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Medical Sociology: A Selective View by David Mechanic

Review by: Peter K. Manning


The Sociological Quarterly, Vol. 11, No. 3 (Summer, 1970), pp. 421-424
Published by: Wiley on behalf of the Midwest Sociological Society
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Book Reviews
delinquency mark Hirschi as an articulate theorist of genuine promise. His
comparison of strain theories, control
theories, and cultural deviance theories,
while brief, provides an impressive frame
from which the author launches his own
control theory and subsequent empirical
testing. Control theories, he asserts, assume that delinquent acts result when
an individual's bond to society is weak or
broken. Four elements of this bond are
(a) attachment, (b) commitment, (c)
involvement, and (d) belief. These are
discussed separately and in relation to
one another. Hirschi concludes his theoretical underpinning with the following
statement: "In the end, then, control
theory remains what it has always been:
a theory in which deviation is not problematic. The question 'Why do they do
it?' is simply not the question the theory
is designed to answer. The question is,
'Why don't we do it?' There is much
evidence that we would if we dared."
(2) A second value lies in Hirschi's
discussion of delinquency definitions.
For this study, he decided that delinquency would be defined by acts, the
detection of which is thought to result
in punishment of the person committing
them by agents of the larger society.
Clearly, Hirschi emphasizes the act
rather than the actor; deeds rather than
doers. His contrast of official delinquency records with self-reported items
represents no small contribution in itself. Unfortunately, this particular chapter is marred by a confusing presentation
of his choice of an index of delinquency.
The difficulty is not so much the measure
but a clumsy description of its derivation from the earlier works of Ivan Nye
and James Short plus that of Robert
Dentler and Lawrence Monroe. (Readers who plan to replicate the work are
advised to compare Hirschi's presentation with the ASR articles cited on pp.
54 and 55.)

421

(3) Another value is in the excellence of the empirical study itself which
most assuredly will stimulate many
additional efforts by others. Hirschi's
data on "attachment to parents," "attachments to the school," and "attachment to peers" shed exciting new light
on these old work horses of delinquency
causation. Valuable as these are, perhaps an even more important contribution lies in Hirschi's testing of the "Techniques of Neutralization" proposed by
Gresham Sykes and David Matza and
the lower class focal concerns suggested
by Walter Miller.
(4) The fourth value is the appendix which provides, among other things,
a complete set of instruments.
These, of course, are not independent of one another. Hirschi shows himself to be a taskmaster in continuously
returning to his theoretical formulations
with which he integrates the whole.
A book of this significance should
invite the finest criticism. Surely the
"strain theorists" will counterattack, the
advocates of cultural deviance theory
will rejoin, and typologists will take
exception to points and positions. Indeed, there is much to take exception to.
But Hirschi knows this. Accordingly, he
is very often his own best critic.
Perhaps, on the trite side, this reviewer wondered if much of this book
were written prior to Delinquency Research. While a publisher's card shows
a publication date of December 15,
1969, the author's preface is dated fourteen months earlier, October, 1968, and
relatively few references are dated as
recently as 1967. This is less a commentary on quality and more a complaint
about lag between conception and delivery. The loss is ours.
JOSEPHW. ROGERS
New Mexico State University

Medical Sociology: A Selective View. By DAVIDMECHANIC. New York: The

Free Press,1968. 504 pp. No price indicated.

MECHANICdivides his "selective view"


