CLIFFSQUICKREVIEW Sociology CHAPTER 13 RELIGION Social Correlates of Religion Religious Fundamentalism CHAPTER 14 HEALTH AND MEDICINE Sociological Perspective on Health The Medical Establishment and Professions Health Care Availability: Costs and Inequality Managed Care as a Means of Cost Control Access to Health Care Euthanasia: The Right to Die? CHAPTER 15 POPULATION AND URBANIZATION Population Urbanization CHAPTER 16 CONTEMPORARY MASS MEDIA The Role and Influence of Mass Media Creating News and Culture Oversimplification and Stereotyping Violence and Pornography in the Media CHAPTER 17 SOCIAL CHANGE AND MOVEMENTS Social Movements Models of Social Change Technology and Social Change Environmentalism and Social Change Resisting Social Change Notes bringing together people of the same turn of mind. The potential for abuse and other problems in such environments has led American society to give much negative press to cults, although not all cults are necessarily abusive. Social Correlates of Religion Religious persuasion seems to relate to political persuasion. Jews and Catholics are more likely to be Democrats than are Protestants. Likewise, Jews tend to be more liberal than Catholics, who tend to be more liberal than Protestants. Membership of religious organizations also correlates positively with socioeconomic status. Baptists tend to be comparatively poor, whereas Anglicans, Presbyterians, and Jews tend to be wealthy. And Catholics, on average, have higher income than comparable members of Protestant denominations do. However, these generalizations are just that: general statements. You must inter- pret statistics with caution. For example, some of the poorest people in the United States belong to the Roman Catholic church, and con- siderable differences exist among members of the Protestant churches. Some of the wealthiest people now belong to the Church of Jesus Christ of Latter Day Saints (the “Mormons”). The vast majority of Americans—around 95 percent—say they have some form of religious beliefs: in God, heaven, the divine inspi- ration of Scriptures, and so on. Whereas 70 percent of Americans belong to religious organizations, only about 40 percent claim to attend weekly synagogue or church services. People in upper social groups, on average, attend church more regularly than those in other social groups. Similarly, Catholics, on average, attend church more regularly than Protestants. Members who actually attend services tend to actively participate within their congregations. 187 SOCIOLOGY RELIGION 8615-7 Ch13.F 6/23/00 9:57 AM Page 187 Religious Fundamentalism One particularly notable feature of religion in the Unites Sates has been the appearance of fundamentalist religious groups. Fundamentalism refers to “black-and-white” thinking that opposes modernism, or pro- gressive thinking about religion and other social topics. Fundamentalist groups tend to oppose anything that challenges their religious group’s interpretations and opinions. For instance, Christian fundamentalists believe in the literal inerrancy of the Bible, and often define themselves as theologically and ritually conservative, or even “not Catholic.” They see themselves as reacting against liberal theology. To most Americans the term fundamentalist conjures up images of “Bible-thumping” Protestants, which is far from the case. All denominations and groups—including those of religions like Islam— contain fundamentalist members. These activists usually think that they have a corner on “the truth,” and do not tolerate other viewpoints or practices. The most well-known fundamentalist denominations in the United States are the Assemblies of God, the Southern Baptist Convention, and the Seventh-Day Adventists. Organizations such as these often become politically active, and support the conservative political “right,” including groups like the Moral Majority. 188 C LIFFS Q UICK R EVIEW RELIGION 8615-7 Ch13.F 6/23/00 9:57 AM Page 188 CHAPTER 14 HEALTH AND MEDICINE 189 SOCIOLOGY Health is a state of complete well-being: physical, mental, and emo- tional. This definition emphasizes the importance of being more than disease free, and recognizes that a healthy body depends upon a healthy environment and a stable mind. Medicine is the social institution that diagnoses, treats, and prevents disease. To accomplish these tasks, medicine depends upon most other sciences—including life and earth sciences, chemistry, physics, and engineering. Preventive medicine is a more recent approach to medicine, which emphasizes health habits that prevent disease, including eating a healthier diet, getting adequate exercise, and insuring a safe environment. Sociological Perspective on Health Sociology assumes that a functioning society depends upon healthy people and upon controlling illness. In examining social constructs of health and illness, sociologist Talcott Parsons identified what he called “the sick role,” or the social definition of, the behavior of, and the behavior toward those whom society defines as ill. Parsons iden- tified four components to the sick role. The sick person is ■ Not held responsible for being sick. ■ Not responsible for normal duties. ■ Not supposed to like the role. ■ Supposed to seek help to get out of the role. 8615-7 Ch14.F 6/23/00 9:56 AM Page 189 Society allows those who fulfill these criteria to assume the sick role, but society loses sympathy for and denies the role to those who appear to like it or those who do not seek treatment. In other cases, family and friends may show sympathy for a while, but lose patience with the victim and assume he or she is seeking attention or is a hypochondriac. Although many believe that science alone determines illness, this sociological view points out that society determines sickness as well. For example, the culture defines diseases as legitimate if they have a clear “scientific” or laboratory diagnosis, such as cancer or heart dis- ease. In the past, society considered conditions such as chemical dependency, whether drug- or alcohol-based, as character weak- nesses, and denied those who suffered from addiction the sick role. Today, drug rehabilitation programs and the broader culture gener- ally recognize addictions as a disease, even though the term “disease” is medically contested. In today’s culture, addicts may take on the sick role as long as they