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Order and Obedience: structure and agency
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www.emeraldinsight.com/0144-333X.htm
Orders and obedience: structure Orders and
obedience
and agency
Michael Jackson
School of Economics and Political Science, University of Sydney,
Sydney, New South Wales, Australia 309
Abstract
Purpose – The major thesis of this article is how social contract theory sheds light on the interaction
of structure and agency. A minor thesis is to rebut the conclusions drawn from Stanley Milgram’s
famous obedience experiments.
Design/methodology/approach – The argument rests in large part on an extensive review of
authentic, empirical evidence found in studies of medical compliance.
Findings – Patient agency is choosing not to comply with medical orders has over the years forced
structural changes in the doctor–patient relations. These changes can be understand through the
evolution of three kinds of social contract.
Practical implications – One important implication is that non-compliance can be a relational
choice in one’s lifeworld.
Originality/value – No other study has brought together Milgram’s evidence with the medical
compliance literature to demonstrate the integration of agency and structure.
Keywords Social audit, Social care, Interpersonal relations
Paper type Conceptual paper
Introduction
In these pages I argue that the interaction of structure and agency is illuminated by
how patients have responded to doctor’s orders over the last three generations. The
evolution of the compliance relationship – the orders – between doctor and patient
shows how agency has influenced structure, leading to changes in the roles of
physician and patient. Understanding this evolution allows us to see something of the
engagement of agency with structure. To make this case, this introduction first reviews
the structure-agency divide, then it introduces social contract theory as a mediation
between structure and agency. Next it summarizes Stanley Milgram’s famous
obedience experiments as empirical evidence proving that structure dominates agency,
and then the argument turns to a rich body of evidence from the empirical research into
doctor’s orders which qualifies Milgram’s findings. The conclusion is that the social
contract is ‘‘a theoretical position that [gives] sufficient weight to both structure and
agency’’ in its evolution (Musolf, 2003, p. 6).
The tension between structure and agency underlies much social theory. Fuchs
(2001, p. 24) called it an ‘‘unresolved enigmata’’. Structure refers the social facts that
surround and mark each of us; these include race, class, sex, gender, institutions,
organizational hierarchies, roles, geographical location, and more (Musolf, 2003, p. 1).
We individually are born into a macro reality defined by social facts. Yet we make and
re-make these social facts. Agency refers to our capacity at the micro level to decide
and act within the constraints of social facts, and sometimes to cut across those International Journal of Sociology
constraints. This is what Parker (2000b, p. 10) calls the ‘‘history-producing power of and Social Policy
Vol. 26 No. 7/8, 2006
agency’’. pp. 309-325
Fuchs argues that at the macro level structure explains events while at the micro # Emerald Group Publishing Limited
0144-333X
level of the lifeworld people have intentions and act. While a number of analysts have DOI 10.1108/01443330610680407
IJSSP called for interrelation between the two. Fuchs (2001, p. 25) observes that ‘‘not much
26,7/8 progress has been made’’ with this mystery, and the tendency remains to reduce one to
the other. At the very least, he notes, we might put aside the essentialist approach that
supposes that something is either one thing or another, either structure or agency
(Fuchs, 2001, p. 6). Perhaps causation is both structure and agency. That suggestion
underwrites this study.
310 One of the most telling arguments for structure appeared in Durkheim’s (1952
[1890]) Suicide. While in this case commonsense affirms agency, Durkheim showed that
even that most extreme and intimate act, suicide, played out of social structure and not
the volition of the individual. In short, structure determined action, not agency. While
many finer grained analyses have appeared, in the 1990s both Luhmann (1995) and
White (1992) offered system theories that dispense with actors and agency. More
generally ‘‘agency is diminished in popular culture and in social science literature’’, as
Musolf (2003, p. 4) says.
Perhaps we are two creatures at once: a macro being shaped by social facts
inextricably bond together with a micro being able and willing to act outside structural
determinants. But which is hard bone and which soft flesh? The tension between
structure and agency remains (Archer, 2000).
The distinction between structure and agency is a border between everyday
experiences and the esoteric knowledge of social science. On one hand, at the micro
level, we know ourselves to be free in word and deed. In addition, at the macro level the
law, to varying degrees, also makes us responsible for our actions. Indeed, this
assertion of responsibility is common throughout social life: in the classroom, in the
home, in the sports club, we treat each other as agents who make choices and bear the
consequences of those choices.
Yet on the other hand, sociologists, political scientists, anthropologists, economists
argue that social structure predicts actions (Shilling, 1999). Even that pioneering social
theorist Parsons who argued strongly for agency (1937) shifted to structure in Social
System (1951) and by 1964 the actor is not a person, much less an individual, but the
outcome of an intersection among four action systems (Fuchs, 2001, p. 27).
