Sm. Sci. & Med. 1973, Vol. 7, pp. 787-805. Pergamon Press. Printed in Great Britain.

PERCEPTIONS

OF ILLNESS

AND HEALING

DONALD A. KENNEDY*
Harvard University School of Public Health, Boston, Mass., U.S.A.
Abstract-Patients,
physicians, scientists and public health officials hold variant perceptions of
the processes of illness, injury and unnecessary death that afflict human populations. As these
different role performers in the field of health care interact, numerous conflicts arise because
the full set of operating values and assumptions are not explicitly revealed. Recognition of
central variations in orientation and special interest can assist policy formulation and decisionmaking where cooperative action is required. Significant improvements in health status for
specific population groups will be retarded until this deeper level of understanding is achieved.

are diverse patterns of belief and behavior associated with the human response to
illness, injury, and premature death. Most of these patterns vary systematically from
culture to culture and according to position and role within any given culture. The purpose
of this paper is to review the state of knowledge in this general field and to make some
suggestions on the transfer of knowledge into practice within the fields of medicine and
public health.

THERE

ASSUMPTIONS

The following set of assumptions gives both an orientation

presentation to follow.

and a framework for the

(1) There are approximately 3.6 billion people in the world. Most of them live within the
political boundaries of 144 nation states and speak at least one of 159 languages. Because
of the universality of experience with death, illness, injury, and handicap, each human group
develops specific patterns of behavior and belief to facilitate individual and group adaptation
to these disturbing events.
(2) The major types of adaptation are: acceptance, escape, prevention, curative treatment,
rehabilitation, emergency response, and scientific research.
(3) It is a worthwhile scientific activity to compare patterns of health practice and belief among
the following groups :
(a) nations and cultures;
(b) consumers and providers of health services:
(c) different types of health practitioners;
(d) biomedical researchers and practitioners.
(4) Analysis of the various patterns may provide new knowledge of use in developing improved
techniques of human intervention in the fields of medicine and public health. These new
methods of professional practice can be expected to produce discernible improvements in
health status for specific populations.
(5) There are five major types of health practice operating within most countries of the world.
They are: folk medicine, religious medicine, scientific medicine, public safety, and public
health.
(6) It is assumed that patterns of health practice from each of these five systems will continue
to coexist within most countries for an indefinite period of time.
(7) Improvement in the health status of families and categories of people can be achieved
through greater integration of knowledge and coordination of effective practice among these
five health practice systems.
* Lecturer on Health Services Administration,
Street, Boston, Massachusetts 02115.

Harvard
787

University

School of Public Health, 55 Shattuck

788

DONALDA. KENNEDY
FORMS

OF ADAPTATION

The basic orientation

of this article focuses upon
ecological framework. As Hughes has argued [ I] :

the issue of adaptation

within

an

In speaking of health and well-being we are, essentially, confronting one aspect of the
ancient and persistent conceptual problem of adaptation, adjustment, and equilibrium.
Dislike it as we may because of the methodological and operational snares involved in use of
these terms, we cannot avoid them; for health and well-being are but indicators or phases of the
more comprehensive phenomenon, life itself; and life is rooted in processes of adaptational
efforts directed at specific environments. . . .
Life and adaptation (and therefore health) is, then, a conriizgenr phenomenon, not to be
discussed except with reference to the specific conditionsof life. One must ask what is adjusting,
is attempting to adapt, and to what? . . . .
Health and disease- are thus concepts which inherently imply the necessity of considering
context, both in terms of definition and of causation. For health is, first of all, rooted in
transaction, in the continuous activity on the part of the organism to establish and maintain
patterns of relative adaptive success in dealing with its environment, both its external
environment and its internal milieu. In this light health, is then, an ecological phenomenon,
always to be considered in terms of contextual relations. . . .
Life is therefore an expression of a stable, continuing constellation of adaptive processes, and
disease represents an exaggerated or abnormal use of defense reactions or mechanisms on the
part of the organism in its attempts at adaptation to threatening circumstances, either
internal or external.
Within this general frame of reference one can identify at least seven kinds of adaptative
behavior. First, there is escape behavior. This refers to patterns of refugee flight from the
site of wars, riots, disease epidemics, and natural disasters. On a family scale, it is often
seen in divorce, job termination or transfer, and a residential move to a new community

or to a foreign country. Decisions on escape behavior are usually made by family units
or individual persons. Both employer organizations
and government
agencies may assist
or obstruct some of these patterns of escape activity.
Second, there is precautionary behavior. Men can protect themselves against certain kinds

of microbial disease by vaccination and regulation of migration. Various forms of shelter

can protect against storm, flood, fire or radioactivity. Injury due to automobile accidents
can be prevented by the design of roads and cars and the habit of wearing seat belts.
Changes in daily eating and exercise pattern can lead to weight reduction and help to
prevent heart disease. Police can act in ways to lessen the threat of riot or criminal assault.
Genetic counselling of prospective marriage partners can reduce the probability of congenital
handicaps in newborn children. Employment and recreational opportunities can reduce
violent behavior among young men in crowded city neighborhoods. Adding chemicals to
the public water supply can reduce the frequency of dental caries.
Third, there is emergency response. If an epidemic of infectious disease breaks out,
rapid vaccination
of the community
population
can limit the mortality
and morbidity
from the disease. Poison centers can give immediate information
about antibiotics
over
the telephone. Rescue personnel attached to fire and police units can provide a variety of
emergency services. Military and medical personnel can provide considerable
assistance to
communities
that have suffered a natural disaster. Fast response ambulance service coupled
with intensive care facilities in local community hospitals can provide life-saving emergency
service for persons suffering from heart attacks.
Fourth, there are curative health services. For a limited set of disease and injury conditions
there are specific medical, surgical, and psychiatric procedures available to produce ameliorative or curative results. A relatively safe surgical procedure is available for curing appendicitis. Many infections will respond to antibiotic medication. The list of curative capabilities

