Social constructivism has acquired something of a bad reputation in recent years, particularly because of the way that it has been used (and misused) in debates over sex and gender identity. I consider this unfortunate, because when done properly, constructivist analysis can be a source of important insights about the world. The background tendency of all human beings is to vastly overestimate the “naturalness” of our social environment, and thus to reify (i.e. treat as an object) what are in fact social arrangements. Many classic works of constructivist analysis pick out some aspect of the social world that we are naively inclined to view as natural and show how it came to be at a particular time, in a particular cultural context. Anyone with a serious interest in intellectual history, or in studying other cultures, tends to become more of a social constructivist over time, due to the inescapable fact that other people, in other times and other places, inhabit social worlds that are radically different from our own.
Many progressive academics, of course, are also enthusiastic proponents of social constructivism because they are offended by various features of our society, and yet recognize that there is no point criticizing things that cannot be changed. If a particular arrangement is a social construct, however, then maybe it can be changed, and so it may be worth criticizing. (Indeed, some critics are inclined to believe – optimistically – that merely pointing out the constructed character of a phenomenon will lead to change, on the supposition that the only reason people tolerate the injustices of the world is that they fail to realize that change is possible.) This unfortunately leads some academics to engage in a common form of wishful thinking, in which they persuade themselves that various things are social constructs merely because they would like to see them changed.
Nevertheless, the fact that some people engage in wishful thinking, and so are promiscuous in their attributions of social construction, should not be used to dismiss constructivist analysis that is grounded in more sober assessment of the evidence. In order to illustrate this, I would like to go back to one of the classic examples of constructivist analysis, which is the American sociologist Talcott Parsons’s discussion of illness (first presented in his 1951 book The Social System). Most people, Parsons observes, hold the naive view that “being sick” is a natural state of affairs, a physiological condition of the human organism. If one attends more carefully to the phenomenon, however, one can see that sickness is a social role, governed by a set of social norms, which specify quite particular entitlements and obligations. Illness, in other words, is a social construct.
Of course, Parsons’ objective in developing this analysis was not to deny that sick people suffer from some bodily condition, which in some sense impairs their health. It was to show that “illness” consists in a great deal more than just this condition. The bodily condition is important because it provides the basis for the entitlement an individual may acquire to adopt the sick role (either directly, or else when certified by a medical professional). A great deal of the individual’s subsequent behavior is determined by the social role, not by the organic condition (which is why the sociologist should be committed to distinguishing to two). For example, the fact that one is entitled to miss work, or to have an exam deferred, is a consequence of the social role that one is occupying as a sick person, not the underlying physiological condition.
The analysis seems to me quite useful, perhaps now more than ever, because it provides a good analogy for many of the debates people have been having about the relationship between sex and gender (along with the claim that gender is a social construct). In particular, it provides a good model for thinking about the relationship between physiological facts and socially constructed roles. Before getting to that, however, it is perhaps worth drawing a distinction between this sort of serious constructivist analysis, which is an attempt to make an important sociological point, from a related set of ideas that has achieved public notoriety.
Most undergraduate students encounter, quite early on, a version of social constructivism that is not really a serious sociological hypothesis, but is more of a debating trick. Because all forms of categorization rely on language, and every natural language contains important conventional elements, it is easy to exploit the ambiguity between the terms we use to refer to objects and the objects themselves, in order to claim that anything and everything is a social construct. For example, one could argue that “sepsis” is a social construct, because prior to the 20th century there was no corresponding category of medical condition (the closest approximation, “blood rot,” was non-overlapping, in the sense that it applied to some conditions that we would not now refer to as sepsis, and excluded some that we would categorize as sepsis). The parlour trick then consists of saying, with a dramatic flourish, things like “before the 20th century, no one ever died of sepsis.” This is true, in the sense that no one died of sepsis under that description, but it is also clearly false, in the sense that throughout all of human history people have died from conditions we would now describe as sepsis.* Nevertheless, one might use this sort of language to trick the unsuspecting into believing that there is a new, silent killer stalking humanity in the modern age.