Intricate arguments have been made to blend structure and agency, notably by
Giddens (1979, 1984) who argues that the concept of structuration leaves room for
agency, but other argue that it does not (King, 2000). Giddens (1984) makes
structuration both the end and the means of agency by arguing that knowledgeable
actors reproduce structure which in turn channels, limits, and determines action (New,
1994). The argument here goes further, showing that even agents who are not
knowledgeable can influence change at the macro, structural level by not following a
doctor’s orders. The conceptual framework for that evidence is social contract theory,
to which we now turn.
Social contract theory
Social contract theory rests on the assumption that we can make free and rational
judgments about institutions and practices (Imbroscio, 1999). But if we are not agents,
then the justification – the consent of the governed – that contract theory imputes to
the political institutions of liberal democracies is also an illusion. The social contract is
one of the fundamental concepts of political life, though usually relegated to history of
political theory textbooks. Yet this dusty concept has something to teach us today
about the greatest of all mysteries – ourselves.
The social contract is a hypothesis that people in a state of nature would consent to Orders and
be governed. The state of nature is conceptually apart from and logically prior to
society. Whatever a rational person would consent to in a state of nature, is justified.
obedience
The social contract is a thought-experiment, a touchstone, to test for consent. The three
great contract theorists, Thomas Hobbes, John Locke, and Jean-Jacques Rousseau, took
different approaches, and each approach adds something to the claim of agency on
structure.
To Hobbes the contract is a once-and-for-all surrender of natural rights in return for
311
survival in an authoritarian political regime. It is an escape from a chaotic and frightful
state of nature to social order (Hobbes, 1651). The rights one has in the authoritarian
regime are only the rights one would fight for in a state of nature, and nothing more, in
other words, the right to life (Carmichael, 1990). A social order that respects these
minimal rights is peaceful. The individual is but a subject who obeys. The individual’s
agency is exhausted in the decision to make the contract, leaving no residue. Thinking
about doctor’s order, the Hobbes position would counsel complete obedience in the
name of survival. From that contract flows the justification of the structures
comprising the society.
Locke’s contract protects life, and also property, not only from others, but also from
the state itself. Locke’s contract occurs in a state of nature more developed than that of
Hobbes, a state of nature with a good deal of social intercourse born of volition and
habit. Locke rests his argument on the insight that each of us owns our own bodies. He
argues by extension we then also own what we achieve by working with our bodies,
which he conceives to be property. Accordingly, his state of nature embodies concepts
of property and the use of money as a store of value. To protect these features of the
state of nature means that Locke’s contract is more detailed than Hobbes’s one-line
contract. Locke’s edition of the contract includes the survival clause – the right to life –
of Hobbes and more besides. In Locke’s conception the individual participates actively
in the prevailing hegemony, while a Hobbesian subject simply reacts. The autonomy of
Locke’s individuals extends to this active participation.
Locke adds a new dimension to the hypothetical social contract with the concept of
tacit consent. He says that someone who benefits from the political order has (Locke,
1988 [1681]) tacitly consented to it. His example is a person using a highway made
possible by the coercion of taxation. To anticipate what follows, we might think
visiting a doctor is tacit consent to following the doctor’s orders that arise in that visit.
Rousseau differed from his English predecessors by seeking a deeper moral
commitment of the one to all and all to the one; this he did in his concept of the general
will (Rousseau, 1972 [1762]). He rejects his two predecessors’ theories because, on his
view, they offer only survival, albeit in the case of Locke, comfortable survival.
Rousseau conceived of the social contract as double: socially it is between each one of
us and all others, and it is also between two parts of oneself, the animal that wants
survival (such as Hobbes and Locke offered as the goal), and the spiritual being that
wants a meaningful life as much as a full stomach.
In this compound Rousseauean contract the individual is a citizen, who obeys and
participates, but whose autonomy is not confined to these activities. The Rousseau
citizen decides and commits continuously, willing the general in word and deed.
Rousseau solved the conflict between the individual and community. We must
create our own freedom expressed in unnatural political union that leads back,
paradoxically, to natural moral relations. We begin by surrendering ourselves to the
polity.
IJSSP The general will is an analytic test, not an historical event. The test is this: Is a law
something all can will? If it is, then each one of us must will it individually to be free.
26,7/8 The general will is the will to treat the good of others as a whole as more important
than our own individual good. In this theoretical context doctor’s orders have to be seen
in the larger context of one’s lifeworld, and not merely a mechanical transaction.
While each theory has rich detail, this summary suffices for the purposes at hand.
The concept of consent embodied evolves from a simple contract in Hobbes, to a
312 detailed one in Locke, to a hybrid internal and external one in Rousseau.
This section has reviewed the concept of the social contract to show its variety and
pertinence to contemporary life, with particular reference to medicine. When the
discussion returns to medicine below we shall see that the three phases of the social
contract map onto the evolution of medical relations in the last halfcentury. However,
before we can appreciate the significance of contract theory and its heart, agency, we
must consider the claim of structure.
