8 A brief introduction to functionalism

The first widely acknowledged sociological critique of the health professions came from the collaborative work of Emile Durkheim (1858-1917) and Talcott Parsons (1902-1979). Durkheim, considered to be one of the fathers of modern sociology, and Parsons, who did as much as anyone to bring scientific respectability to early sociology, defined an approach to the study of society that saw the professions as playing an important stabilising role in society. The professions, they argued, brought balance and order to society by offering services that addressed some of the ‘negative’ conditions prevalent in all developed nations. Where there was illness, we needed doctors and nurses, and we had police officers because there was crime; and so on. When professional groups brought social order, society functioned more effectively and people were happier. And because they claimed that people always preferred order to chaos, those professions that tuned into society’s needs were rewarded most for their service.

Durkheim and Parsons made popular an idea that had been prevalent in Europe since at least the 17th century; that a ‘social contract’ existed between the people of a nation and its government, and that all developed societies possessed an innate collective desire to make living conditions better by improving social stability. Functionalists argued that this ‘collective consciousness’, as Thomas Hobbes (1588-1679) called it in his book The Leviathan in 1651, drove the creation and organisation of things like the healthcare system, the military, schooling, and the legal system, and made it necessary to create a professional class that could do the work of securing the health, wealth, and happiness of the people. The power of this ideal is one of the founding principles of functionalism, and it remains a seductive concept for many people today. Authors like Richard and Daniel Susskind, for instance, recently spoke about automation, digital technology, and the changing nature of globalised life-threatening the historical ‘Grand Bargain’ between the professions and society ^[1].

The functionalist sociologists of the 1930s suggested that the professions were a response to society’s need for order and balance, and that the professions solved problems that lay members of society had neither the experience nor the expertise to address themselves. Durkheim believed that the professions enhanced social cohesion and ‘were (or ought to be) an important integrative force in rapidly changing, industrializing societies’ ^[2]. Durkheim believed that laws governing social life operated in the same way as natural laws, like gravity, and that ‘shared modern beliefs act as a social ‘glue’ and create a sense of harmony in a society’ ^[3]. He put forward the radical suggestion that social rules, laws, cultural beliefs, customs, and practices, or what Durkheim called ‘social facts’, were as real as the physical world that surrounded people, and that knowledge of these rules could promote good society. Key to this operation were the social institutions, especially the family, the workplace, religions, political systems, education, and healthcare. These institutions played a key role in establishing and maintaining social solidarity and stability.

Durkheim provided the template for the belief inherent to all functionalism that societies work better when people depend on each other, and his research promoted the idea that a ‘sense of social solidarity’ ^[4] exceeded the kinds of individualism that he thought was becoming increasingly pervasive in society. Social solidarity underpinned Durkheim’s secular ethics, and he articulated this in a number of forms that related to the work of the professions. Durkheim defined a form of mechanical solidarity between people who share similar work, where there is little division of labour (in trans-disciplinary practice, for instance), as well as organic solidarity, when people performed distinctive roles. It is called ‘organic’ solidarity because Durkheim believed that this kind of division of labour required people to work together to maintain a functioning society, and this kind of collaboration led organically to interdependence.

The idea of social solidarity was not Durkheim’s alone, however. And nor was it a purely sociological idea. John Maynard Keynes (1883-1946), the economist responsible for designing the National Health Service in the UK and developing the principle of macroeconomics, believed that war and inequality, not scarcity and unlimited demand, were the major problems for economists. As a young man, Keynes had believed passionately in free trade and the role of the British Empire, which he saw as a powerful force for democracy and hope around the world. These beliefs were radically altered by World War I, however. Keynes was responsible for British war finance and negotiated the Treaty of Versailles, but he was also a pacifist that became appalled by the war itself, which he saw as being driven by naked self-interest and competition. Keynes argued for an economics that was essentially functionalist. He proposed economics driven and governed by the state as a vehicle of social solidarity. Like Durkheim, Keynes’s ideas were shaped by the remarkable social progress of the late 19th and early 20th centuries, but also by the shocking realisation of what uncontrolled progress could be used for if anomie and inequality went unchecked.

Like Keynes, Durkheim believed that because modern societies had much more complex divisions of labour, and people occupied an enormous number of interconnected roles, social solidarity was much harder to achieve. He believed that humans were prone to antisocial and individualistic behaviour, and needed social norms in order to prevent anomie. Durkheim believed that anomie, meaning ‘without law’ or ‘the lack of a sufficiently secure framework by which people are provided with a sense of moral regulation and social integration’ ^[5], was the result of rampant individualism. And like Karl Marx before him, Durkheim believed that anomie was a major cause of individual and collective ill health.

To counterbalance this, people needed structural forces operating in society to promote social cohesion and integration. People needed to submit to these forces as a condition of their liberation because, ‘For man, freedom consists in the deliverance from blind, unthinking physical forces; this is achieved by posing against them the great and intelligent force which is society, under whose protection he shelters’ ^[6]. Durkheim believed that the nation state bore a key responsibility for diagnosing and maintaining social order, much in the way a doctor might diagnose and treat an illness in a patient. Governments established social agencies, like the professions, regulators, administrators, and judges, and these undertook the empirical work of monitoring and rehabilitating social ills. In this way, the health of the social ‘organism’ as a whole was maintained.

The idea of society as a ‘body’ with interconnected parts and systems was a popular analogy for functionalists. Herbert Spencer (1820-1903), one of the first functionalists, drew heavily on Darwinism to develop the idea that society could be understood like an organism, with discreet institutions performing specific functions and maintaining the health of society as a whole. Spencer believed that the malfunction of individual social institutions (like the breakdown of the nuclear family, for instance), led directly to social pathology. (We will come to some of the criticisms of functionalism shortly, but it is perhaps worth pointing out here that Spencer used his belief in social pathology to argue that some societies were more developed than others, and that a kind of social Darwinism was at play when societies prospered or declined. Spencer believed white, European cultural dominance was justified by its development of social institutions. These ideas have now been widely discredited and seen as racist and abhorrent.) So at its most fundamental level, functionalism operates on the basis that society has ‘certain ‘needs’ that must be fulfilled to ensure its smooth operation’ ^[7].

Cockerham has suggested that social agents like the professions come to prominence as a result of social instability. In other words, ‘when “dysfunctional” processes arise that create instability, like crime, society counterbalances the potential for disorder by creating restorative and/or punitive institutions like criminal justice systems’ ^[8]. This is significant because it is a reminder of one of the fundamental issues raised in Chapter 1, that sociologists largely believe that the professions are the result of social process, not the originators. Pip Jones and Liz Bradbury put it this way;

’The existence of a social institution, of a part of the social structure, is not the result of the members of society deciding to act or think this way. After all, people do not decide to have bowels or a liver or a pair of kidneys. These organs exist because the body needs them to perform necessary functions. In the same way, in functionalist theory, the institutional arrangements of the society take the shape they do not because of any choice on the part of its members, but because they are performing a necessary function for the social structure as a whole’ ^[9].

In functionalist theory then, society is much bigger than the individual, existing ‘above and beyond the level of individuals’ influencing or perhaps even determining their behaviour’ ^[10]. Durkheim’s work argues that social forces can have a direct causal influence on people’s health, and that disruption to organic social homeostasis calls for the creation of groups who can restore stability to society.