Perceptionsof Illnessand Healing

789

grows longer each year. Curative services are often viewed as the near total equivalent of
scientific medicine capability in an industrialized society.
Fifth, there are rehabilitative services. These services differ from all of the others in that
they are concerned with handicaps for which curative procedures are either not available
or were not applied early enough in the natural history of the disease process for individual
persons. The aim of rehabilitation services is to gradually increase the level of behavioral
functioning or to provide compensation for the handicap where possible. This form of
health service can help handicapped people to achieve a maximum degree of independence
and acceptance. Such services are used extensively for wounded veterans, for congenitally
handicapped persons, for the mentally retarded, and for those who have suffered illnesses
that leave lasting deficiencies in the neurological, musculature, or sensory systems of the
body.
Sixth, there is scientific research. A more recent societal response in coping with illness
is to mobilize scientific effort in the field of biomedical research. There have been many
dramatic accomplishments resulting from this endeavor. Biomedical research has produced
a host of new products, instruments, and techniques that provide improved intervention
capability in many areas of scientific medicine and public health.
Seventh, there is acceptance behavior. Both individuals and groups show considerable
variation in their tolerance for suffering, handicap, and premature death. A fatalistic
attitude is often found in countries with a high infant mortality rate and a chronic shortage
of food. Industrial countries may accept high fatality rates from transport and industrial
accidents. Nations may accept warfare, riot control, and capital punishment as acceptable
ways of coping with conflict and deviance. The public response to knowledge about the
causal relationships between cigarette smoking and lung cancer may be yet another example
of acceptance behavior. Patients suffering from negligence or error on the part of a physician
may or may not initiate legal action.
All.seven of these adaptative patterns of response to health hazards are found to some
degree in all countries of the world. The proportions will differ but representative elements
are usually quite evident in most geographic regions.
FIVE HEALTH PRACTICE SYSTEMS
At the level of the individual person it must be granted at the outset that there is tremendous variation in the way in which a specific individual reacts to illness, injury or threats
to his life. But generalizations are possible concerning that manner in which families,
residential communities, and societies generate organized activities to cope with health
hazards on a continuing basis. Due to the division of labor within nations, and the specialization among nations in an emergent world society, there are specific groups, organizations,
and institutions devoted to one or several of the adaptative patterns described above.
Three of these health care practice systems are well known: primitive medicine, scientific
medicine, and public health. Two more activity areas are added here because they
significantly affect the health status of people. There are: folk medicine and public safety.
They are not strictly systems of health care practice in a fully differentiated form. They
represent sub-routines or specific components within large organized systems of activity.
A comprehensive perspective on health care activity requires their inclusion for reasons
that will be developed in the paragraphs to follow.
First, there is scient$c medicine. This is modern medicine as it has evolved in the
industrialized nations of the world. Although it contains elements of magic, pragmatic

790

DONALD A. KENNEDY

empiricism, and folk lore, it is an organized activity which places a scientific orientation
in the position of highest authority. It is differentiated into three major realms: professional
practice, medical education, and medical research. The international mobility of scientific
discoveries and scientifically trained physicians is quite evident. All nations do not have to
support a major biomedical research enterprise in order to benefit from the discovery of
new intervention techniques. Well-trained physicians move from country-to-country
as a
scarce manpower resource in a world market. And hospital practice of medicine and surgery
shows remarkable similarity throughout the world even at this time.
Second, there is primitive medicine or religious medicine. This type of health practice
is more ancient than scientific medicine. It is based upon assumptions about supernatural
and natural events. It is usually more concerned with the psychosocial context of illness
than with the biological content of the disease process. Within this framework disease is
assumed to result from: (1) sorcery; (2) breach of taboo; (3) intrusion of a disease object;
(4) intrusion of a disease-causing spirit; or (5) loss of soul. The use of magic and ceremonial
rituals characterize both its preventive and curative practices. All societies, including the
most highly industrialized ones, have healing activities utilizing this ancient body of knowledge and technique.
Third, there is public health practice. This system of care is similar to scientific medicine in
its commitment to a scientific orientation. It differs from scientific medicine in its primary
concern for population rather than for individuals and its emphasis upon preventive rather
than curative or restorative procedure. Most of its important successes have come from
manipulations of the physical environment. Construction of sanitary water and sewage
systems; vaccination campaigns; construction of adequate housing; education of the general
public about personal hygiene; emergency quarantine and vaccination during epidemics :
these are the major intervention techniques of public health practice.
All three of these systems of health care have trained personnel and defined treatment
settings. The two systems providing services to individual clients have an exchange of
money or goods for the treatment services rendered. The primitive medicine system is
often regarded as a marginal healing activity, not fully legitimate in many industralized
countries. The public health system is closely tied to government agency activity and
usually financed by tax monies.
The health status of individuals and families are also affected by two additional activity
systems. One is folk medical practice and the other is public safety practice. Folk medicine
refers to the illness and treatment behavior engaged in by members of families when they
act independently of contact with either primitive or scientific healers or it may be more
broadly defined as those beliefs and behaviors in a general population that have implications
for helping or hindering the health status of persons living in families or other residential
units. The beliefs and practices often vary between ethnic groups and according to socioeconomic status. The home is the principal health care setting for folk medical practice.
When people first become sick, it is the first treatment setting. Most restricted activity
days and bed disability days are spent at home.
Folk medical beliefs and practices have a profound influence upon the health status of
all people. The daily round of activity exposes each individual to a sizeable number of
health hazards. A complex set of customs and habits have evolved in each human group
to encourage success rather than failure in coping with these threats to survival and wellbeing. All of these patterns of behavior operate each day as precautionary or acceptance
modes of adaptation.

Perceptions

of Illness and Healing

791

When there are indications of injury or illness a set of diagnostic, prognostic, and therapeutic procedures are initiated by the patient in collaboration with friends and kinfolk.
The home becomes the first-stage health care setting. The person is released from work,
school, and other social responsibilities. If the signs of danger diminish within a few days,
the person is defined as recovered and he returns to his normal role behaviors. If the
danger signs continue or become more alarming, a request for medical service is made to
either a primitive healer or to a physician.
The important point to be remembered is that this daily set of cultural routines and
first stage illness behaviors is in operation all the time in every population. Since the initiative
for contacting either the primitive or scientific curative systems is in the hands of the patient
and his kinsmen, there is a high probability that the state of knowledge about human
biology and disease in the general public has a strong limiting affect upon the effectiveness
of the primitive and scientific curative systems. Unreasonable expectations and demands
can be made in asking for service too late or in demanding attention for trivial or selflimiting conditions.
The relationship between folk medicine and public health practice is somewhat different.
Practitioners in public health are granted more initiative than their colleagues in the curative
services. They do not have to wait to be called before their technical services can be utilized.
But, successful public health practitioners must understand the details of folk medical
behavior and the realities of the political process in order to produce effective interventions
in preventing illness and injury.
The fifth area of health care practice, public nzfety, is more difficult to define. It refers
to a set of social problems that often have a serious health hazard component. These
social problems are not usually included in the standard categories of disease nomenclature
but they have the same quality of danger that we perceive as the hallmark of illness, injury,
and death. A list of such problems would include: warfare, crime, riots, labor strikes,
poverty, intergroup prejudice and discrimination, traffic congestion and crowding, delays
or errors in the administration of justice, shortages of residential housing, inadequate or
ineffective public education, various kinds of addictive behavior (smoking, alcoholism,
drug abuse, obesity, gambling), inadequate levels of physical exercise, high level of
unemployment, exploitive behavior by special interest groups, faulty design or operation
of buildings, transportation vehicles, and equipment, economic conditions of inflation or
depression, and major inequalities in the distribution of goods, services, opportunities,
and recognition. All of these problems are associated with unnecessary stress, frustration,
injury and death. One may quarrel with the inclusion of one of more of the items in the
list, but our purpose is to identify activities that pose a threat to health and yet fall outside
the traditional boundary conditions of legitimate concern for the professionals and organizations working in the health service field.
Public safety practice is in many ways like folk medicine. It is a component of nearly
every major organized activity in the society. Legislatures, government agencies, industrial
corporations, business firms, schools, churches, and a host of private organizations make a
continuing stream of decisions. Many of these decisions have a public safety dimension
for specific target populations. Like the domain of folk medical practice, in public safety
practice, there is no explicit jurisdiction or specialized collective effort directed exclusively
to the health dimension of the central activity in question. Responsibilities for influence,
monitoring, and control are distributed to the four winds among thousands of individuals
and groups each pursuing its primary organizational mission.

