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Concepts of Health and Illness: Activity 3

The sociological perspective of `Social constructionism' draws attention to the way in which concepts of disease, rather than conforming to the positivistic conception of science, in practice are not at all universal, nor are they historical or unrelated to the social structures of the society in which they emerge. Below is an excerpt taken from Gillian Hatt`s (1999) chapter on uncertainty in medical decision-making, which focuses upon the measurement of Blood Pressure (B/P) - read the excerpt then attempt the Activity beneath. 

"One example of a procedure and a concept which is frequently taken to be unproblematic by many people (and thus not a cause of uncertainty) is the measurement of a patient’s blood pressure. If we look at this more closely we see that this isn`t necessarily the case. There are wide variations in both the definition of ‘normal', ‘high' and ‘low' blood pressures and the treatment of `abnormal' blood pressure levels in different cultural contexts within what we might call ‘Western Medicine'. Historically, the measurement of B/P has been considered to be a ‘scientific procedure' which yields accurate ‘hard' data. 

One of the fundamental problems associated with introducing B/P measurement into clinical practice at the beginning of this century was the difficulty associated with ascertaining what levels of B/P should be determined ‘normal' from 'abnormal'. An archival analysis of the medical literature illustrates that accompanying the development of B/P measuring devices in the late 19th century there was an ongoing controversy regarding the most effective instrument for measuring B/P, the definition of ‘normal' B/P levels, and the significance of measuring B/P in various clinical states. The desire to measure physiological parameters in order to ascertain ‘normal' distributions in the population was a major preoccupation of late 19th and early 20th century clinical practice. The body became a normalised, mechanised entity which needs to be systematically explained with scientific precision. 

‘Expert' authorities such as the WHO have attempted to set some degree of standardisation in definitions of ‘normal' B/P (allowing obviously for variables such as gender, age, and so forth). However, this knowledge is frequently contested in the process of clinical decision-making, when the doctor must re-evaluate such standards in order to see whether they are applicable to the context of a particular patient. In many respects, as well as diagnosing patients, clinicians must also perform a ‘diagnosis' on the knowledge which they have acquired during clinical training. This re-interpretation of knowledge is reflected in processes of clinical decision-making where the relevance of such knowledge may be re-evaluated. For example, the clinician may ask: ‘This patient’s B/P is high, but what should I regard as ‘normal' for this patient?'.



During the early 1990s several British medical practitioners published articles which took issue with the German medical profession`s treatment of low B/P. Historically, within the context of British Medical Practice low B/P (or hypotension as it is known clinically) has been regarded to be a ‘good thing' or a ‘non-existent clinical syndrome'. British medical practitioners have felt that the treatment of low B/P as a primary condition (in an otherwise healthy patient) is unwarranted. This position is in stark contrast to the approach to treating low B/P in Germany. Within German medical practice, low B/P is frequently treated due to the undesirable psychological and physiological side-effects which it is thought to produce, such as giddiness, headaches, anxiety and tiredness. 

In response to this debate, several British psychiatrists were prompted to publish some ‘new' findings, which contradicted both of the above positions. Some of the conclusions of this new research were that low B/P could be viewed, in some cases, as an effect of some underlying psychological morbidity, such as depression. What is more, it was suggested that this phenomenon was more common among women. This reinforced the views of the ‘type of patient' who was most likely to be ‘afflicted' with hypotension, which has been presented in earlier studies. For example, Robbins (1982:28) stated that ‘subjects receiving the hypotensive label from practitioners were typically women with less education and income'. Robbins also advocated a link between low B/P and ‘low mood', with women considered to be at ‘greater risk' of developing this phenomenon. 

By referring to the medical literature from the late 19th century onwards (when B/P measuring devices became popular) we see the hypotensive sufferer being constructed in a number of different ways. Within the context of psychiatric practice at the beginning of the century, links were drawn between those institutionalised as ‘maniacs' who frequently displayed lower B/P than those considered to be ‘normal'. During the First World War soldiers were often monitored physiologically, and research illustrated that low B/P was common among neurathenic or shell-shocked soldiers in the upper-ranks, whereas soldiers in the lower ranks suffering from the trauma of war were more likely to be diagnosed with hysteria (which historically has been regarded as a ‘feminine' diagnosis, and thus it was considered that this signalled a personal crisis in masculinity).

A Hospital Consultant whom I interviewed summed the current position up: `You`ve got to say something, and you`ve got to say something you can do something about. In England you say it's the nerves and give some valium. In Germany you say it’s your B/P and give some ergot. It just reflects our medical incompetence. I don`t mean incompetence in a negligent sense, but our medical ignorance is such that despite the very sophisticated nature of modern medicine there are a lot of gaps in our knowledge and this is a very elegant example of what happens in a controversial area that`s not nailed, and of course there`ll be conflicting opinions. And it`ll be cultural. It`ll not only be doctors. It`ll be a cultural thing how they handle this gap in scientific knowledge'.

Q. What does this case study tell us about the social construction of medical knowledge and the notion of uncertainty?

 © I Crinson 2007, Lina Martino 2017