One might think that this parlour trick is too obvious to be taken seriously, but in fact it has confused and misled a very large number of people. Michel Foucault was perhaps the worst offender, in this regard, since he had a view of language that obscured the intuitive distinction between objects and the words that we use to refer to them (i.e. le mots et les choses), and he had a personal fondness for making grand pronouncements. This led him to say things like “sex was invented by the Victorians,” or “there were no homosexuals in the ancient world,” despite the obvious fact that people have had sex, both gay and straight, throughout human history. Many of Foucault’s contemporary disciples, like Judith Butler, are drawn to the same style of argument. For example, in Gender Trouble, Butler spends an enormous amount of time trying to show that sex (not just gender) is a social construct. The arguments, such as they are, amount to just variations on the constructivist parlour trick. Butler adduces no empirical facts or observations in support of the claim, it is simply derived from general theses about language (derived, in turn, from the authority of Foucault).
Although this species of social constructivism, which many associate with “postmodern” philosophy, possesses a veneer of radicalism, it is actually trivializing of the hypothesis. Because it derives constructivist conclusions from universal features of language and cognition, it winds up implying that everything is a social construct, which is not all that different from saying that nothing is a social construct. It fails to recognize that some things are a great deal more constructed than others, and that there may be considerable interest in distinguishing the cases. Butler’s argument, aimed at showing that “sex” is a social construct (e.g. p. 117), could just as easily be used to show that “granite” is a social construct (perhaps just a label “assigned at the quarry”).
This account offers some support for what I have elsewhere described as the “academic lab leak” theory of wokeness (according to which certain dangerous arguments, which should be handled only by experts, and even then with a measure of caution, escaped onto the internet, where they proceeded to cause untold confusion in the minds of the vulnerable). Social constructivism is arguably an instance of this. For example, one can find its nefarious effects in debates over the status of race, where people start from the observation that different societies have used different classificatory schemes at different times, then conclude on this basis that race is “not real,” or that it has no biological reality. People used to make the same mistake in reading Parsons, imagining that if illness is a social construct, this must mean that people are not really sick, or that they are all just faking it, which is not really the point Parsons was trying to make.
A better way to think about these issues is to imagine the natural property providing something like an admission ticket to a particular social status (or an entitlement to occupy a social role), ceteris paribus. In the case of race, one must possess a certain biological property (i.e. specific ancestry) in order to be eligible for membership in a certain category, but membership in that category has all sorts of consequences that do not follow merely from possession of that property (and many of these consequences are social and contingent). Similarly, Parsons’ view of illness is that one must possess certain physiological properties in order to be eligible for classification as sick, but being sick has consequences that do not follow merely from possession of those properties. For example, the reason that you don’t have to get out of bed when you’re sick is not that you cannot get out of bed, it’s that you are no longer obliged to do so (i.e. you are exempt from the obligation that the healthy are subject to).
But if the natural property and the social status are so closely related, what is the point of making the distinction? One reason for doing so is to better understand the complex patterns of social behaviour that surround these statuses. For example, an insightful feature of Parsons’ analysis of the sick role is his articulation of the quid pro quo structure that governs it. Although sickness is conventionally regarded as a lamentable status, it also provides certain advantages, in the form of exemptions from everyday social obligations. These extend far beyond the permission to stay home from work or school. The sick are able to cancel any social engagement, they have no obligation to be cheerful or polite, they are entitled to be fed and cared for, and so on. Because of this, the sick have a reciprocal obligation to demonstrate that they are making a good-faith effort to “get better,” and thus to exit the role. This is done primarily by following medical instructions (including those involving pain, discomfort or privation), obtaining appropriate rest, expressing a commitment to recovery, and so on. (The metaphor of “fighting” disease, which hospitals are constantly using to promote their services, serves also the normalizing function of modeling appropriate behavior for patients.)
No one ever writes an obituary that says “doctors gave her only six months to live, but she threw in the towel after four,” even though there is, presumably, a normal distribution around predicted life expectancy. The point of drawing attention to cases on the far side of the mean is not that we consider clinging to life a valuable personality trait. The point is to praise the deceased for exemplary performance of the positive obligations of the sick role.