792

DONALD A. KENNEDY

In an important
sense public safety is the reciprocal of folk medicine for it is the health
aspect of programs and activities conducted by corporations,
institutions,
and organized
groups as they perform their functions in society. It also represents the growing edge
of public health practice. The recent development
of expertise in the fields of population
science, air pollution control, health services management,
radiation protection, and aerospace safety are examples of how public health has extended its scope of concern to cope
with new challenges to health in the social environment.
Perhaps in the near future the
prevention
of violent behavior will become defined as part of the field of public health.
But there will always remain a large residual of activities in public safety that can never
become incorporated
into public health practice or any of the other differentiated
health
service systems. Changes in both folk medicine and public safety are most likely to come
from shifts in public opinion, activities of general education, experiences in political action,
and circulation
of ideas and people.
In summary, then, there are five major areas of health care practice, each with its distinctive knowledge domain and its perspective, value orientation,
and cluster of routine actions.
These five systems of practice co-exist in most human populations.
All have visible effects
upon the levels of health and well-being enjoyed by persons, families, and communities.
Now we turn to a quite different perspective. What are the differences in perception experienced by the various role players within the major service systems?

PATIENT

AND

HEALER

The perceptions
of illness and the expectations
concerning
outcome
differ sharply
between client and professional healer. Both parties to the healing relationship
are brought
together by a significant set of complementary
expectations with reciprocal responsibilities.
But the experience feels very different on the two sides of the interaction.
The person
defined as patient has usually begun to experience a fundamental
shift in activity and
sensation. There is a narrowing down of attention. There is pain and discomfort within the
body. There is often disruption
of normal activity. The headache may be too severe to
permit driving a car or reading a newspaper. The injury to the leg may not allow normal
locomotion.
The person entering patienthood
becomes concerned with his health in a
single-minded
way. Most of his usual interests recede from attention.
Purposeful
action
comes to a halt. Socially, the patient now becomes eligible for legitimate exemption from
one or more social relationships
for an indeterminant
period of time.
At the same time, other members of the family and associates in the work setting must
assume additional
duties. They must adjust their own daily schedules to accommodate
to
the restricted participation
of the person now defined as patient.
Such adjustments
in
the network of interpersonal
relationships
produce a mixture of emotional
states and
perceptions. There is frustration
generated by the transfer of duties and activities; there is
worry about the severity and duration
of the condition
of illness. Depending
upon the
specific roles, some members of the family will assume nurturant
and caretaking responsibilities. Family members will also assist the patient in making a diagnosis and initiating a
plan of treatment.
Predictions
about duration,
severity, and probably outcome will be
made. Symptoms will be monitored and adjustments
made in the treatment plan.
If the condition
persists or intensifies, then outside help will be sought, usually by a
member of the family on behalf of the patient. Here the definition of the situation changes.
Now a person who is specifically trained to perform professional
services for the cure of

Perceptions

of Illness and Healing

193

disease and the relief of suffering has been asked to join in a contract. In exchange for money
or goods a healer is now asked to perform his own set of diagnostic and treatment activities.
But what is the healers perception of this request for attention? His daily cycle of activity
is full of interaction with a collective set of patients. A new request for attention simply
adds one more person into the schedule of professional activities for the day. The physician,
with his collective set of patient care responsibilities, must repeatedly re-adjust his priorities
of attention and application of professional effort. When emergencies develop, he must
shift his effort. He must leave some patients waiting or ask other health care personnel to
assume responsibility for interim caretaking.
With his superior knowledge of human biology and disease, gained through many years
of training and experience, the physician brings an important degree of reality to the situation. Malfunction of internal physiological processes produce worry, fear, and anxiety in
the patient-largely
because of his lack of knowledge about human biology. Since the patient
is feeling ill, there is an additional deficiency-his illness interferes with normal perception,
sensation, and cognition. On the other hand the physician is well and has superior knowledge. Furthermore, he has the advantage of knowing about populations of patients. He
knows the probabilities of outcome for various disease conditions and he knows the current
weather map of infectious conditions travelling through the community on any given
day.
These experimential conditions pervade the perceptions and behavioral reactions of
patients and physicians to each other. In addition, the rules of society add their influence
upon belief and behavior. The patient has the initiative in calling the physician. No physician
is allowed to recruit patients. Only the layman with his low level of understanding about
human biology and disease can place the call for help. His level of knowledge about biology
and disease is far less than that of the physician, yet he is the one who makes this important
decision. This decision-making rule is fundamental to the relationships between persons
with highly technical knowledge and members of the general public.
There have been important studies about this relationship between the physician and
the patient. Excellent summaries have been written by David Mechanic [2], Stanley King
[3], and Eliot Freidson [4]. Mechanic [5] has emphasized the patterns of illness behavior.
He delineates the range of responses to symptoms and to available treatment resources in
the following set of variables that affect the help-seeking process of the patient and his
associates: (1) visibility, recognizability, or perceptual salience of deviant signs and symptoms; (2) the extent to which the symptoms are perceived as serious or dangerous; (3)
the extent to which symptoms disrupt family, work, and other social activities; (4) the
frequency of the appearance of the deviant signs or symptoms, their persistence, or their
frequency of recurrence; (5) the tolerance threshold of those who are exposed to and
evaluate the deviant signs and symptoms; (6) available information, knowledge, and
cultural assumptions and understandings of the evaluator; (7) basic needs which lead to
autistic (defensive) psychological process (i.e. perceptual processes that distort reality or
deny reality); (8) needs competing with illness responses; (9) competing possible interpretations that can be assigned to the symptoms once they are recognized; and (10) availability
of treatment resources, physical proximity, and psychological and monetary costs of taking
action (included are not only physical distance and costs of time, money, and effort, but
also such costs as stigma, social distance, feelings of humiliation, and the like). Mechanic
goes on to point out how the perceptions of the physician on these issues may differ significantly from those of the patient and his kinfolk.