seek help and make progress toward getting out of the sick role. In the past, society first dismissed or judged various ailments, only to later recognize the ailments as legitimate. People now recognize premenstrual syndrome (PMS)—once considered female hypochon- dria—as a legitimate, treatable hormonal condition. Acquired Immunodeficiency Syndrome, or AIDS, first emerged in the early 1980s in the male homosexual community. Because of the disease’s early association with a lifestyle many people considered immoral, society granted those who acquired the disease little to no sympathy and denied them the sick role. People punished these victims for vio- lating the norms and values of the society, rather than recognizing them as legitimately ill. As society became more knowledgeable about the disease, and as the disease affected a broader portion of the population, attitudes toward AIDS and those afflicted changed as well. Today some conditions still struggle for recognition as legitimate ailments. One controversial condition is chronic fatigue syndrome. Called the “yuppie flu,” chronic fatigue syndrome generally affects 190 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 190 middle-class women, though men have also been diagnosed with it. Flu-like symptoms, including low-grade fever, sore throat, extreme fatigue, and emotional malaise, characterize the condition, which is often accompanied by depression. These symptoms may last for years and often result in disability. Sufferers experience difficulty in get- ting their condition recognized, not only by family and friends, but by insurance companies as well. Because of social hesitancy to accept chronic fatigue syndrome as legitimate, sufferers who are unable to work are often denied disability. Advocates have responded by renaming the disorder chronic fatigue immuno-deficiency syn- drome. This renaming associates the disorder with more scientific, readily recognized diseases. More families, physicians, and employ- ers are now taking the disease seriously, so chronic fatigue sufferers are gaining support. People with mental illnesses equally struggle for recognition and understanding. Although treatment conditions and understanding of mental illness have drastically improved, critics and mental health providers argue that considerable work remains. Prior to the 1960s, most mentally ill patients were locked away in places referred to as “insane asylums,” in which patients were often sedated for easy con- trol. Because of new drugs that reduce or eliminate many symptoms and changed attitudes toward mental illness brought about by the work of sociologists and psychologists, many asylums closed and thousands of patients were released to community group homes, halfway houses, or independent living. This movement toward community care pro- duced mixed results, with most mental health professionals conclud- ing that the majority of deinstitutionalized patients adapt well with appropriate community placement and follow-up. Critics point to an increase in homelessness coinciding with deinstitutionalization. They claim many homeless are mentally ill patients who need institution- alization or at least better mental health care. Communities now face a number of issues due to deinstitution- alization because many localities object to group homes and halfway houses being located in their communities. Many wrongly believe that the mentallly ill are more likely to commit crimes. Because of 191 SOCIOLOGY HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 191 192 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE this misperception, as well as others, recovered mentally ill people, as well as those diagnosed and in treatment, are still stigmatized and discriminated against. In addition, turf wars can exist among mental- health professionals and over the use of drugs to control problematic behaviors. Psychiatrists and other medical doctors can prescribe drugs, while nonmedical professionals cannot. Insurance companies limit the kind of professional mentally ill patients may see and the length and cost of treatment. All these issues make it more difficult for mentally ill patients to get and remain in treatment. Some mental illnesses, such as paranoid schizophrenia, require drug treatment for normal functioning. Patients in the community sometimes neglect to take their medication when they start feeling better, opting out of continued treatment and resulting in a relapse. Patients who stop taking their medications are the ones most likely to become homeless or to pose a danger to themselves or others. These are not the majority of patients being treated for a mental ill- ness, however. People with conditions such as depression, panic, bipolar disorder (formerly known as manic depression), and a host of other debilitating conditions can respond well to other therapies in addition to medication. With treatment, they are no different from any other member of society. With increased awareness of mental and emotional disorders, finding cost-effective ways to meet society’s need to appropriately care for these patients and benefit from their many talents will become more critical. Major health problems in the United States Over the 20th century, medicine responded to the most common health threats with effective treatments. By the end of the century, the leading causes of death had changed dramatically. According to the national Center for Health Statistics, the top ten causes of death are: heart disease, cancer, blood vessel diseases, accidents, lung diseases (not cancer), pneumonia and flu, diabetes, suicide, liver disease, and homicide. At the beginning of the century, the leading causes of death were tuberculosis, pneumonia, diarrhea, heart disease, nephritis, acci- dents, blood vessel diseases, cancer, bronchitis, and diphtheria. 