Because occupying the sick role has benefits, a certain number of people can be expected to malinger, dragging their feet or otherwise delaying their exit from the role.** Extreme cases, such as factitious disorder, involve individuals faking symptoms in order to enter or maintain the status of being sick. For this reason, the boundaries of the sick role are always subject to social control. Indeed, one of the major occupational obligations of doctors is not only to treat the physiological conditions underlying illness, but also to police the boundaries of sickness and health. Indeed, one of the reasons that doctors generate mixed feelings among many is that they act simultaneously as healers and as agents of social control.*** (Part of their job is to admit patients to hospital, but part of their job is also to discharge them – often against resistance.)
Of course, the boundaries between improving the patient’s physiological condition and pressuring the patient to get better are not particularly clear, which is why medical schools teach their students that illness is a “biopsychosocial” phenomenon (a term that I used to think was funny but now tend rather to think is apt). For example, while malingering violates the rules of the sick role, it is also not good for one’s health, in the sense that patients who spend too much time in bed, or are too slow to return to a normal activity level, suffer worse outcomes at the physiological level. As a result, “getting better” is an outcome often achieved through a combination of physical recovery and social pressure.
It is worth noting that the discussion of the sick role one can find in Parsons (e.g. The Social System, pp. 436-438) is quite noticeably dated. Having been written in the 1950s, it assumes an extraordinarily high level of deference to the scientific and social authority of the physician. Since that time, the gatekeeping role of the physician has been seriously diminished (which has tended also to expand access to the sick role). This illustrates the central point about social construction. What counts as being sick, what one is owed by virtue of being sick, and how one is expected to act when sick, are socially determined, which is precisely what allows these things to change over the course of time, in response to various social pressures. The value of sociological analysis lies in the way that it dissolves the illusion that illness is merely a physiological condition. This illusion is what leads us to think that the consequences of illness – such as exemption from productive labour – follow necessarily from natural features of the condition, rather than contingently from the social expectations of the role. Seeing through the illusion allows us to reflect more carefully and critically about those consequences, about the current constitution of the role, and about how we should respond to pressures to change it.
The other thing worth noting about Parsons’ discussion of the sick role is that it is noticeably “right-coded” within the contemporary political context. (This is not an accident, since Parsons was politically quite conservative, a proclivity that became more explicit in his later writings.) Indeed, I am surprised that in current debates over rising rates of mental illness and disability more people have not made the point that wellness is only partly a physiological state, but also an effect of successful social control. (In my own workplace, I am exposed to an ongoing search for new ways to “accommodate” our students. Seldom does anyone suggest that not accommodating them might be an important part of the healing process.) All of this speaks to a point that has been made, time and time again, in the academic literature, which is that there is nothing inherently left-wing, or progressive, about social constructivism. First of all, the mere fact that something is socially constructed does not necessarily mean that it can be changed, or changed easily. Religion is also (self-evidently) a social construct, and yet various attempts to abolish it have been surprisingly unsuccessful. Second, the fact that something can be changed does not mean that it should be changed. The practice of “calling in sick” from work, for example, dates back only to the early 20th century, but I’m sure most people think it is a reasonable entitlement (especially for those with contagious diseases). Showing that something is socially constructed may be an important prelude to critique, but it does not actually constitute a critique.
My interest in the sick role is admittedly somewhat limited. Where I find Parsons’ analysis most helpful is when it comes to evaluating claims made in other domains. People who emphasize the socially constructed aspect of gender or race, for example, typically think that certain political implications follow from this claim. In order to determine whether these implications actually follow, or whether one is suffering from belief bias, it is helpful to swap out the example for one that is likely to elicit different sympathies. Substituting “illness” for “gender” can be particularly effective in this regard, allowing one to see more easily what does and does not follow from various constructivist claims.
* To put it in slightly more technical terms, the argument exploits a de re/de dicto ambiguity.
** This observation led Parsons to suggest that sickness was a form of social deviance, a position that does not actually follow from his view. The term deviance in the Parsonian scheme refers to action that violates social norms (with the canonical example being crime). The sick, however, are not actually violating everyday norms, but rather entering a state that offers legitimate exemption. Malingering is form of deviance, because it violates the norms of the sick role, but sickness itself is not.
*** Due to my wife’s occupation, I interact with a lot of doctors. On the occasions when this issue has come up, I have never encountered any who reject the suggestion that this social control function is an important part of their professional role.