Obedience and orders
There is considerable empirical research about structure and agency. Some of it came
in response to World War II and German Nazism. Scholars examined historical and
other evidence to explain Nazi crimes. As the Nuremberg War Crimes Trial and its
national counterparts around the world held individuals responsible for their deeds,
social scientists explained obedience to the Hitler regime as the result of structure in
such works as Adorno et al. (1950) The Authoritarian Personality. It argued that
personality is made by a series of overlapping and reinforcing social structures and
roles that in Germany emphasized hierarchy, compliance, and obedience, from the
home, the church, the school, the factory, the office, the shop, the streetcar, and so on.
Milgram (1974), a social psychologist, designed an experiment to confirm with
additional evidence the importance of structure in producing obedience. He found in
the early 1960s that ordinary people were willing to do extraordinary things to others.
They did these things, he concluded, in the name of the obedience to authority.
Milgram’s experiments featured a researcher who ordered an unwitting subject to
apply electric shocks to another person, the victim. The victim was an actor working
with Milgram. An assistant in Milgram’s employ hired the subject ostensibly to teach
the victim to spell, using electric shocks to punish errors. The assistant giving the
orders claimed to be a scientist. There were many variations of this basic relationship,
including the spatial relationship of the subject to the victim and of the subject and the
scientist. Sometimes the three – scientist, subject, and victim – were in arm’s reach and
at other times the scientist and subject were in one room and the victim in another. In
another variant the victim told the subject of a heart condition and specially asked the
subject to take that into account (Milgram, 1974, p. 66). At times the victim cried in pain
and banged the wall or fell silent. The gauge of ostensible shocks had a red line marked
Fatal XXX.
In the experiments Milgram found that the subjects obeyed authority. Overall, 65
per cent of his subjects continued to administer the shocks when the dials they turned
reached the fatal line. Subjects continued to administer shocks though they themselves
had the clinical symptoms of anxiety and asked the assistant portraying the scientist
for permission to stop (Milgram, 1974, p. 3). When the scientist insisted that they
continue; they did. Some few subjects stopped shocking without telling the scientist,
side-stepping authority (Milgram, 1974, p. 66). Obedience fell when the subject and the
victim sat side-by-side and the assistant (the scientist) was in another room giving
orders. But almost no one challenged authority directly. Milgram concluded that the Orders and
socialization and social structure make obedience the most likely outcome of contact
with authority.
obedience
Milgram argued that social structure produces authority and that individuals
obeyed authority, even authority as abstract and vague as that of the researcher in the
experiments. The authority of the scientist was accentuated in the early experiments:
the assistant portrayed the scientist in a white lab coat with a clipboard in a building at
a great seat of learning, Yale University. In later experiments the aura of science was 313
reduced somewhat, mainly by moving off campus, but still invoking science in the
other ways. The authority of science as a socially legitimate activity prevailed.
Milgram (1974, p. 6) concluded that ‘‘few people have the resources needed to resist
authority. A variety of inhibitions against disobeying authority come into play and
successfully keep the person in his place’’. This happens because people
. lack the inner resolve to resist authority even in extreme cases,
. make themselves readily into agents referring responsibility to the scientist
giving the orders, and
. feel bound to continue by the social inertia that had led them to volunteer, accept
payment, and begin the exercise (Milgram, 1974, pp. 6-9).
He added, ‘‘we have now seen several hundred participants in the obedience
experiment, and we have witnessed a level of obedience to orders that is disturbing . . ..
Good people . . . perform actions that were callous and severe’’ (Milgram, 1974, p. 123).
Milgram concluded that his findings shed light on the obedience to orders that made
the Holocaust possible. Adolph Eichmann’s trial in Israel coincided with the start of the
experiments. By the time Obedience to Authority appeared the My Lai massacre in
Vietnam had come to light (Kelman and Hamilton, 1989). Milgram saw a straight line
from his experiments to war crimes and to other crimes of obedience. At about the
same time other research had found subjects very willing to inflict discomfort and
humiliation on peers (Zimbardo et al., 1973, 2000). Inspired by Milgram’s example and
worried about the readiness to obey, researchers in other countries made comparative
studies, using Milgram’s techniques. They, too, found high levels of obedience (Smith,
1996). While Milgram’s methods have been extensively criticized, and research that
deceives subjects is generally banned, there has been little, if any, rebuttal of his
evidence, argument, and conclusion. Instead his work is cited uncritically (e.g. Parker,
2000a; Blass, 2004). That is the purpose here, to refute the substance of Milgram’s
conclusion with reference to structure and agency.
Doctor’s orders
Medical sociologists found in one empirical study after another that people who
voluntarily came into contact with a respected embodiment of authority in highly
ritualised encounters did not obey orders. They found that a sizeable minority and
sometimes a majority always disobeyed even at the expense of their own self-interest.
In contrast to Milgram they found ordinary people:
. had the inner resolve to resist authority, even in extreme cases,
. accepted personal responsibility, and
. did not feel bound to continue by social inertia.