794

DONALD A. KENNEDY

Stanley King has assembled similar evidence about the reactions of patients to illness and
their encounters
with medical care and treatment.
He describes the typical physiological
effects of illness, the psychological reactions to illness, and the influence of the social requirements of sick role and social class background.
His detailed explication
of the main
dimensions of psychological
reaction are quite valuable. He says :
Needs for attention and sympathetic help often increase in response to illness. The patient is
concerned about his illness, not about pain in the abstract, but about his pain. The sharp,
stabbing sensation in the lower-right quadrant of the abdomen is a very personal thing to him,
not to be regarded impersonally. At the moment it is the center of his world. Most people
who are ill not only want attention paid to their trouble, but also wish to be cared for
and to have a strong int%tx of positive emotional expression by others, affection, and love. The
prescription of tender loving care, comes out of the strong psychogenic needs of the patient
himself [6].

King agrees with Lederer that the patient situation is similar in some respects to conditions
of early childhood.
There is a strong tendency towards emotional
regression. The main
features of their regression are egocentricity, constriction
of interests, emotional dependency,
and hypochondriasis.
Manifestations
of this type of feeling and behavior in a person defined
as a patient are considered
acceptable and normal.
As revealed in studies by Ernest
Dichter [7] and his associates, there is a general theme of fear and need for reassurance.
The fears are of death, mutilation,
incapacity, helplessness, and dependency.
Eliot Freidson has developed a complementary
perspective which places major emphasis
upon social processes that influence definitions of illness and the beliefs and behaviors of
participants.
He reminds us that physicians nearly always tend to over-report
symptoms
and disease conditions
and patients nearly always tend to under-report
such events. His
comments on the interaction
between physician and patient are quite instructive
on this
point :
Given the viewpoints of two worlds, lay and professional, in interaction, they can never be
wholly synonymous. And they are always, if only latently, in conflict. . . .
Hence, interaction in treatment should be seen as a kind of negotiation as well as a kind of
conflict . . . the patient using his symptoms to establish a relationship with the physician . . .
likely to want more information than the doctor is willing to give him. . . .
. . . just as the doctor struggles to find ways of withholding some kinds of information, so
will the patient be- struggling to find ways of gaining access to, or inferring such information.
Similarly, just as the doctor has no alternative but to handle his cases conventionally, so the
patient will be struggling to determine whether or not he is the exception to conventional rules.
And finally, professional healing being an organized practice, the therapist will be struggling
to adjust or fit any single case to the convenience of practice (and other patients), while
the patient will be struggling to gain a mode of management more specifically fitted to him
as an individual irrespective of the demands of the system as a whole.
These conflicts in perspective and interest are built into the interaction and are likely to be
present to some degree in every situation. They are at the core of interaction, and they reflect
the general structural characteristics of illness and its professional treatment as a function of
the relations between two distinct worlds, ordered by professional norms [8].

These perceptions
are quite significant
in understanding
what happens in response to
illness and within the treatment
process. We need to be reminded of this dimension
of
inherent conflict because of the general tendency to assume that full knowledge,
proper
education,
and more complete communication
could eliminate
the tensions frequently
encountered
in the interactions
between clients and professional consultants.
DIFFERENT

PRACTITIONERS

As indicated earlier, there are different kinds of occupational

groups providing health
care services. In a fully differentiated
form there are practitioners
in primitive medicine,

Perceptions

795

of Illness and Healing

scientific medicine, and in public health. Within each of these generic fields there are a
host of occupational specialists. The work of the health practitioners in each of these major
fields is guided by a system of perceptions, beliefs, and values about the phenomena associated with illness, injury, and unnecessary death. We shall examine each of the major systems
in greater detail at this point.
The basic assumptions associated with primitive medical practice have been succinctly
summarized by Erwin Ackerknecht in the following passage:
Diseaseand death among primitives are in the overwhelming majority of cases not explained
by natural causes, but by the action of supernatural forces. In general, the disease mechanisms
are: either the intrusion of a disease-producing foreign body or spirit, or the loss of one of
the souls which may be abducted or devoured. These mechanisms may be put into motion
either by a supernatural agency (God, spirit, etc.) who feels offended, or by a fellow man who
avenges himself either by hiring a sorcerer or by himself acting as a sorcerer.
Supernatural
causes must be discovered by supernatural
means, and thus primitive
diagnostics consist of various types of divination : bone-throwing, crystal-gazing, trances,
etc.
The therapeutics cover a whole gamut of methods, reaching from purely matter-of-fact
treatments (herbs, massage, bath, etc.), a mixture of such objective methods with magic
spells or prayers, to purely magic-religious rites-the
mixed treatments probably prevailing in
number [9].
The author then continues
with a description
of the importance
associated
with medicine
and disease in non-literate cultures.

of the social

relationships

He phrases it this way :

We do not usually associate diseases with whether or not our persona1 relations are good,
whether we keep certain religious or social rules or not. But this is exactly what the primitive
does.
Disease derived from sorcery, from taboo violation, from the anger of ancestral or other
spirits is the expression of social tensions. A seemingly independent, biological problem is
thus woven into the whole socio-religious fabric in such a way that disease and its healer play
a tremendous social role, a role that in our society is assumed rather by judges, priests, soldiers,
and policemen [lo].

In such a system of thought as this the threat of disease or death becomes part of the basic
system of social control of the society. Not only the patient or sinner is involved in the
diagnostic and treatment events but others closely associated with him are participants
as well.
Primitive medicine, then, is based primarily upon principles of magic and religion.
As Hughes has written:
Therapeutic practices in ethnomedicine addresses themselves to both supernatural and
empirical theories of disease causation. Ackerknecht has said that primitive medicine is
magic medicine; certainly much of it is, and, insofar as supernatural causes are involved,
therapeutic regimes are based on countervailing supernatural powers or events.
Thus, the powerful shaman or healer attempts to recover the soul lost or stolen by a human or
supernatural agent.
The intrusion of a disease object or disease-causing spirit is treated by extraction or exorcism,
and diseases which come as punishment for breach of taboo are usually treated by divination or
confession of the infraction.
Forgiveness and reestablishment
of harmony with the moral and supernatural order are
thus important outcomes of the therapy [l I].
This is not the full extent of primitive medical practices. There are pragmatic empirical
practices as well, for no social group is without its simple medical and surgical practices
or the use of plants for medicinal efTect. The knowledge of anatomy is usually very weak
but the knowledge of medicinal effects from plants is often quite extensive. Bonesetting,
minor forms of surgery, and a range of physical treatments are usually well developed.

