Chapter I Moral Rules, Social Problems and Development of Social Policy

Maltreatment and neglect of patients can be perceived as instances of social deviance. When one learns that malpractices have occurred in hospitals whose stated goals are to care for sick people, inevitably questions are posed. ‘How could this happen? Why was nothing done? How could the problem be covered up? Why did no-one complain?’ and the like.

A sociologist in attempting to explain such events examines moral rules, their nature, distribution and situated use. Understanding moral rules allows analysis of any behaviours labelled deviant. All conditions and actions which infringe normative standards of health and demeanor can be viewed as social deviance. A theoretical framework provides a basis for understanding how society selects some people to control frequently by incarcerating them in custodial institutions, and how scandals are produced in chronic hospitals.

Social order, in the sense of routinised patterns of behaviour, is accomplished by participant members in any setting with a degree of permanence. The new member joining an on-going social network of relationships, as for example student nurse, learns by precept and example what is expected. The hospital, like any organisation, has two levels of reality: the physico-bio-chemical world of nature and the psycho-socio-cultural man-made world. Physically, one ward in a chronic hospital is fairly like most others. Socially, there are a range of realities which may or may not conform to the typified patterns believed to prevail by those in authority. The higher the position in the NHS hierarchy, the less likely are incumbents to actually visit, seeing for themselves wards where conditions are conducive to violence. These back wards exhibit a large degree of permanence, generally located in 19th centruy buildings, manned by staff who have given many years of service in the same institution. However, old buildings combined with mature staff are neither necessary or sufficient to cause scandals.

Moral rules

Symbolic meanings, shared rules or normative prescriptions and proscriptions, used by typical actors in typical situations  are the means whereby social order is constructed.  These rules and meanings will generally form part of the ‘world- taken-for-granted’,  the commonsense assumptions providing a structure in which everyday life occurs. The world presents it­self as ahistorical, already organised, being experienced naturalistically or pre-theoretically.  Moral rules are usually presented as absolutes, abstract imperatives to be followed  regardless of specific context or situation.

Objectification of social reality creates an impression of facticity, – the social order being external to rather than created by humans. Similarly in industrialised Western societies scientific rationality and economic laws of market forces are presented as absolute truths. To question or deny these universals may be perceived as subversive to the social order, indicative of irrationality (the unreason of madness ), immorality or criminality.

Rules regulating social interactions are more or less formal, including customs, traditions, routines, rituals and laws. Conformity to social expectations results either because rules have never been consciously questioned, or have been internalis­ed as legitimate. One may, however, comply with rules for expediency or be coerced by fear of real or threatened sanctions. Since social order is largely dependent on conformity, those believed to have broken rules are considered deviant, punished or treated. Sanctions range from mild rebuke, victimisation, cautioning by police, to status degradation ceremonies  leading to imprisonment or confinement in mental hospital.

Meanings rules prescribe or proscribe are understood in everyday moral communications as categories of opposites; dichotomies of good/bad, moral/immoral, creditable/discreditable, normal/abnormal rather than as qualities along a continuum. Attribution of negative qualities to persons or circumstances becomes perceived as a social problem if visibility and frequency increases, with the concomitant belief that social action can effect change. Whereas the perception of a social problem results from routinized or ritualised presentations to awareness, a scandal is more of a sudden dramatic event , – a moral crisis exposed. Scandals occurring too frequently lose their impact to shock, becoming another news headline.

Individuals in any given situation are concerned to evaluate their moral worth against others, particularly those who are non-members of his group. From his perspective they are outsiders unless proved otherwise, with different norms and values. “To the extent…. each individual…want(s) to construct this image of himself…. as a moral and normal member of his society ….he is necessarily committed to a competitive struggle to morally upgrade himself and morally downgrade others..”‘ On the chronic wards, staff and patients form two such distinct groups.

Moral entrepreneurs who successfully downgrade others improve their moral and social status. In societies with intense economic competition, stratified by class, the need to downgrade others to upgrade oneself is accentuated. Economic success or failure is invested with moral meanings. The perceived social problem is the poor, rather than the rich, a model to emulate in their conspicuous consumption. A deviant label has a halo  effect becoming a master status.   Because moral and status comparisons are parallel, congruence is expected. The poor are not expected to be virtuous and powerful. Degradation is legitimised by ideologies blaming the victims for their deficiencies and circumstances, having the effect of keeping them in their place.

Most traditional analyses of moral rules, including those of positivist sociology, have focussed on abstract imperatives and meanings ‘good’ people are assumed to agree with and conf­orm to. Moral meanings, unambiguous, non-problematic and external, are available for internalisation. If man is “social but  not entirely socialised”   deviance may be intentional rather than a consequence of inadequate socialisation or deprived opportunities.

