As my original attraction to philosophy and my decision to teach an intercalated B.Sc unit on the conceptual foundations of modern sociological thought might suggest, I have always been drawn to abstruse matters. It was in the 1980s during my tenure at the Middlesex that I first expressed this in print. I was busy enough – or at least what passed for ‘enough’ then – teaching and publishing other bits and pieces, including publishing a book with my colleagues at the Middlesex entitled The Experience of Illness in 1984 and co-editing a second issue of Sociology as Applied to Medicine with Donald Patrick in 1986. In 1987, however, I turned an intellectual corner by publishing an edited collection under the heading of Sociological Theory and Medical Sociology. This had an explicit purpose, namely, to send a message to sociologists based in sociology departments and inclined to dismiss those of us holding posts in medical schools as second-rate applied or service teachers. The authors were my peers and colleagues: as well as myself, they were David Blane, David Armstrong, Ray Fitzpatrick, Sheila Hillier, Uta Gerhardt, Karl Figlio, Steve Taylor, Clive Ashworth and Simon Williams. I was pleased with the results (and interestingly the book was reissued in its original form by the publisher in 2022). The thinking that went into my chapter on Jurgen Habermas not only represented my first post-flirtatious engagement with theory but also marked a departure of sorts. Looking back, I think it was this project that prefigured the start of a new and more personally stimulating personal intellectual trajectory, and possibly also a new willingness to take time out from settled meta-reflexive conversations with self to indulge in intermittent if still cautious bouts of autonomous reflexivity.
It was ironic in a way that I wrote on Habermas at this time. I had read Bhaskar in the mid- to late 1970s and been enthralled by his dense but, to me at least, clear explication of critical realism in relation to the natural sciences. I was not to return to his writings until later. Having in the interim read a good deal of Habermas’ many papers, chapters and books, including the two-volume Theory of Communicative Action, translated into English in 1984 and 1987 respectively, I saw the potential of his thinking and theorising to inform and render more deeply sociological our understanding of institutions like the doctor-patient relationship. In my chapter for Sociological Theory and Medical Sociology I drew on several aspects of his work, most of which I have continued to espouse and would still defend. In a conversation with Terry Boswell in our garden in Epsom he had dismissed Habermas’ concept of an ‘ideal speech situation’ as philosophical, utopian and unhelpful. I had agreed that it was philosophical and that it had utopian overtones but disputed his view that it was unhelpful. What the ideal speech situation does is formally recognise that when we engage in a conversation or exchange of views we presuppose that all participants are equally able to participate, intervene and be heard, and that a rational consensus is an achievable endpoint. This, Habermas contended, is a universal. Otherwise, why would anybody anywhere bother conversing? Think here of a seminar conducted with a group of students for example. Habermas acknowledged of course that in actual conversations and exchanges – in actual seminars – the ideal speech situation rarely applies in its formal or pure form. What the concept does do, however is give us a yardstick against which we might appraise or analyse actual encounters. Habermas considers various ways in which such encounters can and do deviate from the ideal speech situation.
Elaborating, he draws on Austin’s distinction between three types of ‘speech act’ in the latter’s How To Do Things With Words, published in 1962. Austin wrote of ‘locutionary’, ‘illocutionary’ and ‘perlocutionary’ speech acts. By using locutionary speech acts a speaker says something by expressing a state of affairs. By using illocutionary speech acts a speaker performs an action in saying something, generally by means of a performative verb in the first person present (eg ‘I promise you that ‘p’’). And by using a perlocutionary speech act a speaker produces an effect on a hearer. Habermas characterises these three types of speech act in the following ‘catchphrases’: ‘to say something, to act in saying something, to bring about something throughacting in saying something.’
He frames all this in terms of a distinction between ‘communicative action’ and ‘strategic action’. Communicative action is linguistically mediated interaction in which all speakers pursue illocutionary aims in order to reach ‘an agreement that will provide the basis for a consensual coordination of individually pursued plans of action.’ Strategic action on the other hand occurs when at least one speaker aims to produce perlocutionary effects on his or her hearer(s). Perlocutionary effects ensue ‘whenever a speaker acts with an orientation to success and thereby instrumentalises speech acts for purposes that are contingently related to the meaning of what is said.’ Communicative action, in sum, is oriented to understanding, and strategic action is oriented to success.