8615-7 Ch14.F 6/23/00 9:56 AM Page 192 Discovery and development of vaccines and antibiotics meant that diseases once deadly are curable or nonexistent. People live longer, thus suffering more diseases associated with old age such as heart dis- ease, cancer, and blood vessel diseases. What has also changed is physicians’ abilities to recognize and diagnose disease more accu- rately. In the past a death may have been ascribed to “old age,” when today a physician might diagnose cancer. What cannot be overlooked is the eleventh cause of death: AIDS, or acquired immune deficiency syndrome. First recognized in 1981, the origin of AIDS is still controversial, though many experts find evi- dence pointing to African monkeys. In the United States, the disease first appeared in male homosexuals. According to the Centers for Disease Control, the most common transmission of AIDS is through homosexual sex (52 percent). Other means of transmission are drug injection, 25 percent; heterosexual sex, 8 percent; homosexual sex and drug addiction, 7 percent; undetermined, 6 percent; and blood transfusions, 2 percent. The lengthy incubation period, sometimes lasting several years, contributes to its spread. While AIDS is the eleventh cause of death for the overall population, it is the leading cause of death for men age 24-44 in the United States. Most common drugs: Alcohol and nicotine The most commonly abused drugs in the United States are alcohol and nicotine. According to the statistical abstract, Americans con- sume on average 37 gallons of alcohol per year, the majority being beer at an average of 32 gallons per year. The remaining 5 gallons is comprised of 3 gallons of wine and 2 gallons of other distilled alco- hol. At this rate, Americans consume more beer than either coffee or milk. Beer consumption has become a major issue on college cam- puses with recent epidemics of binge drinking, particularly by college males. Many incidents have resulted in injury and death. Although many recent studies have extolled the health benefits of moderate alcohol consumption, the emphasis of these studies is upon moderate consumption or one or fewer glasses of wine per day. Some emerging 193 SOCIOLOGY HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 193 studies indicate that the health benefits may be the same for grape juice and wine. Alcohol increases the risk of birth defects, and women who are or may become pregnant should not consume alcohol. In 1964 the surgeon general issued the first warning that smok- ing could be hazardous to health. Since then the evidence has mounted and the powerful tobacco industry has increasingly found itself on the losing side of lawsuits. Emphysema, lung cancer, heart disease, and other cancers are attributed to smoking. Morbidity experts estimate nicotine kills about 390,000 Americans each year, making it the most deadly recreational drug. Individuals and states have sued for damages in these losses, and for the costs incurred with caring for nicotine-induced diseases. The role of second-hand smoke in disease has also been recognized. Although cigarette advertising is limited, it remains a central controversy, especially advertising aimed at teens and youth. The Medical Establishment and Professions Over the last 150 years, professionalism and delivery of health care have changed dramatically. Prior to the beginning of the 20th century, the sick could seek treatment from any number of sources besides physicians, including barbers, midwives, druggists, herb specialists, or even ministers. No standardized medical education system or licensing process existed, and no one oversaw the practices of any- one claiming to be a doctor. In many cases, becoming a doctor fol- lowed the same process as any other profession: apprenticeship to someone already a “doctor.” In 1847, the American Medical Association (AMA) was formed as a self-regulating body to set standards of professionalism and fight for a more scientific definition of medicine. At first, the organization exerted limited influence; however, as researchers identified bacteria and viruses as causes of disease and developed effective vaccines, its 194 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 194 influence grew. The AMA also openly fought against alternative approaches to health care and certified only physicians who com- pleted AMA-approved programs. The AMA expelled those who failed to complete such programs, or those who used alternative methods such as chiropractic or herbalism. A definite turning point in medical care came in 1908 with the release of the Flexner report. Funded by the Carnegie Foundation for the Advancement of Teaching, Abraham Flexner investigated medical schools and declared only 82 of 160 acceptable. He cited problems such as inadequate materials, nonexistent libraries, and training programs of only two years. Flexner recommended that the “most promising” medical schools that had high standards of admis- sion and training be supported with foundation and other philan- thropic money. The best schools remained open, while the AMA forced the remainder to close. Thus, the Flexner report led to the pro- fessionalization of medicine. Physicians now had to undergo rigor- ous training, base their approach on theory, self-regulate, exercise authority over patients, and serve society. The importance of the Flexner report was that for the first time it defined acceptable standards and pointed out inconsistencies and extreme deficiencies in medical education at the time. In some cases, folks could “buy” a medical degree by attending a diploma mill, and doctors improved their incomes by taking on more apprentices than they could actually teach. While AMA supporters point to its role in protecting public inter- est and improving medical care, critics point to what they call the AMA’s monopoly over medicine. The organization locked out those who did not adhere to the strict, narrow interpretations of the AMA. Interestingly, the medical schools closed by the Flexner report included all but two schools training blacks and one training women. Critics charge that the AMA became an all-powerful, white male organization that promoted a perception of doctors as all-knowing authority figures with power over nurses, midwives, and patients. 