The Pharmaceutical Journal
Vol 269 No 7212 p246
24 August 2002

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Is the "sick role" still relevant today?

By Philip Bates

The American sociologist Talcott Parsons's concept of a "sick role" in 1951 sought to justify illness in modern society. The sick role creates an acceptable deviance and identity niche for those who become ill in order for them to temporarily opt out of the demands and responsibilities of society until they recover and reintegrate. The "sick actor" may be excused work without blame or stigma, claim any social benefits and be accredited with due sympathy and consideration. In return for these privileges he or she must act as the "good patient" and do everything to aid recovery, including consulting expert medical help and complying with any treatment regimens. A key aspect is the role of the doctor as the authority in medical decision making and legitimising illness.

Today it is easy to criticise Parsons's sick role on the basis that many illnesses, such as arthritis, diabetes and asthma, are chronic and the patient may never improve. The perception of illness also varies between social class, gender and culture. Medical consultation is the tip of the iceberg in terms of the total symptoms that people experience and most are managed without seeing a doctor. Parsons's sick role can also be rejected for illnesses that are poorly defined or not widely accepted as valid, such as myalgic encephalomyelitis (ME), chronic migraine, erectile dysfunction or male baldness.

Parsons accepted that some chronic conditions such as diabetes cannot be "cured" but can be managed with medical advances, and this was not incompatible with his theory. However, Parsons was insistent that even though the doctor-patient relationship is a two-way interaction and patients are not merely passive, it is an asymmetrical relationship because patients must respect the superior knowledge and experience of the doctor. Parsons was critical of lay judgements in health care as "notoriously fallible".

Despite its critics there are many examples in society today that illustrate how Parsons's theory still holds true in thinking about aspects and attitudes of health behaviour.

Hypochondria and trivial illness

Hypochondriasis is a medical condition whereby someone becomes obsessively and persistently worried about the possibility of an undiagnosed disease based on minor symptoms. These patients will typically consult with doctors more frequently, often seeing more than one doctor as they despair with a lack of diagnosis. When their "illness" does not meet the defined "sick role" then hypochondriacs feel ignored, question the validity of the medical profession and may turn to alternative remedies and health care practitioners of less proven value. In turn, doctors find hypochondriacs equally frustrating and difficult to manage. This is not to claim hypochondriacs exploit the sick role to seek attention, privilege and sympathy. The source of their frustration and behaviour may be seated in the strong influence that Parsons's sick role has in society and the health care profession.

People who suffer from the common cold often claim to be "really ill". This is said to justify feeling unwell, being off work and not being able to do normal things. This language is not often heard from patients with chronic conditions who would rather say: "I have a bad chest" than "I have asthma". This is because they have to live with their illness on a daily basis and would rather try to fit into their normal social identity and functionality than be labelled a sick person. People with colds may take on the sick role more readily in order to obtain sympathy, justification and treatment because they know their illness will be relatively short-lived, is of predictable outcome and carries no social stigma or embarrassment.

Antibiotics are over-prescribed and unnecessary for the majority of common colds; however, general practitioners are under pressure to prescribe them. Patients expect to receive medicines as proof of their illness, but also doctors want to be seen to be taking their patient's illness seriously and to do something about it in order to be a "good doctor". The demands on the average GP mean that it is often easier and quicker to prescribe unnecessary antibiotics for viral infections than to attempt to educate the patient, and although the practice is undesirable it is understandable.

Compliance and concordance

Both of these terms relate to "following doctor's orders". However concordance relates to the relationship between patient and health care professional, the differing agendas and beliefs that exist and a therapeutic alliance. Parsons's sick role described the doctor-patient relationship as both parties having independent views and wishes but the knowledge of the doctor having superior academic weight. Medical decision-making since then has sought to avoid this paternalistic approach of health care professionals in favour of informed decisions by the patient.

Many patients have difficulty in accepting antihypertensive drugs and may typically say: "I'm not actually sick, just blood pressure, so why do I have to take these tablets?" Parsons recognised this type of patient as "hyperchondriac". Instead of exaggerating illness, such patients seek to minimise it and sometimes behave against medical advice. People appear to want to define illness according to Parsons's sick role with an onset, treatment and cure. Compliance and concordance may be a problem with conditions that do not fit the sick role pattern. Research suggests 50 per cent of patients with chronic illnesses fail to take their medicines as prescribed. It has been questioned whether it is right for patients to override the views of health care professionals when human rights get in the way of good health outcomes.

The sick role can be used to explain why some patients are accepters of illness and others are in denial of it. A study revealed that those who rejected asthma as a diagnosis were often ordering repeat prescriptions for their steroid inhalers out of habit, and not wishing to upset the doctor, but not using them. There was a tendency to conceal the condition in order to be seen as normal. The sick role spoils the image of oneself, and the use of medical devices such as inhalers and nebulisers can label the individual with an undesirable image of a sick role. The problem is that such thought and behaviour result in unnecessary deaths.

Trust and blame

Adoption of the sick role involves consultation with any number of health care professionals, including pharmacists. A medicine dispensed or purchased represents a "trophy" that confirms sickness. The medicine is expected to cure or alleviate symptoms and if it achieves this aim it reinforces the patient's trust. If the medicine does not work, or it causes side effects, then this trust may be damaged and blame attached.

Patients can use the sick role to their advantage by adopting a passive role and shifting the accountability for health outcomes away from themselves to the health care professional. A breach of trust in the relationship between patient and health care professional can result in hostility, loss of confidence and possibly legal action on behalf of the patient. Doctors feel pressure to be optimistic, definite and effective about the outcome of serious illness in order to fit their sick role when this may not be the case because of medical limitations. Patients expect doctors to know what to do and by regressing into the passive sick role they can leave the decision making entirely up to the doctor and therefore pass blame when the outcome is not as they expected. Doctors find this type of behaviour frustrating and it is not always in the patient's best interests.

There has been a shift in thinking from the paternalistic approach of Parsons to more emphasis on patients as health care consumers with active participation and expectations. However, some patients who may not be, or want to be, adequately informed about health care may still want the "doctor knows best" approach and use the sick role if it works best for them. The criticisms of the sick role are valid, but it is because the sick role is still ingrained in society that it explains health behaviour today.