud, in favor of a cognitive-behavioral explanation for actions. Directly or indirectly, the advocates of alternative views often agreed with the neo-Marxist belief that disease was caused by social deprivation and exploitation (Morgan, Calnan and Manning, 1985: esp. ch. 2; Gerhardt, 1989).

Several varieties of critics of Parsons and structural functionalists held that the basis for social life was not trying to maintain a constant equilibrium, as in functionalism and the sick role, but, rather, conflict. Often writing in terms of power and dominance, they cited the texts of the French philosopher, Michel Foucault. One group portrayed all social interactions as a constant series of social negotiations and pointed out that the bargaining power between doctor and patient was uneven, and therefore one goal of sociology should be to bring power to the patient. The critics in general wanted sociologists to shift away from what united people who share the same society, as in Parsons’ social system, to a perhaps romantic emphasis on what makes each person different. They therefore turned away from the conformity that they believed use of the sick role concept supported (Gerhardt, 1989; Sumner, 1994). ²¹ A closely related additional reason for young sociologists to reject the sick role was their perception that it was part of structural functionalism, and by the 1970s, many politically sensitive investigators were denouncing functionalism as inherently conservative and therefore unacceptable in any form (see especially Sumner [ibid.]).

It is all very well to rehearse the conflict between different social theories competing in the market place of ideas. In this case, however, the rhetoric that anti-Parsonians used often degenerated into polemics and political labeling. The practical outcome was that the sick role to a substantial extent became represented by incomplete and distorted versions repeated over and over until they leaked into standard secondary sources and textbooks. By the end of the 20th century, glib dismissals of the sick role concept, often including it in dismissals of all of Parsons’ social system, were commonplace in the sociological literature. ²²

It is disconcerting to find that a remarkable number of these later summaries of the idea of the sick role and its context of structural functionalism were all expressed in phrases that appeared in a book published in 1974, The Exploitation of Illness in Capitalist Society, by Howard Waitzkin and Barbara Waterman. Or sometimes the misrepresentations merely cited the book. Waitzkin at the time was an activist physician with a Harvard doctorate in sociology, and Waterman was a Harvard doctoral candidate in social psychology who was active in the women’s movement. Waitzkin and Waterman made a case that physicians and the whole medical establishment acted as instruments of exploitive capitalism. By portraying the sick role as a status needing legitimation by a physician, the sick role appeared in many contexts as a means for social control carried out by doctors. Physicians, by certifying a sick role, provide ‘a temporary exemption for individuals who encounter strain in their usual roles’, a strain produced by the pressures of the existing social order. ‘The sick role provides a convenient mechanism of social control by which institutions can allow deviant behavior within carefully controlled limits’, continued Waitzkin and Waterman. Physicians’ actions in trying to help the individual deviant ‘patient’, the authors continued, ‘may result in unintended conservative and perhaps counterrevolutionary consequences’ (Waitzkin and Waterman, 1974: 24, 65). ²³ A large part of a generation of medical sociologists apparently learned about the sick role in this context, although they generally later left out ‘counterrevolutionary’ when they borrowed the phrasing. ²⁴ This interpretation specifically depended upon the common misperception that what is important is the physician’s certifying the sick role for a patient, not a sick person’s trying to cope with illness.

Gerhardt, for one, was obviously bemused by the many misreadings and misrepresentations of Parsons’ work that accompanied otherwise interesting theoretical arguments. At one point, in 1987, she undertook to refute two major misrepresentations of the sick role: that it ‘failed to account for’ individual variations in expectations and behavior in ill people and that it did not ‘account for chronic illness’, which was a constantly growing problem. She suggested that critics look at Parsons’ ‘conceptual stance … in its full original version’, but the strongest condemnation she could manage was the comment that ‘Possibly the impact of the continuous misreading of Parsons’s [sic] theory has become stronger over the last twenty-five years than the impact of the authentic contents of the original works’ (Gerhardt, 1987: 110, 114). ²⁵

A number of medical sociologists had put forth alternative conceptualizations, many of which emphasized the physician figure. ²⁶ Because they were fundamentally concerned about the physician figure, they might better have used the term ‘patient role’, rather than a term that was derived originally from group relationships in which the role of the ill person was primary. Some did so occasionally, thus overtly conserving the primacy of the physician, without whom, in their eyes, there could be no ‘patient’. In this way, they set the stage for doctor–patient conflict. Parsons’ distinction of the sick person from the patient continually separated his contribution from that of most of his successors. It was only in his general social system that the physician figure became central. Ironically, as J. T. Young wrote in 2004, most of the critics in fact modified rather than rejected Parsons’ conceptualization. Most transparent was ‘the narrative turn’ that changed the sick role into ‘stories of self’ (Charmaz, 1999).