195 SOCIOLOGY HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 195 196 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE Doctors’ use of technical language, confusing and intimidating to patients, reinforced their superiority, as they possessed the power to dispense or withhold information or treatment. Patient advocates argue, and substantial recent research supports the view that passive patients are likely to remain quiet, depriving the doctor of informa- tion that can alter a diagnosis. According to these critics, the hierar- chy of medicine with doctors on top and everyone else at the bottom can negatively influence patient care. Millions of Americans, disenchanted with or discouraged by tra- ditional medicine, have returned to alternative forms of medicine. In recent years, naturopaths, herbalists, acupuncturists, and chiroprac- tors have gained new clout and business. Each of these groups has also become more professional, regulating itself and setting stan- dards. However, most alternative therapists work to avoid exerting too much authority over patients, aiming instead for partnership in treatment. Chiropractors, who generally receive more training than most other practitioners of alternative medicine, have started to gain respect and recognition from the AMA. Many physicians practicing traditional medicine work cooperatively with alternative practitioners to treat patients. Others still openly oppose alternative medicine. Nevertheless, the current trend is for patients to seek greater control and understand- ing of their health care, demanding more information and choices in the process. Health Care Availability: Costs and Inequality No one denies that modern health care is expensive, but what factors contribute to the rising cost? Of course, continually advancing technology provides the most obvious and perhaps greatest cause. Innovations in all forms of med- ical equipment, surgical techniques, and therapies are costly on their 8615-7 Ch14.F 6/23/00 9:56 AM Page 196 own, but also require specialists to operate them, or additional train- ing for existing specialists. Patients, with more access to information about new technology through the Internet and other sources, expect the latest technology in their own treatment. Research and physician demands to use new techniques to explore all possibilities in patient care fuel this expectation. The rising cost of physician care provides the next most signifi- cant contributor to rising medical costs. As technologies have increased so have the numbers of, types of, and demands for specialists. Specialists generally charge more for services than general practition- ers, family practitioners, or internal medicine practitioners. Surgeons, radiologists, and endocrinologists earn as much as $80,000 more per year than a general practitioner. Cardiologists, gynecologists, and anes- thesiologists earn approximately $30,000 more per year. Some special- ists, such as pathologists, oncologists, and pediatricians, actually earn less than general practitioners. Even so, physicians, as a group, are in the top 1-percent income bracket, with incomes that consistently remain ahead of inflation. Another contributor to rising health-care costs is malpractice insurance. From the 1980s to the 1990s, the cost of malpractice insur- ance doubled or tripled, depending upon the specialty, and most spe- cialists pay higher rates. The availability of newer, more expensive drugs, particularly newer antibiotics and drug treatments for AIDS patients, also con- tribute substantially to rising costs. Some of these medications may cost more than a hundred dollars for a single dose. The cost of med- icine has become a public policy issue and a social problem as peo- ple forgo medication to pay for food and housing; this is especially true among those elderly who do not have prescription medicine coverage. 197 SOCIOLOGY HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 197 198 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE Managed Care as a Means of Cost Control With health-care costs increasing, health insurance providers are looking for ways to reduce costs. Traditionally, patients paid for most medical care on a fee-for-service basis, where physicians, laborato- ries, and hospitals charged set fees for procedures. Patients either paid the fees directly or paid a partial fee with a private insurance com- pany paying the remainder. The patient and his or her employer shared the cost of premium payments to the insurance company. Such systems do not typically cover serious illness, or if they do, insurance companies substantially raise premiums for the individual and the employer. Until the last decade or so, most traditional insurance plans cov- ered serious illness but not routine care. Blue Cross had separate plans for doctor visits and hospitalizations. In most plans, patients would pay the cost of check-ups and preventive testing. Insurance covered costs associated with a diagnosed illness and with hospital- ization. “Gold-standard” plans, such as those held by the Auto Workers and Steel Workers, covered virtually everything. This sys- tem did not promote wellness, however, as many patients whose plans did not cover routine doctor visits and minor illnesses did not go for checkups and preventive tests. If you didn’t have a lump, insurance did not pay for a mammogram; the patient did and the cost was pro- hibitive. But most people who had insurance were covered to some extent (mostly 80 percent insurance, 20 percent patient, until the patient reached a set limit). HMOs were set up to approach health from a wellness perspec- tive rather than a disease perspective. HMOs believed you could save money and lives by getting regular checkups and treating illnesses in their earliest stages, where the costs were lower and the prognoses better. Some argue that the current HMO system, which expects insurance to pay for wellness and illness, increases costs by encour- aging visits for minor illnesses that a patient would forego if he had to pay the bill. Most hospitals at the time were nonprofit or not-for- profit, so the expectations of high profits based on holding down costs 8615-7 Ch14.F 6/23/00 9:56 AM Page 198 were not part of that system, though “profits” were indeed made. The requirements of remaining nonprofit funneled most of these profits into new programs or expanded facilities. In response to this situation, managed care organizations emerged as nonprofit organizations to reduce health-care costs and provide broader coverage. Managed care organizations are groups of physi- cians, specialists, and often hospitals, coordinating with each other to provide care for a set monthly fee. These systems control the patient’s access to doctors, specialists, laboratories, and treatment facilities. HMOs hire physicians as salaried employees rather than paying them on a fee-for-service basis. In this system, the