Traditional analysis is unacceptable for adherents to the theoretic phenomenological approach. This has developed beyond deviancy theories of labelling and societal reaction by observing the everyday usage of linguistic categories including moral meanings in actual situations. The concern is to understand members’ meanings as shared intersubjectively, and their relation to/situated actions. This has led to “the principle of the contextual determination of meaning….the context within which a given statement or action occurs is of fundamental importance in determining the meanings imputed to it by the members of society.”  Context includes both linguistic and practical use, the latter involves spatial and temporal location and relevant stock of knowledge.

Categorisation and application of deviant labels are problematic and situational processes. Imputations of moral­ity or immorality are dependent on judgements of the respons­ibility of the actor for his infractions. Judgement of culpability cannot be made abstractly without knowledge of context. The deviant will be held morally responsible if he intended to commit the action, knowing the rules, and chose voluntarily to deviate when he could have done otherwise. In the  case of children or the mentally disordered, these criteria of theoreticity and conventionality do not apply, the latter being given the status sick. In previous centuries when moral rules were applied more absolutely, these two groups would not be excused.

In the everyday life of the hospital ward, commonsense meanings generally prevail. Behaviours of patients which irritate or make additional work for staff are likely to be perceived as badness and punished, rather than sickness which elicits caring. The borderline between the usage of some med­ical technologies as bio-physical treatment or as control and punishment is very indistinct. Medical ideology can legitimate the latter as being the former.

In routinised situations members do not have to account, justify or explain the rationality of their actions which sustain social order. The shared taken-for-grantedness of meanings, both situational and trans-situational from previous experience tend to become absolutes for them. Where there are conflicts of values, pressure is put on the dissident to conform. In time compliance may become conformity as group norms become ‘natural’.

If moral meanings are problematic and situational, there will be conflicting opinions regarding their applicability, or value conflicts. Several points follow. First, for maintenance of social order at micro or macro-levels such conflicts must be resolved or contained or obscured. Second, use of legitimate power or authority is more effective than overt force to deal with conflict. Third, power is legitimated at times by various mystifications or ideologies which make the morality of the dominant group seem ‘natural’ and inevitable for others, reducing the likelihood of conflicts emerging. Fourth, conflicts of values are the basis for aspects of social life being perceived as social problems.

In everyday life disagreements occur, especially in situations involving authority relationships. “Subordinates generally disagree with superordinates about many concrete questions of  morality, but generally in silence.” Other strategies are available, with various consequences. In the work situation, the individual may complain to those above his immediate super­ior. This may result in victimisation as he is blamed for being a ‘trouble-maker’, promotion may be blocked, others avoid him, he is shifted elsewhere or dismissed. Silence can be explained because of fear of such processes, and is a precondition for abuse becoming or remaining entrenched. The individual who cannot resolve or tolerate the conflict is likely to suffer from low morale, become ill or leave that employment.  He may also complain to external authorities who have the power to investigate the situation. Collective strategies may be used whereby the ‘dissidents’ organise in an attempt to effect change. This includes trade union activities as well as the formation of non-occupational pressure groups. If these strategies fail, those determined to expose the perceived malpractice enlist the aid of the media who may cooperate. Thus are scandals produced.

Social Problems

Underlying subjective feelings of distress and powerlessness when the subordinate is faced with conflicts of values in situated relationships, are not so much ‘clashes of personality’ but different perceptions based on previous experiences and structural locations. To account for “personal troubles of the milieu” in individualised terms is to be “falsely conscious of (one’s) social position.” Similarly to find instances of malpractices after investigations into one hospital, and assume it is unique is to be falsely conscious of the location of organisational structures and processes in the context of wider society. The sociological imagination enables one to understand what appears as a problem of individual circumstances is a public issue or social problem transcending any specific instance, whose causation lies largely in structural factors. In analysing perceived problems at the micro-level of situated interpersonal relationships, the focus should be the meanings administrative procedures of organisational function and daily activities have for members. At the macro-level, ideological beliefs, influencing political and economic factors in the societal context, impacting on organisations are important.

Traditional sociologists, ‘taking’ rather than ‘making’ problems explain negatively evaluated aspects of social life from the viewpoint of dominant ideologies. Individual or social pathology, or social disorganisation are favoured explanations. The remedy for the latter is seen as improved organisation, communications, staff training, more resources – a recipe familiar to those reading government reports or business man­agement panaceas based on technical and administrative solutions.

