11 The sick role

Arthur Frank has suggested that the sick role represents perhaps ‘the root of social scientific consideration of the medical complex’ ^[1], and its influence on the way we think about healthcare in Western societies cannot be understated. Parsons suggested that being sick represented a specific role that people fulfilled at times in their lives, and this role came with certain rights and obligations. The sick role was a position people adopted during bouts of short-term illness or injury. For a short period of time, the sick person was allowed to be exempted from their normal duties. They could take time off work or school, take to their bed, and avoid all commitments and responsibilities, if they could show that they were genuinely sick. They could hand over some of their responsibilities to others, who would pick up their burden for them. And they would receive the sympathy of their family and friends. In return, the sick person was expected to seek medical help, rest, accept help from those around them, and, crucially, work hard to get well again. Because after a few days, people’s tolerance for the sick person would start to wear thin, and they would be expected to return to their ‘normal’ role and their period in the sick role comes to an end.

This model explains what is probably a familiar experience for most of us. For a few days, we become model docile patients, and society mobilises to make the impact of our illness as short-lived as possible. Parsons’ model, though, says much more than this. It explains, for example, how healthcare is orientated towards acute, short-term conditions, in preference to long-term, chronic disorders. As a society, we are much less tolerant of people who either cannot take up ‘normal’ life roles, or become dependent on others for an extended period of time. The sick role was also one of the first models to show that health and illness could not be understood only as a pathological phenomenon, and that it was ‘self-evident that the institutional shape of the illness-health-medicine complex can be understood only within more extensive conceptualisations of how society works’ ^[2].

Parsons showed that being sick was ‘a role granted by society to those who accept its core values’ ^[3]. Being sick could be seen as a sociological rather than a biological phenomenon which, in turn, provided some of the impetus to think about why we had health professions because it was clear to many of the early functionalists that the biological basis of health and illness could not explain why health professionals had appeared and risen to prominence only in the previous half century. To put this in physiotherapeutic terms, one might say that a person does not have physiotherapy because they have a pathology; people have had illnesses and injuries for ever, and for much of human history there have been no physiotherapists. Rather, they have physiotherapy because physiotherapists have shown their aptitude in restoring the delicate balance of society. As long as physiotherapists restore social order more effectively than others, they will continue to receive their mandate. So contrary to the ethos of person-centred care, in functionalism, society, not the individual, comes first.

Uta Gerhardt ^[4] has suggested that there are two distinctive approaches to illness at work in Parsons’ sick role:

1. The first she calls the ‘capacity’ model. Here the person has failed to keep well and has become incapacitated by an illness that has overwhelmed their ‘capacity’ (an acute sport’s injury or debilitating flu, for example). The illness is seen by society as a natural phenomenon and not the result of some failure of personal motivation. The person’s recovery is often relatively uncomplicated, and rarely involves social judgement or punitive measures. Patients are given a window of time in which to recover and rehabilitate. Most then return to work or ‘normal’ life, without question or judgement;
2. The second model of illness Gerhardt calls the ‘deviance’ model. Here people are often believed to be layering personal, social, psychological, and cultural factors on to a biological process, manifesting what society sees as ‘deviant behaviour’. They are subject to social judgements and accusations of malingering, fraud, over exaggeration, hypochondria, attention seeking, and so on, and experience social judgement and pressure to return to ‘normal’, socially-mandated roles. Numerous studies have shown how stigma and labelling function in this way as social rather than biological readings of illness (see more on this in Chapter 6).

Gerhardt’s work reinforces functionalist beliefs that acute and chronic illnesses are first-and-foremost expressions of the things society finds intolerable, rather than purely medical pathologies. Given this, Parsons’ sick role perhaps does a better job than biology in explaining why the boundaries have shifted around disease and illness concepts over the last century. Parsons’ interest in developing the sick role was not, however, on illness in and of itself, but on understanding how practices like medicine used particular ways of thinking about illness for its own professionalisation project. Parsons was interested in how doctors became key agents in the management of what had been for centuries a very personal experience.

Parsons was enamoured with the success of medicine, and suggested that medical practice in the 1930s represented an ideal working example of a synthesis between the self-interest of capitalism and business, and the collective control of socialism ^[5]. Indeed, Parsons saw the relationship between the medical profession, the state, and the population as a model for future democratic capitalism. Perhaps it is not surprising, therefore, that medicine came to be seen by many as an ideal-type profession.