796

DOXALD A. KENNEDY

Many of these practices are not anchored in magical reasoning but survive on the grounds
of visible cause and effect relationship. The mechanisms of causality may not be understood
in detail but the subjective probability associated with successful outcome after the use of
a specific herb reinforces the pattern of treatment.
Primitive medicine has a longer history than scientific medicine and public health. It was
developed prior to the invention of the scientific method, and it developed in a cultural
climate where there was intense human concern and relatively little empirical knowledge
about biological processes. Primitive medicine performed multiple functions within small
tribal societies with economies based upon hunting and gathering or agriculture.
Perhaps its greatest and most lasting strength is found in those practices that helped the
psychological and social responses to illness, injury, and death, for all participants. Even
today it provides a reasonable outlet of activity to cope with the anxieties associated with
the inherent uncertainty of outcome of the disease process for any given person. Present
day scientific medical practice which is so technical and impersonal in its delivery of services
is often deficient in this respect.
The patterns of belief and reasoning in scientific medicine differ from primitive medicine.
Here the supernatural assumptions are excluded and only those processes of the natural
world amenable to scientific observation and experimental study are included. Data obtained
through the human senses with the aid of various instruments is combined with principles
of logical reasoning to produce public findings that are subject to independent verification
by other scientists. This is the knowledge orientation of scientific clinical medicine. Its
historic development is of relatively short duration. Only 60 years ago Abraham Flexner
urged medicine to adopt a strong scientific orientation. He said:
From the earliest time-s, medicine has been a curious blend of superstitution, empiricism, and
that kind of sagacious observation out of which ultimate science is made. . . .
The general trend of medicine has been away from magic and empiricism and in the direction
of rationality and definiteness [12].

Flexner then went on to define science as the severest effort capable of being made in the
direction of purifying, extending, and organizing knowledge. The effort is scientific
so long as men strive to transcend their native phenomena in a dry light. He was concerned
with emphasizing an orientation, a direction, and a point of view. And he felt that a
scientific perspective could characterize both medical research and clinical practice.
This meant that medical practices ought to be tied closely to those fields of scientific
study that could yield continuing improvements in clinical performance. In the early first
decade of this century, those fields were anatomy, pathology, biochemistry, pharmacology,
bacteriology, and physiology. Within the past 25 years biomedical research activities have
been greatly expanded with support from charitable foundations and national governments.
The life sciences have grown to an impressive level of maturity, and many of the physical
sciences and engineering fields have found specialized application in the field of clinical
medicine.
In most recent years the behavioral and social sciences have grown to a point where their
methods and generalizations are finding increasing application in the professional worlds of
medicine and public health. In comparison with the other professions, such as law and
architecture, medicine has certainly developed the strongest scientific orientation and
provided the strongest institutional arrangements for collaboration between the sciences
and the practicing professionals. Societal support for biomedical research has finally
achieved a level where we can expect a continuing flow of new discoveries that will constantly

Perceptions

of Illness and Healing

797

improve the effectiveness of interventions in the health arena. This new knowledge and
technology is available to most physicians with a scientific orientation throughout the
world.
The reasoning pattern of scientific clinical medicine is characterized by a highly analytic
approach, a dominant concern for single-factor etiology, and a preoccupation with biological
and biochemical events inside the skin. Patterns of total body function, relationships
with the environment, and patterns of behavior or social relationship are only weakly
perceived as relevant to the clinical practice of medicine. The central social role of providing
healing services to one patient at a time leaves its stamp on most patterns of reasoning in
clinical medicine. The highly successful experience in identifying microbes that were specific
and singular causes of serious disease produced an intellectual heritage and a trajectory of
perception and value that continues to shape most professional actions and perceptions
in this field today. The central assumption is that there is a specific virus, bacteria, or genetic
deficiency behind each and every one of the many thousands of classified disease conditions.
The established treatments are surgery, chemotherapy, exhortation, and reassurance.
The third type of practitioner operates according to the perspective of the field of public
health. This field of knowledge and practice is also scientific in its basic orientation. But
the central focus is upon prevention of illness and injury in populations, not the cure and
rehabilitation of individuals who define themselves as needing medical attention. Leave11
and Clark have described the essential differences in the form of a series of comparisons
(see chart, p. 798). One might add an additional point of comparison: the initiative lies
with the patient in relationship to the physician and in public health the initiative lies
in the hands of the director. The major techniques of intervention in public health
are : political, legal, administrative, educational, and by vaccination.
COMPARISON

OF PRACTICES

[13]

The orientation of public health practice emphasizes prevention and a concern for
populations rather than individuals. The central methodologies of public health come
from epidemilogy, biostatistics, engineering, and applied behavioral science. There is a
strong tendency to use multidisciplinary teams both in research and in practice. There are
strong working relationships with a large spectrum of scientific and engineering disciplines.
The involvement with the behavioral and social sciences has been much in advance of the
field of clinical medicine. The collective or population focus of public health and its central
dependence upon political, legal, and educational techniques of intervention has provided
both supportive climate for the participation of the social sciences. There is a similar strength
of expertise in management, planning, and evaluation of service programs. An understanding
of the workings of communities, organizations, and government agencies has been essential
for the public health practitioner.
The cognitive style of public health bends in the direction of identifying diseases and
environmental conditions hazardous to health in specific populations. The mission is to
find means of preventive intervention prior to the appearance of visible symptoms or
restricted activity. For nations with high frequency of infectious disease, the interventions
of vaccination, sanitary engineering and the application of pesticides have a demonstrated
effectiveness. In countries where chronic disease dominate in the epidemiological patterning
of mortality and morbidity, the methods of intervention often emphasize educational
techniques and modifications of the environment. The frame of reference is ecological.
S.S.M.
7/10-D

DONALD A.

798

Public Health Director

1. He is trained as a specialist in preventive
medicine.
2. His primary concern is with the various aspects

of prevention.
3. His patient is the community, and his major
concern is with disease as it affects groups of
people. In numerous instances, of which the
health of mothers and children is a good
example, the approach to the group must be
through individual patients.
4. He seeks health procedures which can be
applied economically
to large numbers of
people with satisfactory results for a high
percentage of them.
5. He uses community health education technics to
persuade individuals to avail themselves of
helpful procedures.
6. He functions through organized community
effort and has legal backing if it should be
necessary in certain cases.
7. He and his associates are financed by funds
coming largely from taxation.
8. He is responsible to the entire community in
which he practices his specialty.
9. He has a sort of monopoly in certain aspects
of mass preventive medicine in the geographic
area in which he works.
10. He must deal with many administrative problems, since his department ordinarily employs a
number of people and is a branch of government, and its successful operation requires the
cooperation of many agencies and individuals.