Macintyre suggests social problems exist in a moral context characterised by competing interests, namely values based on organisational or humanitarian orientations. A somewhat similar explanation by George and Wilding proposes there is “a continuum of social problems, ranging from conflicts of moral values to conflicts of economic interests”‘  although problems may involve both. Examples of conflicting moral values (humanitarian) include issues like homosexuality and groups with physical or mental malfunctioning because “of conflicts between the(ir) problematic situation…. and society’s ethical value system. The inability of such groups to live a normal life without help…. makes their situation challenging to certain ethical values.” This, as stated, gives a positivist view of what physical or mental malfunctioning is and does not clarify ‘normal’ life. In industrialised societies, normal typically means economically productive rather than part of the reserve army of the unemployed, Thus problems experienced by those with physical or mental mal­function lies more towards the other end of the continuum.

Underlying conflicting moral views regarding sexuality are political and economic issues of the continuation of the group by biological reproduction. Examples of conflicts of economic interests are poverty and unemployment.  Whilst one would agree class interests of rich and poor, employers and employees are involved, moral values implicit in stratification seem to be ignored, A theoretic-phenomenological approach is necessary so that analysis is not limited by positivist or naturalist stances which fail to elicit underlying assumptions. The fact that more of the poor occupy beds in custodial institutions has more to do with conflicts of moral values and social controls than economic interests.

Social Policy

What collective responses are made to social reality perceived as problematic when conflicts of values occur? Voluntary organisations, including charities,, pressure groups and occupational associations may mobilise to act on the perceived problem or lobby government to do so. What is perceived suitable for government intervention and the nature of the intervention are likely to be defined in terms of the dominant group’s pol­itical ideology.

The term, Welfare State, used when discussing social policy can be provisionally described as that part of the state apparatus concerned with two kinds of activities.   First, to provide services to individuals or families whose stated aims is to enhance welfare, but which are also effective mechanisms of social control. Second, to regulate and inspect private activities which directly alter immediate conditions of life.

Historically the state has often intervened by regulation or inspection before becoming a provider of services. The most relevant example for this dissertation is the inspection and licensing of mad-houses from the 18th Century.

Policy formation consists of decisions regarding:

  1. whether to legislate
  2. the contents of legislation
  3. the means of implementation.

At all stages decisions are compromises between conflicting interests and values which exist within any dominant class as well as between classes. Legislation is often deliberately obscure and ambiguous. Policy delegated to another agency such as local or health authorities may be largely symbolic.

“..since central government …is the dominant influence on the availability of…. finance, there is a certain political duplicity…in legislation….requir(ing) local agencies to provide benefits the centre knows they are unlikely…. to afford.” Community based services to replace hospital care are unlikely to be forthcoming with present economic policies, yet chronic beds continue to be reduced in number.

Gough considers the nature of the state in capitalist society is more complex than either pluralist or Marxist theory suggests. The state is neither “a neutral mechanism for reconciling conflicting interests and for representing the ‘common interest’ ..(or) ‘a committee for managing the affairs of the whole bourgeoisie’….under capitalism the ‘economy’ becomes separated from politics, the ‘private’ sphere from the ‘public’. The state may appear distinct from the ‘economy’ but although relatively autonomous does “act in the long-term interests of the capitalist class…”

To explain the state’s partiality, Milliband suggests:

1.      the elite in all branches of the state have similar class and educational backgrounds to economic, cultural and other  elites, including the medical profession. This will lead to similar perceptions of social reality, which due to hegemony large proportions of the public may share.

2.      the voice of those with wealth and control of economic re­sources has more influence uith government than that of the more numerous but less affluent. ‘ Corporate groups can persuade government what issues should be considered, and prevent others from reaching the agenda.

3.     structural constraints operative because of the capitalist mode of production affect state decisions and actions.

Renaud ‘ discusses the third point in some detail regarding state interventions in health. Structural constraints pre­select what issues the state responds to, setting upper limits on what is done. Given specific constraints due to particular historical developments in a given country, there are general constraints operative in all capitalist societies. Health needs are equated with consumption of goods and services, but the  commodity form of their satisfaction both creates more needs and facilitates economic growth frequently detrimental to health.

Contemporary medical knowledge, including traditional somatic psychiatric knowledge, is based on the paradigm of the specific aetiology of diseases incorporating Cartesian dualism. Illness is conceptualised as caused endogenously at the organic rather than functional or social levels.   This leads to use of specific therapies “pursued on an individual bio-chemo-surgical basis relegating the recognition and implications of social causes …to secondary importance.”  Thus we have a curative torientation using technological fixes, the engineering approach of plumbing medicine. The ineffectiveness of contemporary medicine to improve health status (measured by morbidity and mortality rates) despite increased expenditure   is due to “the institutionalised relationships between capitalism, health needs, medicine and the state…” When the latter intervenes in health care delivery it “cannot legitimately overcome the deeply embedded equation between health and consumption…”

What Kelman calls the second paradigm of medical knowledge has relatively little influence. The social epidemiological and environmentalist or ecological approach to physical health as a developmental process, is similar to sociotherapy in psychiatry, variously called milieu therapy, therapeutic communities or moral treatment.