This empirical research continues today with similar findings.
IJSSP At the outset of this discussion a visit to a doctor was evoked. It is time to return to
that setting in the company of Parsons (1951). He conceived of the ‘‘being sick’’ as a
26,7/8 patterned social role. His analysis starts from the assumption that it is both in the
rational interest of the society and the individual to minimize illness; the sick have an
obligation to get well (Parsons, 1951, p. 430). Medicine arises from the assumption that
all illness is physiological and biological in diagnosis and therapy. The treatment of
illness is then a matter of applied science which must be considered problematical and
314 not taken for granted as common sense, Parsons (1951, pp. 431-42) says. In other
words, it rests on technical knowledge of the physician possesses and which is opaque
to the patient (Parsons, 1951, p. 434). Doctor’s orders are to be obeyed in the sense that
‘‘a physician’s recommendations to a patient imply that the patient has no choice but to
do whatever told’’ (Shapiro, 1990, p. 106, emphasis added).
The social role of the doctor is a neutral, objective, and professional focused on the
ailment. It does not matter whether the physician likes the patient or not, nor is the
physician influenced by the profit motive (Parsons, 1951, p. 436). The doctor is an
applied scientist whose laboratory is a patient.
Parsons’s innovation was to match this doctor’s role with the patient’s sick role.
Among the features of the sick role are these (Parsons, 1951, p. 436):
(1) a sick person cannot help it, cannot overcome it by will power, and needs
treatment;
(2) a patient must want to get well;
(3) ‘‘the closely related element is the obligation – in proportion to the severity of
the condition, of course – to seek technically competent help, namely, in the
most usual case, that of a physician and to cooperate with him in the process of
trying to get well’’ [emphasis added].
The last point above is obedience to doctor’s orders, which follows from Parsons’s
stress on the assumption that the patient wants to get well and in seeking the advice of
the physician has entered a contract to participate in medical orders. Parsons puts it
this way:
The patient has an obvious self-interest in getting well in most cases, though this point may
not always be so simple. But once he has called in a physician the attitude is clearly marked,
that he has assumed the obligation to cooperate with the physician in what is regarded as a
common task (Parsons, 1951, p. 411).
Parsons takes for granted as ‘‘obvious’’ the interest of the patient in getting well. He
goes on to emphasize the technical knowledge the physician has, but notes that the
doctor deals with people, unlike an engineer who deals with materials (Parsons, 1951,
p. 451). In the sick role the problematic is the illness, but in this passage Parsons briefly
acknowledges another problematic, namely the patient.
The contract between physician and patient relates to the three kinds of social
contract. As the concept of the social contract changed over time so has the relationship
of doctor and patient. In the post war world it was a simple Hobbesian contract, then it
became more a Lockean contract, and today it has features of a Rousseauean contract.
The Hobbes social contract
In the post World War II period the contract between doctor and patient was a simple
one of Hobbesian obedience. Motivated by survival the patient must rationally follow
the instructions of the physician. The doctor commands and the patient obeys, hence,
the very phrase ‘‘doctor’s orders’’. In this conception the problem is the illness and the Orders and
solution to that is technical knowledge of the physician. Often the physician did not
bother to explain the reasoning behind either diagnosis or therapy because it would not
obedience
be understood and because it would waste the doctor’s precious time.
In this period, the physician was presented as an applied scientist with something
akin to military authority. In addition, the post war years were a time when formality
and orders were commonly accepted by adults who had been mobilized in the war, be it
in armies or in factories. Many treatments and drugs had emerged from the war effort
315
and these and some of the attitudes associated with them migrated to civilian medicine.
The family doctor wore a uniform equipped with the symbols of science, the white coat
and the stethoscope around the neck surrounded by mysterious texts, charts,
prescription forms, locked cabinets, all veiled behind Latin words written in
astoundingly bad handwriting. The men wore neckties, and the women dressed with
comparable formality. Rather like the faux researcher in Milgram’s obedience
experiments, the physician at this time gave orders, without explanation. The only task
for the patient was to obey. Patients were Hobbesian subjects whose autonomy was left
at the door of the doctor’s office. The relationship was authoritarian and paternal.
Theirs was to obey.
Medical doctors then, as now, enjoy great social prestige. Yet at that time, when
Milgram predicts obedience to authority would high it was low. The bland assumption
of patient obedience in the sick role eroded with empirical studies of medical adherence
in the 1960s. There are scores of these studies. Medline delivered more than 28,000 hits
on the single search term ‘‘non-compliance’’. One review of 196 empirical studies found
that up to 80 per cent of patients do not comply with doctor’s orders enough to gain
therapeutic benefit (Krueger et al., 2005, p. 313). Even in serious cases compliance is
often dangerously low (Scheikowski, 1995; Altman, 2002). One meta-analysis of 70
empirical studies of compliance by diabetic patients found half do not adhere to the
regimen (Nagasawa et al., 1990). For patients with hypertension the figure is 40 per cent
(Clark, 1991). More generally, other observers continue to note, despite the wealth of
evidence that compliance is still an underestimated problem in medicine (Bander and
Walters, 1998; and Gascon et al., 2004). To drive the point home the appendix
summarizes some of the empirical studies readily to hand. It includes more than 45,000
patients from nine countries over nearly 50 years with a wide variety of diseases,
therapies, side-effects, social circumstances, and kinds of patient.