My apologies for launching into more detail here, but the rationale for doing so is that these aspects of Habermas’ theorising have remained salient for me, inform my later work, and are perhaps best got out of the way now. We are in fact getting closer to analysing doctor-patient encounters. For Habermas, simple imperatives, like requests or demands, are illocutionary acts with which the speaker ‘openly’ purses his or her aim of influencing the hearer(s), and with which a power claim is associated (as in ‘doctor’s orders’). In such instances the speaker pursues illocutionary aims unreservedly, but nonetheless acts with an orientation to success rather than understanding. Habermas calls this open strategic action. When speakers employ speech acts for perlocutionary ends, this is referred to as concealed strategic action. In the case of either open or concealed strategic action the potential for attaining an agreeable rational consensus remains unexploited. This potential is only realised in communicative action, when illocutionary speech acts express ‘criticisable validity claims’. Habermas regards what he terms ‘communicative pathologies’ as the result of confusion between actions oriented to understanding and actions oriented to success. Instances of concealed strategic action may involve either ‘conscious deception’ or ‘unconscious deception’. In the case of conscious deception at least one of the participants acts with an orientation to success but allows the other(s) to assume that all the conditions of communicative action are being satisfied. Unconscious deception – which Habermas calls ‘systematically distorted communication’ – occurs when at least one participant is deceiving himself or herself about the fact that he or she is acting with an attitude oriented to success and is only ‘keeping up appearances’ of communicative action.
I hope it will be clear why I found this framework helpful in considering doctor-patient encounters. In my chapter I drew on Ann Oakley’s studies of women’s consultations with obstetricians in her The Captured Womb published in 1984 to reflect on doctors’ regular use of both open strategic action and conscious deception to reconcile or steer women to accept their expert guidance, which at that time was to agree to a hospital birth and likely clinical interventions during childbirth. More interestingly perhaps, I also explored the salience of systematically distorted communication, suggesting that women and obstetricians often seemed genuinely but mistakenly to believe that a hospital birth was invariably safer than a home birth. In a later book I edited in 2001 called Habermas, Critical Theory and Health, Nicky Britten and I applied this thinking to more routine doctor-patient exchanges in primary care.
So much for micro-interactions. Another attraction of Habermas’ theories was the way in which they opened up opportunities to explore linkages between micro- and macro-phenomena. The key distinction here is between the ‘lifeworld’ and the ‘system’. The former refers to everyday social worlds we inhabit, combines the private sphere of the household and the public sphere of the mass media, and is characterised by communicative action; and the latter embraces the economy and the state and is characterised by strategic action. The private sphere of the lifeworld delivers commitment, while the public sphere delivers influence; the economy operates via money and the state through power. There exist trade-offs between these: thus, the economy relies on the state to establish and police legal institutions like property and contract, on the public sphere of the lifeworld to influence consumption patterns and on the private sphere to provide a committed labour force, while it sends money into each other subsystem. Habermas argues that in modern times the system has increasingly become ‘decoupled’ from and come to ‘colonise’ the lifeworld. More and more of our everyday lives are dominated by systemic imperatives. This seems incontrovertibly to be the case, and Habermas’ macro-analysis gives sociological context not only to the seemingly distant phenomenon of routine medical consultations but opens the door to a more generalised theorising of linkages between social structures or relations, culture and what might otherwise be misleading seen as discrete and individualised decision-making.