medical clinics receive the same amount of money regardless of how frequently patients see the doctor. Because no connection exists between services rendered and fees paid, the incentive is to keep costs down. Critics of this sys- tem point out that business managers or non-medical personnel trying to hold down costs frequently overturn medical decisions made by doctors. Although the number of HMOs has skyrocketed in the last few years, medical experts predict the decline if not the demise of HMOs because of the impact on patient care and widespread public dissatis- faction. HMOs are not traditionally considered managed care, and there are more managed care models than just HMOs, such as Preferred Provider Systems. Although begun as nonprofits, most man- aged care systems are for-profit, and many hospitals are now for- profit, introducing a strong profit-motive (not just a hold-down-costs motive) throughout the system. Members of managed care organiza- tions can only visit approved doctors and stay at approved hospitals and get approved tests. They cannot see other doctors or even special- ists within the managed care system without an okay from a primary care physician, who is incentivized not to make such recommenda- tions. The blatant profit motive in many cases accounts for patient dis- trust of the system and dissatisfaction from everyone involved except for high-salaried system administrators and CEOs. Other issues include replacing highly trained nursing and physician staff with lesser trained assistants to save costs, overuse of emergency rooms, a growing 199 SOCIOLOGY HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 199 200 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE shortage of hospital beds for critically ill patients, hospice and home health care, and the provision of follow-up social services to patients. Access to Health Care Discussion of fee-for-service or HMOs generally applies to middle- class employed persons. But what about the working poor, the unem- ployed, or the disabled? What options exist for them? Unfortunately, in the United States, access to health care is still closely tied to the ability to pay for such care, either personally or through insurance. Therefore, people who are not covered by health plans, are unem- ployed, or are disabled qualify for only limited access to health care. The United States, as one of the few Western nations without a national health care plan, falls far behind most other industrialized nations in providing care for such people. This fact is ironic consid- ering that the United States spends more per person on health care than any other industrialized nation. Without a doubt, the need for health care is significant, especially among the poor. Sociologists point to substantial evidence that shows the poor are sicker, die younger, and have higher infant mortality rates than the non-poor. Because minorities also tend to be poorer than non-minorities, poor-quality health care disproportionately affects them. Blacks have the highest death rate in the United States, fol- lowed by Hispanics. Whites have the lowest. Violence and accidents, both of whose rates are higher in the United States than in other indus- trialized nations, also contribute to high health costs. The government tried to respond to the needs of the poor in the 1960s with Medicaid and Medicare. Medicaid is a federally funded program that provides medical insurance to the poor, disabled, and welfare recipients. Similarly, Medicare is a federally funded program that provides medical insurance for all people age 65 and older. 8615-7 Ch14.F 6/23/00 9:56 AM Page 200 Although these programs have provided considerable benefits to many people, they have come under fire for a variety of reasons. Critics argue that the programs are too costly for the services pro- vided, many are wasteful and inefficient, and, because of poor moni- toring, these programs are often routinely abused by unscrupulous medical practitioners who defraud the system. To address billing fraud, the Office of the Inspector General (OIG) now aggressively investigates questionable billing to the Health Care and Finance Administration (HCFA), which oversees Medicare and Medicaid. The OIG expects all providers to implement and audit a compliance plan, that is, a comprehensive procedure and audit manual that demonstrates diligence in correct billing and avoidance of fraud. A new industry of consultants and legal advisors emerged during the 1990s and continue to assist practices with their compliance plans. Recent political debates have sought to reform or abolish Medicare and Medicaid in their present forms or reduce the amounts paid for some procedures. Unfortunately, efforts to reduce Medicaid and Medicare costs may actually contribute to the overall rise in the cost of medical care. For example, many laboratory services are reim- bursed at or below the cost to perform the test and produce the report. A laboratory processing a standard biopsy may break even or lose money depending on the complexity of the case. For every dollar lost on Medicare cases, the laboratory needs to make up that loss else- where. If Medicare or Medicaid were to pay less for these services, laboratories would be forced to charge more for tests to non-Medicare and Medicaid patients, refuse to accept Medicare and Medicaid tests, or go out of business. Also, there is a gap between where Medicaid ends and private insurance picks up. Many of the working poor are not covered by Medicaid, their companies do not provide health insurance, and they can’t afford private insurance, so they are among the 40 to 60 million uninsured. Medicare is also facing problems as Medicare HMOs go out of business and doctors limit or refuse to accept patients covered by Medicare and Medicaid because of low payments, late payments, and excessive paperwork. 