Low compliance is the ‘‘tragic problem’’ (Cochrane, 1992) of modern medicine. The
tragedy is that life-saving therapies are not used with considerable personal and social
costs. The personal costs are borne by the patient whose health is damaged, and who
pays for treatment not performed. It creates expense for the medical and health
systems, e.g. perhaps a quarter of all emergency treatments in a hospital arise from
patients who do not comply with prescribed therapies. Moreover, low levels of
compliance undermine clinical trials, i.e. if patients do not follow the therapy and this is
unknown it compromises the conclusions (Melnikow and Kiefe, 1994). If so, one
estimate is that a five-fold increase in sample sizes would be necessary to get the same
predicative power, bringing in its wake a five-fold increase in costs (Goldsmith, 1979) of
developing therapeutic drugs.
If obedience to the specialist knowledge of the physician is logical, then the only
explanation for medical disobedience is that patients are irrational (Roberson, 1992;
Playle and Keeley, 1998). They jeopardize their survival for no reason, on the logic of
Thomas Hobbes. Within this framework the only conclusion is that disobedience is
IJSSP unintentional (Mishler, 1984; Ley, 1985; Donovan, 1995). But non-compliance might be
26,7/8 rational in a patient’s own life (Mishler, 1984, p. 120; Brittan, 1994).
The Locke social contract
A Lockean contract between doctor and patient evolved from empirical studies that
found patients did not routinely and automatically obey doctor’s orders. The term ‘‘non-
316 compliance’’ rather than disobedience came into use partly to recognize that patients
make choices (Sackett et al., 1979) that they are autonomous agents. People act as
owners of their own bodies and do not blindly follow every direction.
The first response to non-compliance was to eliminate unintentional non-
compliance. Written instructions were inserted in medications, leaflets were handed
out in the doctor’s office and the pharmacy. Pills were color coded or numbered and
dispensed in calendar packages and so on. In some hospital and private practices social
workers review therapies with patients in exit and entry interviews. These steps went
some ways toward ending unintentional non-compliance.
Beyond these approaches to reducing unintentional non-compliance, doctors also
began to educate patients. The physician explains to the patient both the ailment and
the benefits and logic of the therapy. To achieve this goal the social distance between
doctor and patient was reduced by taking off the white coat and stethoscope. Patients
now often sat side-by-side with the doctor like teammates rather than across the desk
like an adversary. The goal was to induct the patient into the hegemony of therapy.
This is analogous to a Lockean contract, extending beyond the once-off contract of
Hobbes, into a more elaborate relationship between doctor and patient in which the
patient participates in the treatment, but it is the participation of a subject not a citizen.
The problem has changed from the illness to a combination of the illness and patient’s
understanding of and reaction to it.
The patient participates by accepting the hegemony of medical knowledge of
medicine. The relationship is at core paternal. Now in addition to telling the patient
what to do, the physician explains why it is best for the patient to do that.
When the shift to explanation began medicine spoke the technical language of
science and was often incomprehensible to patients. Over time physicians learned to
explain in ordinary language without using much of the technical language of medical
science. These changes are reflected in changing curricula in medical schools around
the world, which came to emphasize social skills as well as technical knowledge. In
some medical practices now a social worker interviews patients after the doctor to
insure that the patient understands what must be done, and agrees to the hegemony of
the therapy. More recently they have also learned to ask if the patient understands.
Though they do not yet ask what it is that the patient understands. A nod suffices.
Taken together the efforts to reduce unintentional non-compliance and emphasize
explanations to patients does increase patients’ knowledge of therapies, but not their
compliance (McGavock, 1996; West, 1990, p. 109).
Finding the independent variable that explains compliance has been tried.
Researchers have tested a host of independent variables, separately in correlation
studies and jointly in models. The nature of the disease itself does not explain
compliance. There is no association between the severity of the disease and
compliance. Nor is there is relationship between the therapy and compliance. Reducing
the unpleasant side effects of therapies does not increase compliance. The
characteristics of the patient have also been examined, but no social or psychological
characteristics explain compliance. Nor do any features of the doctor, including Orders and
objective matters like gender, race, and age, or any subjective aspects of the medical obedience
interview (Park and Lipman, 1964; Hayes-Bautista, 1976; Evans and Spelman 1983;
Conrad, 1985; Trostle, 1988; Donovan and Blake, 1992; Donovan, 1995; Demyttenaere,
1997; Centorrino et al., 2001; Griffin and Elkin, 2001; Vermeire et al., 2001). Non-
compliance occurs in hospitals where supervision is greatest (Gordis, 1979). Moreover
as the appendix shows, non-compliance occurs around the world. 317
There are methodological aspects of compliance research to consider as well
(Gordis, 1979; Vander Stichele, 1991; Morris and Schulz, 1992). The definition of
compliance is sufficient adherence to achieve a benefit, not slavish obedience. Skipping
one session alone is not non-compliance in most studies. Measures of compliance are
often subjective, patient reports on questionnaires or in interviews with third parties. If
compliance with doctor’s order is the socially acceptable behavior, then such low
levels of reported compliance are all the more remarkable (Stewart, 1984, 1987;
Aronson and Hardman, 1992; Kruse, 1992; Teach et al., 1998).