I have taken some pains to introduce aspects of Habermasian theory because it has remained with me as an important fuel and aid to my own studies and will crop up in subsequent sketches. While I am critical of some of his thinking, like what I see as his premature abandonment of explicitly Marxian thinking, I continue to make selective use of his communicative/strategic and lifeworld/system dichotomies. But I should now address how ‘coming out’ as an apprentice sociological theorist impacted on my career. Once more the distinction between welfare state and rentier capitalism is pertinent. During my early days as a university lecturer in the mid-to-late 1970s I was regarded as an oddball in a medical school and largely left alone, which suited this well-trained only child perfectly. Occasionally I was quizzed. I remember my Head of Department at Charing Cross, psychiatrist Steve Hirsch, once saying to me: ‘I don’t know what you do, I’d like you to keep a diary so I have some idea.’ Without giving much thought to it, I replied: ‘I don’t know what you do either, so I’ll keep one if you do.’ In retrospect this seems a foolish and risky response, but in the event Steve grinned and I was to hear no more about it. In fact, I spent a fair amount of time out and about then (and since), exploring second-hand bookshops in Charing Cross Road and off Tottenham Court Road and writing in cafes. I felt then and feel now that this was time well spent. And I was reasonably ‘productive’ according to the criteria being loosely applied then. I taught well enough, and I was ticking over with publications; if I was deficient in bringing in research revenue, nobody seemed unduly distressed by that. This status quo eased into my years at the Middlesex, where old-school John Hinton put no pressure on me. This is such a marked contrast with academic life now that I feel compelled – almost a duty – to record and commend it. The change, when it came, was to be a feature of the post-1995 rationalised and corporate phases of medical education mentioned earlier.
While at the Middlesex it was suggested that it might profit me to ‘present’ as a theorist. Given that I was still an oddity in a medical school, I might possibly occupy my own exclusive silo to my advantage, both in terms of confusing senior medics and defending my CV should opportunities for promotion arise. So the 1990s bore witness to my consolidation as a sociological theorist through a series of further publications. Not all of these were applications or elaborations of Habermas’ work. One was however, and this seems an opportune time to discuss it. In my first publication in a mainstream sociological journal, Sociology, in 1996, I argued that Habermas was right to maintain that we should remain committed to a reconstructed version of European Enlightenment thinking. This was not of course to deny that the ‘unreconstructed’ version was classed, gendered and racialised, quite the contrary; but it was to insist that we should keep our nerves in the face of a ‘cultural turn’ that threatened the very possibility of rational decision-making emergent from communicative action.
My argument in this paper drew on several of Habermas’ concepts already introduced in this sketch, but it was presented in terms of five theses. The first paved the way for the remainder, asserting that sociology’s system ties have in modern times come to outweigh its ties to the lifeworld. It has, in other words, become more answerable to the pervasive influence of money and power, the steering media of the economy and the state respectively. Sociology has become subject to what Habermas called ‘system rationalisation’. The second thesis invited a more comprehensive analysis of sociology’s subjection to system rationalisation. Citing Ritzer’s then novel diagnosis in his The McDonaldisation of Society, published in 1994, I noted a trend towards a McDonalisation of academic life, with British sociologists experiencing intense institutional pressure to meet short-term system needs by attaining funding from increasingly commissioned research programmes. I gave as examples of the taming of medical sociology the unseemly rush to win career-enhancing funding and the adjustment of research on health inequalities by neglecting the role of class-related material factors and focusing on individual lifestyles and behaviours. Some even consented to write of ‘health variations’ rather than health inequalities.
The third thesis reflected my agreement with Habermas on the critical importance of retaining faith in a reconstruction of European Enlightenment philosophy. Sociology’s principal commitment, I insisted then (as I would now), is to what Habermas called the ‘rationalisation of the lifeworld’. It is simply unacceptable, indeed an affront to the discipline, to genuflect in the face of system rationalisation. Medical sociologists, for example, must follow the evidence and not be deflected into prioritising, to stick with the previous example, research into lifestyles and individual behaviours rather than material factors as social determinants of health inequalities. Nor should they, I maintained, allow themselves to become, or even to communicate primarily with, what Eyerman and Jamison in 1991 called system-based or ‘established intellectuals, for such intellectuals are either agents of manipulation in the lifeworld or unwitting agents of systematically distorted communication: their work serves strategic action, system rationalisation and lifeworld colonisation rather than communicative action and lifeworld rationalisation.