201 SOCIOLOGY HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 201 202 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE Euthanasia: The Right to Die? While health and medicine usually look at improving and extending life, increasingly medical professionals and society are being forced to ask how far those efforts should go. Perhaps the most pressing eth- ical medical dilemma concerns whether an individual has the right to die. Euthanasia, or mercy killing, means the deliberate killing of a patient who is terminally ill and/or in severe and chronic pain. More recently, “physician-assisted suicide” has superseded the term euthanasia as terminally ill patients take more assertive roles in expressing their wishes and requesting physician support. Although technology and advanced drugs provide physicians with “heroic” means of prolonging life, more people are questioning whether doing so is the right action, and, more importantly, many are asking why they must suffer at all with painful terminal diseases like Huntington’s Disease, Alzheimer’s, or the end-stages of AIDS. Those in favor of physician-assisted suicide argue that patients remain in control, administer the lethal drugs themselves, and die by choice with limited pain and suffering. Dr. Jack Kevorkian has stood at the center of the debate for providing lethal drugs to terminally ill or pro- foundly suffering patients who want to die. Despite arrests and jail sentences, Kevorkian continues to assist patients in their deaths. Opponents to physician-assisted suicide point to several concerns: ■ Making an accurate terminal diagnosis can be difficult because doctors do make mistakes and many patients beat the odds. ■ Patients who claim they want physician-assisted suicide may be reasoning through the clouds of depression, which often triggers suicidal thoughts. Treat the depression, and the patient regains the will to live. 8615-7 Ch14.F 6/23/00 9:56 AM Page 202 ■ Inadequate pain management often causes patients to long for death. Many people harshly criticize a medical establishment that they claim is insensitive to or outright fails to provide ade- quate pain management. In these cases, critics say, relieve the pain (even with addictive drugs) and many patients enjoy life again. ■ Of greatest concern to opponents of physician-assisted suicide is the risk that the “right to die” could become the “responsi- bility to die.” People may see poor or vulnerable individuals, especially the elderly, as a burden and pressure them into “doing their duty” of dying. Overall, opponents feel that allowing physician-assisted suicide devalues human life and fails to address deeper issues in the society. After protracted debate and two years of court challenges, the state of Oregon legalized physician-assisted suicide. A terminally ill patient must obtain a terminal diagnosis from at least two physicians who declare that the patient has six months or less to live. The patient must be evaluated for depression and meet other qualifications. If the request is approved, the patient must wait a minimum of two weeks before becoming eligible to receive the lethal prescription. Although the physician-assisted suicide law has seen limited use since its implementation, it has had an unexpected consequence. The debate over the law has forced medical professionals to reevaluate pain treatment in Oregon. Physicians are more willing to prescribe pain medications, and the number and quality of hospice care facili- ties has rapidly increased. Harshest opponents of physician-assisted suicide admit there have been some positive outcomes from the Oregon experiment, although they still oppose the law, and the debate continues. 203 SOCIOLOGY HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 203 204 C LIFFS Q UICK R EVIEW HEALTH AND MEDICINE 8615-7 Ch14.F 6/23/00 9:56 AM Page 204 CHAPTER 15 POPULATION AND URBANIZATION Humans throughout history have generally favored large families— for the most part to assure survival of a particular family line or racial group. High death rates from plagues, predators, and wars led people to produce as many offspring as possible. However, the situation has changed dramatically in the 20th century as technological advances of one sort or another have caused a global “population explosion,” with the world currently gaining 90 million people each year (most of this increase in poorer countries). Given this trend, the global pop- ulation will exceed 6 billion in the early 2000s, and 8 billion by the 2020s. Understandably, sociologists around the world exhibit urgent concern about increases in the global population. Population Demography (from the Greek word meaning “description of peo- ple”) is the study of human populations. The discipline examines the size and composition of populations, as well as the movement of peo- ple from locale to locale. Demographers also analyze the effects of population growth and its control. Several demographic variables play central roles in the study of human populations, especially fertility and fecundity, mortality and life expectancy, and migration. Fertility and fecundity A population’s size is first affected by fertility, which refers to the number of children that an average woman bears during her reproduc- tive years—from puberty to menopause. People sometimes confuse the 205 SOCIOLOGY 8615-7 Ch15.F 6/23/00 9:51 AM Page 205 term fertility with fecundity, which refers to the number of children an average woman is capable of bearing. Such factors as health, finances, and personal decision sharply affect fecundity. To determine a country’s fertility rate, demographers use govern- mental records to figure the crude birth rate (the number of live births for every thousand people in a population). They calculate this rate by dividing the number of live births in a year by the total popu- lation, and then multiplying the result by 1,000. As one might expect, the governmental records used in this type of research may not be completely accurate, especially in third-world countries where such records may not even exist. While the world’s average fertility rate is about 3 children per woman, its fecundity rate is about 20 per woman. The highest fertil- ity rate (nearly 6 children per woman) in the world occurs in Africa, whereas the lowest occurs in Europe (about 1.5). The fertility rate for women in the United States is about 2. Mortality and expectancy Mortality, or the number of deaths in a society’s population, also influences population size. Similar to the crude birth rate, demogra- phers calculate the crude death rate, or the number of deaths annu- ally per 1,000 people in the population. Demographers calculate this figure by dividing the number of deaths in a year by the total popula- tion, and then multiplying the result by 1,000. The crude death rate in the United States normally stays around 8 or 9. Infant mortality rate, which is the number of deaths among infants under age one for each 1,000 live births in a year, provides demographers with another measure. Compared to other countries, North American infant mortality rates tend to be low. Still, the fig- ures can vary considerably within a society. For example, African Americans have an infant mortality rate of about 19 compared to those of whites who have a rate of about 8. 