In hospital studies, measurement of non-compliance is objective, pill counts, and
urine samples, and surveillance is high, yet compliance is low. Finally, doctors
themselves as patients have been studied and it seems they are no more likely to
comply than any other kind of patient (Dunbar, 1980; Roter et al., 1998). Nor are
physicians able to predict which patients comply (Melnikow and Kiefe, 1994; Goldberg
et al., 1998; Bogart et al., 2001) and so cannot compensate for it.
The Rousseau social contract
The third stage is a Rousseauean contract to make the patient the centre of the doctor–
patient relationship. In so doing, it makes the therapy the problematic. The term
‘‘adherence’’ is intended to emphasize the decision-making of the patient and make
patients’ decisions a positive part of the process, escaping the negative connotations of
‘‘non-compliance’’. The role of the physician is to act as a broker who offers the patient
choices and supports the decisions the patient makes, arriving at a ‘‘concordance’’
(Conrad, 1987; Brock and Wartman, 1990; Holm, 1993; Deber, 1994; Marinker, 1997).
The best illustration of this new relation springs from bad patients.
There is a distinction between the ‘‘good patient’’ and the ‘‘bad patient’’. A good
patient treats the physician with respect, nods at explanations, promises to comply and
later reports compliance, even when it is not true. It is very easy for the physician to
work with a good patient (Goffman, 1961). The bad patient quarrels, demands
explanations and rejects them. Some researchers think that bad patients often fare
better than good patients, for two reasons (Glogow, 1973; Robins and Wolf, 1988;
Wright and Morgan, 1990; Fogarty, 1997): first because their non-compliance is visible,
and second because they are entering into the therapy aggressively, not sitting back in
denial, which some good patients may do.
The concordance approach explicitly recognizes the patient is autonomous, and
must be convinced, and neither educated into compliance nor given orders. Patients are
citizens when the physician discusses alternatives with them and the patients decide
the approach that best suits their micro lifeworld. It becomes a double social contract,
the first face is between patient and doctor and the second is between two parts of the
patient in the Rousseau manner. That part of the patient that does want to get well is
brought to the surface and makes a contract with its reluctant other self. It is a
IJSSP Rousseauean contract not a Lockean one. One forces oneself to be free by willing a
26,7/8 therapy through one’s action.
Conclusion
In the 21st century there is new conception of the doctor–patient relationship. It
recognizes that the patient is a sovereign agent. It imagines the encounter between
318 doctor and patient as something like a social contract where the patient through the
medium of the physician contracts with a part of the self to perform certain tasks. It is
the social contract of Jean-Jacques Rousseau, and not of John Locke or Thomas Hobbes
because it makes the patient the problematic and not the ailment, nor superficial
compliance.
The relationship of the doctor and patient has evolved from the applied scientist
who treats the disease, to a teacher who educates the sufferer into participation in the
therapy, to a broker who offers the patient alternatives and supports choices the patient
makes. The problematic is now the therapy rather than the disease or the patient.
Contrary to the experiments of Stanley Milgram, authentic empirical evidence from
medicine reveals that ordinary people can act against the constraints of structure.
Moreover, their actions have, over the generations, led to structural changes in the
doctor–patient relationship.
The social contract theory provides a means of seeing the interaction of macro
structure and micro agency over time, as non-compliant patients stimulated change in
the structure of medical relations. These map onto the three kinds of social contract
theory considered above. In so doing, the doctor–patient relation offers one site where
agency and structure mesh. We live within what Alexis de Tocqueville called a ‘‘fatal
circle beyond which we cannot pass, but within the wide verge of that circle we are
free’’ (Tocqueville, 2000 [1835 and 1840], p. 676). Sometimes this free agency changes
structure.