Thesis four inferred that sociology’s commitment to lifeworld rationalisation requires its promotion in the public sphere of the lifeworld, which, it will be remembered, harbours and delivers influence. Societies like Britain, Habermas argues are ‘formally democracies’: they embody a legitimation process that elicits generalised motives – ‘a diffuse mass loyalty’ – whilst avoiding participation. Social policy priorities are in fact framed by private investment decisions in the subsystem of the economy, and politics is democratic in form only: hence it doesn’t really matter which political party is in power. Formal democracy can be contrasted with ‘substantive democracy’, which opens the way for genuine participation of citizens in the process of will-formation. Substantive democracy, it might be contended, institutionalises in the public sphere the fundamentals of communicative action, though Habermas insists on eschewing any ‘utopian’ equation of substantive democracy with any specific form of societal organisation. So lifeworld rationalisation entails the incremental rationalisation of the lifeworld via the reconstitution of the public sphere out of its present ‘re-feudalised’ or corrupted home of image creation and opinion management. Finally, in the fifth thesis, I suggested that if sociology is to be effective, to ‘make a difference’, it must build alliances with both system-based and lifeworld-based intellectuals and activists. I stressed the importance of lifeworld-based ‘movement intellectuals’, thinking less at the time of ‘old’ class-based movements than of Europe’s ‘new’ social movements provoked into action by lifeworld colonisation. Reason, I rather grandiosely concluded, ‘conceived formally or procedurally as universal, commits sociology to what Habermas has referred to as the reconstructed, and as yet incomplete, project of modernity; that this commitment requires that sociology be directed first and foremost to the decolonisation of and further rationalisation of the lifeworld; and that this, in turn, necessitates sociologists, fated to be actors in high modernity, acting consciously, through alliances of interest with other system-based and lifeworld-based activists, perhaps most notably from the new social movements, to promote and engage with a reconstituted public sphere of the lifeworld.’ I certainly still agree now the thrust of this.
To conclude this preliminary theoretical excursion, it is relevant to record that my ‘theoretical turn’ via this engagement with Habermas was an issue as well as a confirmation of my natural – biological, psychological – only child’s aptitude for solitude. Only Habermas and I, plus a handful of others through their published commentaries, were protagonists. I was and am generally content in my own company, and this holds also for the business of thinking and writing. This meant that the inevitable isolation which was for some a burden carried by sociologists in medical schools was never a hardship for me. It was not that I didn’t enjoy the company of David Blane and Ray Fitzpatrick, quite the opposite, but rather that my own company was always a viable and amicable option. This has pros and cons for us academics. On the one hand, I was until the 1990s free to dwell on what mattered to me and to edge forward in my thinking; and theorising, but on the other hand, I did not then and have never really benefitted from the sustained critical inputs of close colleagues. Indeed, I have often been unaccountably but obstinately reluctant even to be drawn into that type of conversation. My dialogues have overwhelmingly been internal conversations or dialogues with distal others, often deceased, via their writings. I recognise that this has probably been a failing on my part, but I have insufficient energy and no intention or wish to remedy it well into retirement.
In retrospect I can see three other sequelae of my reading and application of Habermas’ theories. First, despite the fact that I started from the micro-phenomenon of doctor-patient interaction, it represented the beginning of a long-term interest in how macro-structures filter down to inform not only institutions like doctor-patient encounters but also the more mundane day-to-day dealings we have with others. Social structures, I have come to argue with growing vehemence, exercise a strong causal influence on such dealings, though without ever determining them. I still find the Habermas’ critical theoretical frame has much to commend it in addressing this matter. Second, from this point on I took it as a given that although it is important to represent other theorists’ perspectives and arguments faithfully, it is quite another thing to feel bound to leave them alone: in other words, I have little compunction in ‘using’ others’ works, even if this means departing from authors’ stances or intent. What matters here is clarity about what one is doing. Finally, and perhaps most significantly, it heralded the commencement of a sociological project to complement and shape that of enabling further lifeworld rationalisation, namely, the building of good weight-bearing bridges between two only too often discrete discourses, that of philosophy and theory on the one hand, and that of empirical research on the other. It was only with hindsight that I could properly discern these ramifications of my early engagement with Habermas.