of the field of medical sociology into

three parts and two appendices. In the


first part, he demonstrates the many

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422

THE

SOCIOLOGICAL

QUARTERLY

similarities between the study of disease


and deviance, and then discusses health
and illness from the doctor's and the
patient's perspectives. He makes a significant attempt to contrast these perspectives as well as to underscore the
differences between the perspective of
the "ill person" and those around him
who respond and attempt to shape his
behavior with reference to his illness.
Although the distinctions between selfdefinitions and other definitions are
reified at some points, there is ample
evidence presented to document the influence of the social location of the
observer on his interpretation of the
meaning of behavior. The second section
contains a methodological approach to
the study of disease processes, particularly mortality, morbidity, and stress.
The previously published appendices
deal with the sources of power of lower
participants in complex organizations
and issues in the treatment of mental
illness.
Mechanic emulates a good bridge
player by leading with his longest and
strongest suit, explicating the distinctions between disease (a bodily process), illness (any condition which
causes, or might usefully cause, an individual to concern himself with his signs
and symptoms and seek help), and illness behavior (behavior which results
from the differential evaluation, perception, and definition of illness). The
sociological significance of Mechanic's
conceptualization is apparent in his application of his ideas to the process of
help-seeking. The methodology section
will have greatest interest for public
health educators and researchers. The
final section of the book, although it
draws some interesting contrasts between the British and American health
systems, lacks a central theme and is
disappointingly discursive and descriptive.
Hughes insists that the question
"What Other?", or the relative significance of the audiences to whom one
plays, always plays a part in the role
drama of work. In this postscript, Me-

chanic seems sensitive to the inherent


dilemmas of writing a book apparently
directed both to physicians and to sociologists. Unfortunately, medical sociology and criminology have a long
history of resorting to what Garfinkel
calls "practical theories" developed for
the special purposes of the occupations
they serve. Sociologists have permitted
the unexamined assumptions and operational procedures of the host occupation
to supply data and concepts (e.g., legal
categories and criminal statistics, psychiatric nosology, and mental hospital
diagnostic records). Once the dependent
variables are thus conveniently derived,
sociologically relevant independent variables are assembled to "predict," "explain," or "account for" the posited
variance. This is not an adequate substitute for a sociological theory of the
entire phenomenon, including the practical operations and ideologies of the
occupations themselves. At least one of
the consequences of this situation can be
an uncritical stance toward the institution. (I have heard sociologists speak of
medical sociologists as "house men" in
an unkind comparison to the shils in
large gambling casinos.) Mechanic on
several occasions makes statements
which I consider inaccurate or uncritical
of the medical profession. The following
is an example:
In order to be accredited, American hospitals must have tissue committees which
examine the reports on tissue removed
through surgery to ascertain whether the
tissue was normal or abnormal. Such a procedure makes the surgeon who removes
normal tissue too frequently visible to his
medical colleagues. The better hospitals will
have several other committees to audit
record maintenance, to evaluate the quality
of hospital work, to review deaths which
occur in the hospital, and so on. Although
such committees are frequently reluctant to
take action against an offending colleague,
the American hospital has excellent control
mechanisms (172), which are likely to be
developed to a greater extent in the future.
Although controls develop slowly, and although they are vigorously resisted by
many doctors who, like other professionals,

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Book Reviews 423


resist surveillance, there is no question but
that American hospitals offer good opportunities for evaluating and controlling the
quality of medical care.
The work of Freidson and Rhea
(1963, 1964, 1965) and Goss (1961)
and other references cited by Mechanic
give little cause for such optimism with
reference to the self-regulation of physicians. In light of the work of Szasz
Scheff (1966),
and Kutner
(1968),
(1962) I would likewise disagree with
his polyanna approach to the problem of
involuntary commitment of the "mentally
ill" (cf. pp. 375-381). I regret the
absence of an extended critical discussion of the gross inadequacies of present
systems of medical care for the poor,
black, or rural dweller and the spiralling
costs of good care for the middle classes.
The absence of a discussion of these
issues from a major textbook for the
instruction of health professionals and
those who will research their problems
is unfortunate.
I found the book most stimulating
not as a compendium of data and research in medical sociology, but as an
illustration of the importance of develop-

ing a situational social psychology. Mechanic's particular interest is the problematic nature of man's coping with the
stress of disease, but his concepts have
a more general relevance. Mechanic reminds us that it was in the first empirical
classic in American sociology, The Polish
Peasant, that W. I. Thomas and F.
Znaniecki initially suggested that if sociology is to capture the fragile, shifting
and complex nature of modem society,
it must adopt a situational perspective.
If anything, we now have even more
appealing evidence for supporting such
a claim: we may have to finally take
W. I. Thomas seriously (see Donald W.
Ball's paper of similar title in a forth-

coming book, Analyzing Everyday Life).