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IJSSP Appendix
26,7/8
Number of %
Author Country Year Malady patients Non-compliant
322 Dixon, W., Stradling, P. and UK 1954 TB 705 34
Wootton, D. (1954), ‘‘Outpatient PAS
therapy’’, Lancet, p. 871
Rigby, J.P. (1958), ‘‘On omitting UK 1958 TB 114 31
PAS’’, Tuberculosis, Vol. 39, p. 336
Stott, H. (1959), ‘‘Drug acceptability UK 1959 TB 98 72
and chemoprophylasix in under-
developed countries’’, Bulletin of the
International Union of Tuberculosis,
Vol. 29, p. 285
Luntz, G. and Austin, R. (1960), UK 1960 TB 444 34
‘‘New stick test for PAS in urine’’,
British Medical Journal, p. 1679
Curtis, E.B. (1961), ‘‘Medication USA 1961 Elderly 26 61
errors made by patients’’, Nursing
Outlook, Vol. 9, p. 290
Joyce, C. (1962), ‘‘Patient UK 1962 Rheumatism 78 49
cooperation and the sensitivity of
clinical trials’’, Journal of Chronic
Diseases, Vol. 15, p. 1025
Schwartz, D., Wang, M., Zeitz, L. USA 1962 Elderly 178 59
and Goss, M. (1962), ‘‘Medication
errors made by elderly chronically
ill patients’’, American Journal of
Public Health, Vol. 52, p. 2018
Berry, D., Ross, A. and Deushle, K. USA 1963 TB 26 32
(1963), ‘‘Tuberculosis patients treated
at home’’, American Review of
Respiratory Diseases, Vol. 88, p. 769
Park, L.C. and Lipman, R. (1964), USA 1964 Neuroses 117 51
‘‘A comparison of patient dosage
deviation reports with pill counts’’,
Psychopharmacy, Vol. 6, p. 299.
Lipman, R.S. et al. (1965), USA 1965 Neuroses 254 46
‘‘Neurotics who fail to take their
drugs’’, British Journal of
Psychiatry, Vol. 111, p. 1043
Wilcox, D., Gillian, R. and Hare, E. UK 1965 Psychiatric 125 48
(1965), ‘‘Do psychiatric outpatients
take their drugs?’’, British Medical
Journal, Vol. 2, p. 790
Charney, R., et al. (1967), ‘‘How well USA 1967 Children 107 44
do patients take oral penicillin?’’
Table AI. Paediatrics, Vol. 40, p. 188
A chronological and Wynn-Williams, N. and Arris, M. UK 1967 TB 153 49
comparative selection of (1967), ‘‘On omitting PAS’’,
empirical studies of Tuberculosis, Vol. 199, p. 169
medical compliance (Continued)
Number of % Orders and
Author Country Year Malady patients Non-compliant obedience
Maddox, R. (1967), ‘‘Patient USA 1967 TB 50 30
cooperation in taking medicine’’,
Journal of the American Medical
Association, p. 199
Davis, M. (1968), ‘‘Variations in USA 1968 GP 154 37 323
patient’s compliance with doctor’s
advice’’, American Journal of Public
Health, Vol. 58, p. 274
Bonner, J., Goldberg, A. and Smith, UK 1969 Pregnancy 60 32
J. (1969), ‘‘Do pregnant women take
their iron?’’ Lancet, p. 457
Francis, V., Korsch, B. and Morris, USA 1969 Children 587 49
M. (1969), ‘‘Gaps in doctor – patient
communications’’. New England
Journal of Medicine, Vol. 280, p. 535
Gordis, L., Markowitz, W. and USA 1969 Children 103 67
Lilienfield, A. (1969), ‘‘The
inaccuracy in using interviews to
estimate patient reliability in taking
medications at home’’, Medical
Care, Vol. 7, p. 49
Porter, A. (1969), ‘‘Drug defaulting in UK 1969 GP 82 24
general practice’’, British Medical
Journal, Vol. 1, p. 218
Buchanan, G.R., Siegel, J., Smith, S. UK 1982 Sickle cell 37 35
and DePasse, B.M. (1982), ‘‘Oral
penicillin prophylaxis in children
with imparied splenic function: a
study of compliance’’, Pediatrics,
Vol. 70 No. 6, pp. 926-30
Cummins, D., Heuschkel, R. and UK 1991 Sickle cell 23 56
Davis, S. (1991), ‘‘Penicillin
prophylaxis in children with sickle
cell anaemia’’, British Medical
Journal, Vol. 302, pp. 989-90
Pegelow, C.H., et al. (1991), USA 1991 Sickle cell 20 45
‘‘Experience with the use of
prophylactic penicillin in children
with sickle cell anaemia’’, Journal
of Paediatrics, Vol. 118, pp. 736-8
Dew, M.A., et al. (1996), ‘‘Medical USA 1996 Transplant 101 37
compliance and its predictors in the
first year after heart transplant’’,
Journal of Heart and Lung Trans-
plantation, Vol. 15 No. 6, pp. 631-45
Smith, S.K. (1996), ‘‘Patient non- USA 1996 Lens 145 69
compliance with wear and replace-
ment schedules of disposable
contact lens’’, Journal of the
American Optometrric Association,
Vol. 67, pp. 160-4
(Continued) Table AI.