KENNEDY

Private Practitioner
1. He is a general practitioner of preventive
medicine. This is true whether he is a specialist
in some branch of dentistry, medicine, or
surgery, or a general practitioner in all respects.
2. His primary concern has been conventionally
with the treatment of disease and injury.
3. His patient is an individual, though he may
take responsibility for the health problems of
an entire family.
4. He strives to approach perfection in serving
the individual patient, despite expense which
would preclude application of such procedures
generally in the community.
5. He is bound by medical ethics not to advertise for oatients. althouah individual and
family health education is his duty.
6. He functions as an individual provider of
health services, with legal obligations but no
legal authority except the right to practice.
7. He is usually paid by individual fees, which
may or may not be covered by some form of
insurance.
8. He is responsible directly to his patient, who
is nevertheless
protected
legally against
malpractice.
9. He is in competition with other practitioners
in his geographic area.
problems are minimal,
10. His administrative
since his practice has the characteristics of a
small business.
(Leave11 and Clark [13])

Public health practitioners

assure that interaction with his environment
must be understood
in depth in order to identify points of preventive
intervention.
With the exception of
vaccination
techniques
and health education
programs,
the bulk of the public health
interventions
are directed to events and processes in the physical<hemical,
biological,
man-constructed,
and social environments
of man. Evidence of success is measured in
statistical indices of health status in target populations.
Public health practitioners
have been instrumental
in developing and maintaining
governmental reporting systems that record births, deaths, illnesses, accidents, and utilization
of
medical and dental services. This data on demography, vital statistics, and service utilization
provides the empirical base for making objective appraisals of health status levels in most
population
groups. Public health officials are also responsible
for emergency response to
outbreaks of contagious disease, food poisoning, and accidental injury.
In summary, there are three major classes of practitioner
each following a distinctive
perceptual-cognitive
map. Recognition
and reaction to health events in the environment
are tied to key assumptions
about cause, cure, and prevention
of disease and suffering in
human beings. Trajectories
of customary behavior exert a dominant influence upon their
professional
actions today. The incremental
changes that occur in belief and professional
performance stem from adaptations
to shifts in expectation of clients and from the unrelenting pressure of new scientific knowledge.

Perceptions
BIOMEDICAL

SCIENTISTS

of Illness and Healing

AND

PRACTICING

799
PHYSICIANS

The medical schools represent a central intersection for the worlds of biomedical research
and the training of practicing clinicians. Every physician, no matter what his career specialization, must pass through this academic setting. Here both students and faculty cope with
two competing world views: those associated with scientific research and those associated
with clinical practice. There are differences in the requisite patterns of reasoning, action,
and criteria for making judgements.
The biomedical scientist is interested in the discovery of new knowledge. His reference
group is that set of scientists engaged in research in his field of special interest. These
people may be scattered all over the world and may publish their results in several different
languages. The scientist is interested in generalizations and in the development of theory;
he is not interested in the application of knowledge to a specific person in need of medical
services. Furthermore, he is trained to be skeptical about all assertions of factual knowledge.
A pattern of organized skepticism motivates scientists to keep testing, challenging, and
refining a body of knowledge. Since they are not constrained by the requirement ofproviding
an individualized consulting service, they shy away from making decisive statements about
clinical problems.
The position of the clinical physician is different. Eliot Freidson has described the
difference in the following words:
What is the work of the profession? It is the attempted solution of the concrete problems of
individuals . . . it is by its nature applied rather than theoretical in character. . . and markedly
different from the work of the scientist.
. . . At best, the practicing physician may use general principles to deal with concrete problems:
the scientist typically investigates concrete phenomena in order to test, elaborate, or arrive
at general principles.
Insofar as the practice of medicine it all uses science, it is characteristically
oriented
to applying rather than creating or contributing to it.
Indeed, since its focus is on the practical solution of concrete problems, it is obliged to carry
on even when it lacks a scientific justification for its activities. It is oriented to intervention
irrespective of the existence of reliable knowledge. . . .
Furthermore, medical practice is typically occupied with the problems of individuals rather than
of aggregates or statistical units. Probabilities can only guide determination of whether a
patient does or does not have a disease. Thus, even when general scientific knowledge may be
available, the mere fact of individual variability poses a constant problem for assessment . . .
it emphasizes the necessity for personal, first hand examination of every individual case and the

difficulty of disposition on some formal, abstract scientific basis [14].

Freidson then goes on to indicate the essential
associated with the practicing physician :

features

of the clinical

mentality

that is

First, the aim of the practitioner is not knowledge but action. Successful action is preferred,
but action with very little chance for success is to be preferred over no action at all.
Second, the practitioner is likely to have to believe in what he is doing in order to practiceto believe that what he does good rather than harm, and that what he does makes the difference
between success and failure rather than no difference at all. . . Given a commitment to action and
practical solution, in the face of ambiguity the practitioner is more likely to manifest a certain
will to believe in the value of his actions than to manifest a skeptical detachment.
Third, perhaps because of his action orientation, perhaps because of the complexity and variety
of the concrete, the practitioner is a fairly crude pragmatist. He is prone to rely on apparent
results rather than on theory, and he is prone to tinker if he does not seem to be getting
results by conventional means.
Fourth, the clinician is prone in time to trust his own accumulation of personal, firsthand
experience in preference to abstract principles or book knowledge, particularly in assessing
and managing those aspects of his work that cannot be treated routinely. . . . Highest value
is placed upon emotional experience . . . widening the range of gut response as a means of

800

DONALDA. KENNEDY
understanding what is going on in oneself and in the patient. This represents a certain subjectivism in his approach.
And fifth, the practitioner is very prone to emphasize indeterminancy or uncertainty, not
the idea of regularity or lawful, scientific behavior. Whether or not that idea faithfully
represents actual deficiencies in available knowledge or technique, it does provide the
practitioner with a psychological ground from which to justify his pragmatic emphasis on
firsthand experience [15].