Moreover, as became significant at the end of the 20th century, a basic problem with the sick role was not just that it was a familiar idea but that it was a descriptive concept based originally on qualitative observation. A number of sociologists expressed doubt about the sick role because they took the idea of social determinism very literally, and they found that in practice in society there were numerous exceptions and variations to the sick role pattern. They were unwilling to follow Parsons and others to see a general pattern, which of course would anticipate and accommodate exceptions. In particular, the sick role was an ideal type. That meant that there would be many exceptions in actual practice, people who did not go through all of the stages or react as social norms might have prescribed (Segall, 1976: 165; Hekman, 1983). Many sociologists found all of this soft science intolerable, and some went to the extreme of trying to deny that people in other, non-Western societies and cultures acted out ‘the’ sick role. Such critics pointed out that the concept did not fundamentally involve measurement and prediction, which was one important way to make an idea hard-headedly scientific.

Contingent factors operating to obscure the sick role concept

Beyond their theoretical and interpretive concerns, medical sociologists in the last part of the 20th century found that new generations were coming along, and a variety of social circumstances was changing – not least the shift to consumerism, for the sick role was based in the world of the work ethic when producer roles were dominant. After the First World War, injured soldiers, for example, were expected to try to fit into a producer society and follow an ‘ethic of rehabilitation’, parallel to the work ethic and the obligation in the sick role to try to get well and be a productive worker (Linker, 2011: 1).

Because the idea of the sick role was confirmed, and even elaborated, but not developed very much further after 1951, by Parsons or anyone else, for academics, if not all intellectuals, it ceased being of great interest as a cutting-edge attraction. ²⁷ Ultimately even the alternatives that sprang up gave way, especially after the period of the 1960s, when younger scholars had made the sick role a foil for their rebelliousness and resurgent romantic individualism (Day, 1981: 95–8, chs 5–6).

There was ultimately another, decisive contingent reason that sociologists moved away from the sick role concept: in the 1990s especially, the subdiscipline tilted strongly toward applied medical sociology and generally attempting directly to improve the world. The sick role, medical sociologists found, was difficult or impossible to use as an instrument to improve treatment, that is, actively to intervene in what happened to individual ‘patients’ or statistical ‘risk groups’.

By the end of the 1980s, it was possible to see that the social functioning of sick people or patients was passing into a new type of study. In the literature in which sociologists might use the idea of the sick role, a series of steps appeared. The first was to write about ‘illness behavior’ instead of the sick role, although taking the sick role could be one of the behaviors – along with many others. It was at this point, with the term ‘behavior’, that social psychologists came into an area that had previously been claimed by sociologists. The journal Health Psychology, for example, had been founded in 1982. ²⁸

The second step was to change ‘illness behavior’ to ‘health behavior’. The change signified by the new language was profound. Sociologists, and now social psychologists alongside them, could describe how ill people behaved, as in the sick role, but those studying ‘behavior’ implied or believed that they could change that behavior. That is, they assumed that by changing immediate social circumstances, they could induce adaptation on the part of the sick person and so alter social actions. The new goal was not just description and understanding but policy change and reformed behavior – reform on the part of people who were part of the ill person’s social environment as well as on the part of the patient.

Indeed, reformers shifted from sick behavior to ‘health behavior’ because the reformers believed explicitly that the new positive term would help improve individual behavior and so prevent illness. There was a moral obligation ‘to behave, think and feel “healthily”’ (Greco, 1993: 362). One of the elements feeding in to first illness behavior and then health behavior was the ‘health belief model’, in which investigators from public health, education and psychology tried to find the beliefs and values that would cause people to behave in ways that would maintain and improve their health – or not. Simultaneously with the sick role in sociology, the health belief model had developed in public health to explain why one or another strategy, such as screening for tuberculosis, was or was not effective. In one transitional volume (Gochman, 1988), for example, the sick role was conspicuous, but so was the health belief model (Rosenstock, 1990; Janz and Becker, 1984). ²⁹ Medical sociologists (e.g. Glik and Kronenfeld, 1989) ultimately could even speak of a ‘well role’.

Their new emphasis on health indicated that medical sociologists had been drawn into the prevention crusade, in which people were blamed for their own illnesses, particularly illnesses brought on by smoking, bad diet and obesity, sloth and/or stress. In the long history of sociology, participating in this crusade could look like a return to the reform and religious origins of sociology. Or it could look simply like an adaptation to the new preventive style in medical practice, based on risk groups (Karlawish, 2010). The sick role was for individuals; risk groups consisted of passive membership in an epidemiological cluster (Bunton and Burrows, 1995). Any remnant of the sick role thus was ultimately forced into the ‘wellness’ morality form and adapted to new styles of medical care that came with the new century.