The consequences of the dominance of the bio-mechanistic paradigm and the commodification of health needs are numerous and serious in their implications.

  • Nosology, especially with chronic impairments, becomes more important than what the person can or could learn to do, given both suitable training and adaptation of the environment.
  • Epistemologically ‘society’ or the social system of the ward regime is eliminated as a causal factor. Scientific rationality legitimates concepts of individual pathology.
  • A ‘healthy’ person has functional health, capacity to be economically productive. The marginal resources directed to maintain functional health should contribute “as much to overall productivity and accumulation as it would if diverted towards direct capital investment….this policy suggest(s) termination of health care resources to the non-productive the aged, chronically unemployed, and the catastrophically ill.   The latter two includes the mentally ill, congenitally sub-normal and physically handicapped.
  • The whole person is not involved but specific organs become the province of expert intervention. “The patient is reduced to an object being repaired…”   In psychiatry, the psyche is detached from the person…converting  (him) into the case.” “Separating the patients…is called making a ‘differential diagnosis’. Separating the physicians….is called ‘specialising’ in…(a) branch of medicine.”
  • There is expanding demand by professionals and public for the consumption of more complex technologies and drugs which increase costs of health care. Because of political pressures arising from economic requirements of the health industry and demands of the public for access to care, the state is faced with the dilemma of containing costs without reducing economic growth. Two ways are to reduce hospitalisation by shortening  length of stay, and to cut numbers of long-stay beds without developing community based services despite the rhetoric of community care.

An understanding of the dynamics of capitalism – the need for a reserve army of labour to constrain wages, and to incr ease productivity and profitability to remain competitive and the dominant medical paradigm, can explain why scandals are likely to be produced and reproduced in chronic hospitals, as well as the trend towards decarceration which may lead to new scandals.

Scandals are most likely to arise if:

  • 1.      the service is under-resourced with regard to staffing and equipment. As wages have risen in productive manufacture those of service workers have followed. It is difficult to increase productivity without either increasing bed-turnover or reducing staffing. Current expenditure for food, fuel, linens etc. can be cut.
  • attitudes and practices of staff oriented to the medical paradigm are task-centred and tend to depersonalise patients,
  • inspectorates have advisory functions only.
  • staff, especially subordinates, are unable to effectively voice complaints when feeling moral rules are broken.

All these conditions are likely to be present in back wards.

Given limited resources, if a constant amount of GNP is spent for health, as more is spent on expensive technology for the acute sector, less is available for the chronic hospitals, uhose incurable patients cannot become functionally healthy. A humane, personalised regime using various socialisation and rehabilitation techniques, uhich are educational and social, is labour intensive AND refutes the medical paradigm.

The Social Problem of Chronic Patients and Their Care

The concept, scandal, indicates a disgraceful, discreditable action or circumstance, an offence caused by fault or misdeed  causing public disgrace and damage to reputation. As such, it seems to fall within the larger categories of private mis­eries attributed to individual pathology, or public issues caused by social disorganisation. This depoliticises the problem as causation is rarely seen as lying partly within struct­ural conflicts of political values. To blame lack of resources or poor management is a partial excuse as some under-resourced hospitals provide good standards of care and staff-patient relationships.   Conflicts of moral values at the micro-level are implicated when  misconduct is persistent and long-standing.

Definitions of what constitutes a scandal in the care of patients are like any other aspect of social reality, a social construction. The meanings of malpractice will vary with diff­erent times, places and cultures as perceived by different actors involved directly, or indirectly as members of the organisational hierarchy or committee of inquiry. Even more remotely involved are the lay audience who read press reports or view television documentaries. The exposure and investigation of malpractice often leads to the discovery of further conditions deemed abusive.

A survey of the literature reveals interrelated themes which have given concern, albeit in modified form, over the past two centuries. Some of these issues have been interpreted as scandals. These issues may be briefly outlined as follows: (see Appendix 2 for full outline)

  1. issues of social policy, the role of the state
  2. issues of the manner of providing care
  3. issues of organisational management
  4. issues which are a ‘hidden agenda’ on official reports- the medicalisation of deviance.

The latter is of crucial importance, being the basis for the mode and locus of care as they have developed over time. A discussion of social control and the medicalisation of deviance is the next chapter.