Each of the roles, scientist and practitioner,

produce pressures to perceive, think, reason,
and judge events in different ways. The central motivational
dynamics and career rewards
are different. This is painfully clear in the study of the ethics of clinical research practice
where the discovery of new knowledge comes into potential conflict with the rights of the
research subject (patient or healthy volunteer)
who thinks he is receiving a professional
service rather than assuming a risk and making a contribution
to knowledge.
The biomedical scientist is guided by a set of norms and values that encourage him to
act in a distinctive way. Norman Storer has identified six basic norms. They are as follows :
(1) Universalism
This norm . . . refers both to the assumption that physical laws are everywhere the same and to
the principle that the truth and value of a scientific statement is independent of the characteristics
of its author. . . .
(2) Organized skepticism
This norm is directive . . . each scientist should be held individually responsible for making sure that
previous research by others on which he bases his work is valid. . . .
The scientist is obligated also by this norm to make public his criticisms of the work of others
when he believes it to be in error.
(3) Communism or communality
This norm directs the scientist to share his findings with other scientists freely and without favor,
for knowledge that is not in the public domain cannot be part of the legitimate body of knowledge
against which creativity is measured and to which other scientists refer in their work.
Further, since other scientists cannot be expected to know what one is working on, this norm
encourages the scientist to take the initiative in placing his findings before his fellow scientists.
(4) Disinterestedness
This orientational norm . . . makes it illicit for the scientist to profit personally in any way from
his research . . . it prohibits the scientist from making the search for professional recognition his
explicit goal . . . it dissuades the scientist from an active interest in doing research as a means toward
financial success or gaining prestige in the lay community . . . it serves to make research and discovery
an end in itself.
(5) Rationality
Barber defines rationality essentially as a faith in the moral virtue of reason, pointing out that the
morality of science tends to drive it into all empirical areas. . . . This goal is based on the moral
value that all things must be understood in as abstract and general a fashion as possible.
It may be interpreted also as the assumption that necessary to the achievement of the goals of
science are:
(1) empirical test rather than tradition and
(2) a critical approach to all empirical phenomena rather than acceptance of certain phenomena as
exempt from scrutiny.
(6) Emotional neutrality
Emotional neutrality . . . enjoins the scientist to avoid so much emotional involvement in his work
that he cannot adopt a new approach or reject an old answer when its tindings suggest that this is
necessary, or that he unintentionally
distorts his findings in order to support a particular
hypothesis [16].
When

we compare

the differences

noted

the two Sets of norms we find some surprising similarities as well as

by Freidson.
Both clinician and scientist must remain emotionally

Perceptionsof Illnessand Healing

801

neutral and disinterested. Both are expected to be rational but one emphasizes the creation
of theoretical knowledge while the other stresses the application of a wide range of general
knowledge to solve a complex problem embodied in the suffering of a single human being.
The clinician is convinced, and properly so, that universal statements of truth are found
seriously deficient when they are applied to solving practical problems in the real world.
The clinician must eventually assume an authoritative position in reference to a diagnosed
condition of illness so he can proceed with therapeutic treatment. His role does not allow
him the freedom to remain skeptical or critical of factual propositions for extended or
indefinite periods of time. And finally, the clinician is not expected to share the results of
his therapeutic experience with patients. The record of his experience with each patient is
defined as private and confidential. Satisfactory service to clients rather than the publication
of abstract generalizations are the keystone to successful professional performance for the
practicing physician.
PERCEPTIONS AND BEHAVIOR
Within any geographic setting with its specific cluster of health hazards, the resident
human population has evolved patterns of behavior to assist the imperative processes of
adaptation and adjustment. Although patterns of belief and behavior are strongly interconnected, we may judge the behavior patterns as having priority in their relative impact
upon the health status of the group. If families typically dispose of human excrement and
garbage by burial in the ground, the result is a sanitary environment which reduces the
opportunities for insects to breed and thus to transmit infectious diseases, some of which are
harmful to man. The reasons given for the burial behavior may be couched in terms of
preventing witchcraft, as is the case among the Navaho Indians of the American SouthWest, or in terms of germ theory interrupting the transmission of infectious disease. The
behavior and the pattern of reasoning often vary independently, and the health outcome
usually results from the behavior rather than the belief. It is important to recognize this
conceptual independence of associations between behavior and belief with reference to
health status outcome. Most successful public health and community development programs
have had to recognize and utilize this finding.
There is an additional generalization. Patterns of perception, belief, and ideology, are
interconnected and tend to form a coherent unity for the social actors concerned. As
Kluckhohn has said:
Every groups way of life . . . is a structure-not
a haphazard collection of all the different
physically possible and functionally effective patterns of belief and action but an interdependent
system based upon linked premises and categories whose influence is greater than less
because they are seldom brought out into explicit discussion. Some degree of internal coherence
which is perceived rather than rationally constructed seems to be. demanded by most of the
participants in any culture 1171.
The total context of categories and assumptions about the world tends to permeate each
and every activity domain, including health. This finding suggests that all health practitioners
must learn the covert assumptions and basic reasoning patterns of their clients. Health
professionals are interpreters and intermediaries between a body of scientific knowledge
about health enhancement and the realities of folk medicine, primitive medicine, and
public safety practice within any given community. To render a valuable and effective
professional service, the physician and the public health director must master both worlds
of thought and behavior. He must know how providers think and behave; and he must

802

DONALD A. KENNEDY

know how clients believe and act. Continuities and differences between these worlds of
perception and behavior are often critical in determining effective performance of the
physicians professional duties.
The client must also learn more about these two worlds of thought and action. To an
increasing degree, patients must assume a major responsibility for their health status.
Many conditions of chronic disease and accidental injury require this. As John Millis has
recently written :
. . . the availability and the skill of a physician has very little to do with morbidity
automobile accidents, from cigarette-induced cancer, from alcoholism and its effects,
drug abuse and its results, from obesity, from the lack of self-discipline which sometimes
to mental and organic disease. . . .
The point is that here there are fewer things that the physician can dofir the patient, but
are many things that the patient must do fir himsel The doctor cannot stop the patient
smoking in order to save him from lung cancer. The patient must take the action [18].

from
from
leads
there
from

This pattern of client responsibility is likely to strengthen in the years ahead. The reasons
for this include: (1) the nature of the major health hazards in contemporary behavior settings
throughout the world; (2) the unrealistic expectations that many patients have about the
intervention capability of the various healers and provider assistants in the field of health
care; and (3) the serious shortage of health care services in terms of geography, specialty,
or eligibility. All of these trends are likely to continue for the next decade or so. In combination, they place a significant degree of responsibility upon the clients, individually and
collectively, to learn new knowledge and skills for preventing illness and coping with
injury and disease.
These considerations in turn lead to a serious concern with the concepts of self and other.
There is an inherent tendency for all persons to become totally absorbed in their own
personal perception of the world. Although evqry social role involves a relationship between
two or more parties, individual participants tend to forget the two-sided nature of the
interaction. We all tend to neglect a careful consideration of the rather basic differences in
perception being experienced by our role partner. As Parsons has recently summarized
the central conceptual issue :
The crucialreference points for analyzinginteractionare two: (1) that each actor is borh acting
agent and object of orientation both to himself, and to the others; and (2) that, as acting agent,
he orients to himself and to others and, as object, has meaning to himself and to others, in all
of the primary modes or aspects. The actor is knower and object of cognition, utilizer of
instrumental means and himself a means, emotionally attached to others and an object of
attachment, evaluator and object of evaluation, interpreter of symbols, and himself a
symbol 1191.
Illness and injury are events that trigger the most fundamental levels of human meaning
and social relationship. The ability to subjectively manipulate perspectives so that one can
momentarily take the position of the other and can even enact a convincing performance
of the role of the other partner-this
ability is needed in situations when there is a threat to
health and well being. But no matter how many times we read, write, or talk about this
key issue of self-other perspective we still have difficulty living it in daily interactions.
Under the impact of the emotional alarm that accompanies illness, we become less competent
to manage our thoughts and perceptions-we retreat to an egocentric and one-sided position.
It is difficult to generate and maintain empathy in such circumstances. And without empathy
there is danger of depersonalization in the delivery of medical services.
There is an additional generalization to be made. The rapid growth of specialization