What was clear was that sociologists were now among those attempting to change people’s health. These sociologists closed out the sick role by applying sociology and not focusing on general sociological principles. A survey in 1973 found that ‘very few’ medical sociologists were doing applied work (Day, 1981: 75). The contrast a quarter of a century later was enormous.

By 2000, if there was any theory, now it tended to be cognitive and social psychological. Moreover, external forces again helped determine events. As Bloom (2002: 266–70) points out, in the United States, the funding that had earlier fueled medical sociology as a field was greatly diminished. Instead, the prevention crusade, designed to change people’s lifestyle from sick to healthful, offered new opportunities for sociologists to join teams of educators and psychologists and benefit from the funding of health initiatives. At the turn of the 21st century, sociologist Ronald Manderscheid remarked that the new crop of medical sociologists was turning into ‘the hired hand researchers’. To that comment, Bloom adds: ‘These are a much more technologically oriented group of people than they are intellectuals.’

The sick role, as Hafferty and Salloway (1994) show, could not survive unchanged in the new circumstances. In the late 20th century, what had been the structural or cultural components of the sick role were being heavily medicalized by changes in the popularization of health. Physicians wrote and spoke about prevention and healthful living so that folk and lay elements in assuming and recognizing a sick role now moved the doctor into acting as an agent of the sick person’s conceptualizing and being blamed for ill health. At the end of the 20th century, many people knew what symptoms meant and why they themselves had responsibility for being sick – if they were overweight or smoked, for example. Ironically, the neo-Marxist-distorted emphasis on physicians’ involvement in one’s becoming ‘sick’ could now be partially justified by health advocates’ open attempts at social control of the public’s behavior. Moreover, as Hart (2003), for example, shows, employers were using ‘healthy beliefs’ to lower labor costs by not recognizing that illness was excusable, with the consequence that sick leave was de-legitimized.

In many ways, therefore, the pressures from external forces around the turn of the 21st century transparently were affecting sociology and, particularly, medical sociology, now called the sociology of health and illness (Levine, 1995). But even that field of study, as Bernice A. Pescosolido and Jennie J. Kronenfeld observed as early as 1995, was being marginalized by the increasing dominance of economics and psychology in health work in the 1990s. Leaders of sociology spoke openly of the fragmenting of the discipline and the disconnect of medical sociology from general sociology.

There may have been some agreement among medical sociologists that the biomedical model was in error, but there was fundamental and detailed disagreement about what to substitute for that model. In 1992, Leonard J. Pearlin could list among recent research interests of medical sociologists:

… national health policy issues; rehabilitation from illness and disability; health care professionals, their training, socialization, and behavior; the formal organization of health care settings; stigma; the origins and health consequences of stress; medical ethics; health risk behavior; services utilization; AIDS; alcohol and substance abuse; social epidemiology; death and dying; the social history of health practices and precepts; and on and on. (Pearlin, 1992: 1–2)

Sociologists themselves (Cockerham, 2005: 51–2; Pescosolido, 2006) were very much aware that the original focus of the subdiscipline, medicine, was itself in the throes of basic change in perceptions of disease, in technological innovations and in social identification. Clearly the shift to emphasizing health, illness prevention and individual responsibility was a challenge to traditional medical sociology. In 2004, the editor of the Journal of Health and Social Behavior (Hughes, 2004: iv) reported that for the previous 10 years, fewer than 10 per cent of the articles ‘have been concerned with the social organization and social processes of health care’.

Conclusion

Beyond contingent events and circumstances, one additional way of understanding what happened is to see that medical sociologists turned away from acting as members of a scholarly discipline and instead wanted to intervene in society, that is, to have the role of professionals. ³⁰ From a disciplinary point of view, the sick role did not meet the new methodological standards of quantitative, reductionistic sociology. From a professional point of view, the intellectual and observational function of the concept did not survive well in the activist period that began especially in the 1990s, when the emphasis in medical sociology changed from sickness to health.

It is true that in the fragmented field of medical sociology, a few sociologists, particularly in Britain and other areas in which theory received more emphasis than in the USA, still found the concept interesting and possibly useful in the 21st century. ³¹ Without the old factor of misrepresentation and a possibly temporary diversion to health behavior, how successful such advocates of the sick role concept might be with coming generations of sociologists is still unclear.