IJSSP Number of %
26,7/8 Author Country Year Malady patients Non-compliant
van Essen, G., Kuyvenhoven, M. Netherlands 1997 Elderly 505 36
and Melker, R. (1997), ‘‘Why do
healthy elderly people fail to comply
with influenza vaccinations?’’, Age
324 and Aging, Vol. 26, pp. 275-9
Faulkner, D.I., et al. (1998), ‘‘Patient USA 1998 HRT 28,718 54
non-compliance with hormone
replacement therapy’’, Menopause,
Vol. 5, pp. 226-9
Teach, S., Lillis, K. and Grossi, M. USA 1998 Sickle cell 123 57
(1998), ‘‘Compliance with penicillin
prophylaxis in patients with
sickle cell disease’’, Archives of
Paediatrics and Adolescent
Medicine, Vol. 152, p. 274
Bruckett, G., Simonentta, C. and France 1999 Drugs 3,845 25
Giral, P. (1999), ‘‘Compliance with
fluvastation treatment’’, Journal of
Clinical Epidemiology, Vol. 52,
pp. 589-94
Blake, P., et al. (2000), ‘‘A Canada and 2000 Dialysis 656 20
Multicenter study of noncompliance USA
with continuous ambulatory
peritoneal dialysis exchanges in US
and Canadian patients’’, American
Journal of Kidney Diseases, Vol. 35
No. 3, pp. 506-14
Laederach-Hofman, K. and Bunzel, Germany 2000 Organ 3,500 50
B. (2000), ‘‘Non-compliance in organ transplants
transplant recipients’’, General Hos-
pital Psychiatry, Vol. 22, pp. 412-24
Sherman, J., et al. (2000), ‘‘Tele- USA 2000 Asthma 116 62
phoning the patient’s pharmacy to
assess adherence’’, Journal of Pae-
diatrics, Vol. 136 No. 4, pp. 532-526
Viller, F., et al. (2000), ‘‘Compliance France 2000 Arthritis 556 65
with drug therapy in rheumatoid
arthritis: a longitudinal European
study’’, Joint, Bone, Spine: Revue du
Rhumatisme, Vol. 67 No. 3, pp. 178-82
Castellano, P., Wenger, N. and USA 2001 Cancer # 41
Graves, W. (2001), ‘‘Adherence to
screening guidelines for breast and
cervical cancer’’, Journal of
Women’s Health and Gender-Based
Medicine, Vol. 10 No. 5, pp. 451-61
Nieuwkerk, P.T., et al. (2001), Netherlands 2001 Antiretroviral 224 53
‘‘Limited patient adherence to highly
active antiretroviral therapy’’,
Archives of Internal Medicine, Vol.
161 No. 16, pp. 1962-8
Table AI. (Continued)
Number of % Orders and
Author Country Year Malady patients Non-compliant obedience
Novaes, A., Jr. and Novaes, A. Brazil 2001 Periodontal 874 47
(2001), ‘‘Compliance with supportive
periodontal therapy’’, Journal of
Periodontology, Vol. 70 No. 6,
pp. 679-82 325
Valenstein, M., et al. (2001), USA 2001 Schizophrenia 1,307 49
‘‘Adherence Assessments and the
use of depot anti-psychotics in
patients with schizophrenia’’,
Journal of Clinical Psychiatry, Vol.
62 No. 7, pp. 5435-551
Stone, A., Shiffman, S., Schwartz, J., UK 2002 Chronic pain 80 90
Broderick, J. and Hufford, M.
(2002), ‘‘Patient non-compliance
with paper diaries’’, British Medical
Journal, Vol. 324, pp. 1193-5
Forsen, L., Sandvig, S., Schuller, A. Norway 2004 Hip protectors 1,000 45
and Sogaard, A.J. ‘‘Compliance with
external hip protectors in nursing
homes in Norway’’, Injury
Prevention, Vol. 10 No. 6, pp. 344-9
Burton-Jeangros, C., Golay, M. and Switzerland 2005 Immunization 1,295 43
Sudre, P. (2005), ‘‘Compliance and
resistance to child vaccination: a
study among Swiss mothers’’,
Revue d’Epidemiologie et de Sante
Publique, Vol. 53 No. 4, pp. 341-50
Linden, J., Oldeg, P., Mehta, S., USA 2005 HIV 181 88
McCabe, K. and LaBelle, C. (2005),
‘‘HIV postexposure prophylaxis in
sexual assault: current practice and
patient adherence to treatment
recommendations in a large urban
teaching hospital’’, Academic
Emergency Medicine, Vol. 12 No. 7,
pp. 640-6
Wang Y., Wu, D., Wang, Y., Ma, R., China 2006 Stroke 500 45
Wang, C. and Zhao, W. (2006), ‘‘A
survey on adherence to secondary
ischemic stroke prevention’’,
Neurological Research, Vol. 28 No. 1,
pp. 16-20 Table AI.
Corresponding author
Michael Jackson can be contacted at: m.jackson@econ.usyd.edu.au
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