206 C LIFFS Q UICK R EVIEW POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 206 A low infant mortality correlates with a higher life expectancy, which is the average lifespan of a society’s population. U.S. males and females born today can look forward to living into their 70s, which exceeds the life expectancy of those in low-income countries by 20 years. Migration Finally, migration (the movement of people from one place to another) affects population size. While some migration is involun- tary, such as when slaves where brought to America, other migration is voluntary, such as when families move from cities into suburbs. Migration into an area, called immigration, is measured as the immigration rate, which is the number of people entering a region per each 1,000 people in the population. Migration out of an area, or emigration, is measured as the emigration rate, which is the num- ber leaving per each 1,000 people in the population. Internal migra- tion is the movement from one area to another within a country’s borders. Population growth Fertility, mortality, and migration all influence the size of a society’s population. Poorer countries tend to grow almost completely from internal causes (for example, high birth rates due to the absence of reliable contraception), while richer countries tend to grow from both internal causes and migration. Demographers determine a popula- tion’s natural growth rate by subtracting the crude death rate from the crude birth rate. The world’s low-growth nations tend to be more industrialized, such as the United States and Europe. The high-growth countries tend to be less industrialized, such as Africa and Latin America. 207 SOCIOLOGY POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 207 Population composition Demographers also take an interest in the composition of a society’s population. For example, they study the gender ratio (or sex ratio), which is the number of males per 100 females in a population. The sex ratio in the United States is about 93 males for every 100 females. In most areas of the world, the gender ratio is less than 100 because females normally outlive men. Yet in some cultures that practice female infanticide, such as among the Yanomamo, the ratio can reach well above 100. Malthusian theory The field of demography arose two centuries ago in response to the population growth of that day. Thomas Robert Malthus (1766-1834), English economist and clergyman, argued that increases in population, if left unchecked, would eventually result in social chaos. Malthus predicted that the human population would continue to increase exponentially (1, 2, 4, 16, 256 . . .) until the situ- ation is out of control. He also warned that food production would only increase arithmetically (1, 2, 3, 4, 5 . . .) because of limitations in available farmland. To say the least, Malthus provided a disturbing vision of the future that included massive, global starvation as a con- sequence of unrestrained population growth. As it turned out, Malthus’ predictions were mistaken because he failed to account for technological advancements and ingenuity that would increase agricultural and farm production, not to mention the increasing development and acceptance of birth control methods. Yet Malthus’ forebodings do not lack merit. As noted by the New Malthusians, a group of demographers, assets such as habitable and fertile land, clean air, and fresh water are finite resources. And with medical advances increasing fertility and lowering death rates, the global population continues to grow exponentially with no end in sight. 208 C LIFFS Q UICK R EVIEW POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 208 Demographic transition theory Replacing Malthus’ ideas today, demographic transition theory defines population growth in an alternating pattern of stability, rapid growth, and then stability again. This theory proposes a three-stage model of growth. ■ Stage 1: Stable population growth. In this stage, birth and death rates roughly balance each other. Most societies throughout history have stayed at this stage. ■ Stage 2: Rapid population growth. Death rates fall sharply while birth rates remain high in Stage 2. Most poor countries today fit into this stage. Malthus formed his ideas during one such high-growth period. ■ Stage 3: Stable population growth. In this stage, fertility falls because high living standards make raising children expensive. Women working outside the home also favor smaller families, brought about by widespread use of birth control. Death rates drop because of technological advances in medicine. With low birth rates and death rates, the popula- tion only grows slowly, if at all. It may, in fact, witness popu- lation shrinkage, in which deaths outnumber births in a society. Stage 3 suggests that technology holds the key to population con- trol. Instead of the out-of-control population explosions that Malthus predicted, demographic transition theory claims that technology will ultimately control population growth and ensure enough food for all. Population control: The importance of family planning Historically, many groups and societies have discouraged contracep- tion (the prevention of conception, or birth control) to assure survival of its members and humanity as a whole. Certain religious groups strongly disapprove of sexual activity that does not culminate in coitus and the possibility of conception. Other groups place little 209 SOCIOLOGY POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 209 importance on the matter of contraception. The Yanomamo of South America, for instance, harbor little or no concept of contraception. Instead, they parent as many children as possible, and then kill off those they view as the undesirable, such as some females and deformed infants. Modern medicine has spread throughout different parts of the world, and