Perceptionsof Illnessand Healing

803

and division of labor within the health care field has spawned a multitude of tight little
cultural islands of knowledge, perspective, and technical language. This process in turn
generates the need for integration, synthesis, coordination, and control. As Durkheim
pointed out many years ago, the division of labor requires the use of coordinating
mechanisms if useful work is to be accomplished. This means that our intellectual quest is
increasingly directed toward a search for general principles, rather than additional descriptive detail. Clyde Kluckhohn urged the study of implicit culture and values as an approach
to this problem. He wrote:
accidentsof history, every people not only has a sentiment structure which
is to some degree unique but also a more or less coherent body of characteristic presuppositions
about the world. This last is really a borderland between reason and feeling. And the trouble
is that the most critical premises are so often unstated--n
by the intellectuals of the
group [20].
Cultures or group lifeways do not manifest themselves solely in observable customs and
artifacts. There is much more to social and cultural phenomena than immediately meets the

As a result of the

ear and eye. If the behavioral facts are to be correctly understood, certain presuppositions
constituting what might be termed a philosophy or ideology must also be- known. . . . In a
certain deep sense the logic . . . of all members of the human species is the same. It is the
premises that are different. Moreover, the premises are learned as part of a cultural tradition.
Synthesis within a culture is achieved partly through the overt statement of the dominant
conceptions, assumptions, and aspirations of the group in its religious lore, secular thought, and
ethical code; and partly through unconscious apperceptive habits, ways of looking at the stream
of events that are so taken for granted as seldom or never to be verbalized explicitly. These
habitual ways of begging certain questions . . . are distinctive of different cultures . . .[21].

More studies of implicit culture and value orientation need to be made in the health
field, especially with reference to the service groups. One gets the impression that we know
more about latent assumptions in the area of folk medicine then we do in scientific medicine
or public health. Freidsons description of the clinical mentality [22] represents a refreshing opening-statement for this field of inquiry but we need more empirical investigations
by social scientists from a variety of disciplinary perspectives. People in the United States
place high value on activism, mastery over nature, youth, and a future time orientation
[23]. Do these values produce specific lacunae in our controlling ideas about health care
and biomedical research? Do they help to explain the differential allocation of resources
among the specialties of medicine and for different types of health services? These questions
and others suggest the strategic importance in studies of implicit culture.

FRAMES

OF REFERENCE

There are subtle but profound differences in feeling and action associated with beliefs,
attitudes, and values. These images, symbols, and sentiments, acquire their meaning through
association with experienced events in the natural world and through their special placement
within frameworks of assumption
and reasoning [24]. Our whole perspective about a field

of knowledge can change when we actively search for a new frame of reference or attempt
to compare competing frameworks. This is the case when Hughes [25] argues the case for
an ecological perspective in the study of health and disease; Alan Sheldon [26] and his
associates apply a general system-a theory approach to the field of health care; Boulding
[27] writes about images and the science of iconics or Etizoni [28] describes the active
society. As we read one treatise after another our viewpoint shifts and we are tempted to
design and then to construct our own frame of reasoning for the same field of empirical
events.

DONALDA. KENNEDY

804

The provocative
quality of this process can be illustrated
by quoting
analysis of the medical profession. His basic argument is as follows:

from Freidsons

. . . it is useful to think of a profession as an occupation which has assumed a dominant

position in a division of labor, so that it gains control over the determination of the substance
of its own work. Unlike most occupations, it is autonomous or self-directing. The occupation
sustains this special status by its persuasive profession of the extraordinary trustworthiness of
its members.
The trustworthiness it professes naturally includes ethicality and also knowledgeable skill.
In fact, the profession claims to be the most reliable authority on the nature of the reality it
deals with. When its characteristic work lies in the attempt to deal with the problems people
bring to it, the profession develops its own independent conception of those problems and
tries to manage both clients and problems in its own way.
In developing its own professional approach, the profession changes the definition and
shape of problems as experienced and interpreted by the layman. The laymans problem is
recreated as it is managed-a
new social reality is created by the profession. It is the
autonomous position of the profession in society which permits it to recreate the laymans
world [29].
Freidson

then goes on to comment

about

the isolation

of the professions:

. . . the characteristics of professional autonomy are such as to give professions a splendid

isolation, indeed, the opportunity to develop a protected insularity without peer among
occupations lacking the same privilege.
This is the critical flaw in professional autonomy: by allowing and encouraging the development of self-sufficient institutions, it develops and maintains in the profession a self-deceiving
view of the objectivity and reliability of its knowledge and of the virtues of its members.
Furthermore, it encourages the profession to see itself as the sole possessor of knowledge and
virtue, to be somewhat suspicious of the technical and moral capacity of other occupations,
and to be at best patronizing and at worst contemptuous of its clientele.
Protecting the profession from the demands of interaction on a free and equal basis with those
in the world outside, its autonomy leads the profession to so distinguish its own virtues from
those- outside as to be unable to even perceive the need for, let alone undertake, the selfregulation it promises.
I do not mean to deprecate either the real knowledge or the intent of the profession at large.
Both its knowledge and its intent are admirable. The problem is that once given its special
status, the profession quite naturally forms a perspective of its own, a perspective all the more
distorted and narrow by its source in a status answerable to no one but itself. Once the
profession forms such a self-sustaining perspective, protected from others perspectives,
insulated from the necessity of justifying itself to outsiders, it cannot reasonably be expected
to see its self and its mission with clear eyes, nor can it be reasonably expected to assume the
perspective of its clientele. ___
Their autonomy has created their narrow perspective and their self-deceiving views of
themselves and their work, their conviction that they know best what humanity needs. It is
time their autonomy be tempered [30].

The author is challenging several fundamental

assumptions
that support the legitimacy of
the medical profession to continue its traditional
role in the delivery of health services in
modern society. Evidence is mobilized to support a new kind of understanding
about the
function of professionals in relation to their clients and to the general public. This paves the
way for planning
new organizational
arrangements
in the training and management
of
physicians as well as other health service personnel.
It also provides some imaginative
suggestions for further study.

REFERENCES
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Comparative Theories of&ciuI Change (edited by PETER,HOLLISW.) pp. 118-162. Braun & Brumfield,
Ann Arbor, Michigan, 1966.
2. MECHANIC,DAVID. Medical Sociology, The Free Press, New York, 1968.

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_
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