Mechanic makes an important contribution to this emergent sociology in his


analysis of the active, creative ways in
which men cope with or adapt to stressful situations, e.g., anxiety-producing, or

threatening episodes such as the recognition of disease and related illness behavior. The emphasis here is on the positive construction of lines of action. A
most telling comparison can be made
between Parsons' conception of the sick
role which conceives the role-norms as
providing for a withdrawal of the person
into a potentially dysfunctional and dependent relationship and Mechanic's
stress-coping notion which sees men
creatively constructing meanings and
acting in terms of their definition of the
situation.
Situations often contain ambiguities,
stresses, risks, or uncertainty; it seems
that to focus on situational action requires attending to the problematic in
the structuring of encounters as well as
to those aspects of structure which partially account for encounters. A disease
represents in many cases a threat to a
self. A self-defined "threat" may be defined and acted upon in a variety of
ways. Some ways involve personal risktaking; some require others to take the
risks; some involve risk avoidance
through inaction. This view of man suggests a parallel conception of social life
as containing risks which are sometimes
sought, sometimes just happen to people,
and sometimes are avoided. Some of the
insights of Goffman, Klausner, Wallach,
and Hughes might be developed into an
imagery of social organization as a means
for the creation, allocation, and distribution of risks. This task will require us, in
addition, to illuminate a dimension of
man usually only dealt with in novelshis "darker side," his despair, pathos,
debauchery and evil-for illness, as one
sort of risky experience, is all this as
well. But I cannot require this of Mechanic.
The book is a selective view of
medical sociology which focuses to a
considerable degree on social illness
("mental illness," and the social-phychological aspects of the practice and the
experience of medicine). A succinct
"topical summary of medical sociology"
introduces the book. It will be useful in
both graduate courses in social sciences

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424

THE

SOCIOLOGICAL

QUARTERLY

and in medical education. The bibliography is excellent, containing nearly 500


items. However, the use of the bibliography as a list of citations makes for a
great deal of fumbling to the rear of
the book and back again. The indexes

are comprehensive and there are no annoying typographical errors.


PETER

K. MANNING

Michigan State University

REFERENCES
Freidson, E. and B. Rhea
1965 "Knowledge and judgment in professional evaluations." Administrative Science
Quarterly 10 (June):107-124.
1964 "Physicians in large medical groups" Journal of Chronic Diseases 17 (April):827836.
1963 "Processes of control in a company of equals." Social Problems 11 (Fall):119-131.
Goss, M. E. W.
1961 "Influence and authority among physicians in an outpatient clinic." American
Sociological Review 26 (February) :39-50.
Kutner, L.
1962 "The illusion of due process in commitment proceedings." Northwestern University
Law Review 57 (September-October):383-399.
Scheff, Thomas
1966 Becoming Mentally Ill. Chicago: Aldine.
Szasz, Thomas
1968 Law, Liberty and Psychiatry.New York: Collier Books.

The Peter Principle. By LAWRENCE


HULL. New York:
J. PETERand RAYMOND
William Morrow & Company, Inc., 1969. 179 pp. $4.95.
PETER and Hull combine sharp insight
and humor in a style much like that of
C. N. Parkinson. The Peter Principle is
simply stated: "In a hierarchy every

employee tends ro rise to his level of

incompetence" (p. 25). Given sufficient


time and the existence of a hierarchy
having many rather than few ranks,

Peter's Corollaryfollows: "In time, every


post tends to be occupied by an employee who is incompetent to carry out
its duties" (p. 27). Students of large
organizations have long noted that however low morale may be among participants in a given organization, the essential work still gets done. Peter and
Hull observe: "Work is accomplished by
those employees who have not yet

reached their level of incompetence"

(p. 27).

A major problem in any large organization is maintaining open lines of promotion for competence, in spite of blockages by incompetence at any given

level. Two major strategies are widely


known: "percussive sublimation," and
"lateral arabesque." A case of "percussive sublimation" is one in which the
victim is moved from his present position of incompetence to one at a higher
rank. Such a move is designed to deceive people outside the organization.
Peter and Hull quite clearly indicate
that success here requires that the immediate super-ordinate is still at his level
of competence. This move saves a poor
promotion policy, supports the morale
of competent others still at lower levels
in the organization, and above all, reduces the possibility that the victim will
take his critical knowledge with him and
become a threat from a competitive
organization. When this is actually done,
such persons are viewed as traitors.
Even if a government organization has
no internal competitors, there are other
governments outside. The "lateral ara-

besque" is applied by Peter and Hull to

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