people of all ages now live longer, causing the world’s population to explode in growth. In fact, at five billion today, the world’s population doubles, on average, every 35 years, with most of this growth occurring in developing countries. Given this population crisis, certain governments, like that of China, regulate the number of births allowed per household. Besides the issue of controlling overpopulation, other benefits to practicing contraception exist. For example, a young couple may want to postpone having children until their finances improve. Or an unmarried, sexually active teenager may wish to finish her education or get married before starting a family, thereby reducing her chances of eventually relying on the government for financial support. Family planning also plays an important role in protecting the physical health of both mother and child. The older or younger a woman is, and the closer together she bears children (that is, more frequently than every two years), the greater the risk of pregnancy and birth complications, early infant mortality, and maternal death. For example, women over age 40 or under age 19 have an increased risk of bearing a child of low birth weight, and thus a variety of birth defects and even outright death. Estimates say that approximately one million teenage women in the United States become pregnant each year. 210 C LIFFS Q UICK R EVIEW POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 210 Urbanization By the early 1900s both Great Britain and the United States had become predominantly urbanized nations; since that time, urbaniza- tion has been occurring around the globe at a rapid rate. Today, as many as 50 percent of the world’s population lives in urban areas, compared to only a few percent just 200 years ago. Sociologists studying urbanization trends note three distinct his- torical stages in the development of cities: preindustrial, industrial, and metropolitan-megalopolitan stages. Preindustrial cities For the vast majority of human history, as far as anyone knows, peo- ple roamed about in search of sustenance. While they gathered edi- ble plants, fished, and hunted, our ancestors could never find enough food in one area to sustain themselves for an extended period of time. Consequently, they had to keep moving until they could find another place in which to settle temporarily. Eventual technological improvements—such as simple tools and information on how to farm and raise animals—allowed people to set- tle in one place. They built villages, with perhaps only a few hundred people living in each, and, for the following 5,000 years, produced just enough food for themselves—with nothing more in reserve. About 5,000 years ago, however, humans developed such inno- vations as irrigation, metallurgy, and animal-drawn plows. These developments allowed farmers to produce an excess of food beyond their immediate needs. The resulting surplus of food led some people to make their living in other ways: for instance, by making pottery, weaving, and engaging in other nonagricultural activities that they could sell or exchange with others for the surplus food. As a result, 211 SOCIOLOGY POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 211 people moved off the farms, commerce developed, and cities began to form. Preindustrial cities—which first arose on fertile lands along rivers in the Middle East, Egypt, and China—were quite small com- pared to today’s cities. Most preindustrial cities housed fewer than 10,000 inhabitants. Others, like Rome, may have contained as many as several hundred thousand people. Preindustrial cities differed significantly from today’s cities. The residential and commercial districts were not as sharply separated as they are today. Most traders and artisans worked at home, although people with the same trades tended to live in the same areas of town. People in cities also segregated themselves from one another accord- ing to class, ethnicity, and religion—with little or no chance for social mobility or interaction with other groups. Industrial cities Between 1700 and 1900, increasing numbers of people moved into cities, resulting in an urban revolution. For example, in 1700 less than 2 percent of British people lived in cities, but by 1900 the major- ity of them did so. The United States and other European countries soon attained similar levels of urbanization, driven by the Industrial Revolution. Industrialization produced the mechanization of agriculture, which, in turn, limited the amount of work available on farms. This lack of employment forced farm laborers to move to cities to find work. This migration of workers from rural to urban areas then gave rise to the industrial city. The industrial city was larger, more densely populated, and more diverse than its preindustrial counterpart. It contained many people of varying backgrounds, interests, and skills who lived and worked together in a defined amount of space. The industrial city also served as a commercial center, supporting many businesses and factories. 212 C LIFFS Q UICK R EVIEW POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 212 The latter attracted large numbers of immigrants from other countries hoping to better themselves by securing stable work and finding a “fresh start.” Metropolis and megalopolis cities As larger and larger industrial cities spread outward in the early 1900s, they formed metropolises (large cities that include surround- ing suburbs, which are lands outside the city limits, usually with sep- arate governance). While some suburbs become distinct cities in and of themselves, they retain strong geographic, economic, and cultural ties to their “parent” city. Many metropolitan areas house a million or more residents. The upper and middle classes ultimately brought about the so- called flight to the suburbs. As economic woes increasingly plagued cities in the latter half of the 1900s, many families decided to move out of their inner-city neighborhoods and into the suburbs. The abil- ity to afford an automobile also influenced this migration. Beginning in the 1970s, most suburbs were largely “bedroom communities,” which means that suburban residents commuted into the city to work and shop, and then returned to the suburb at night. Commuting pre- sented a downside, but most people felt that escaping “urban ghet- toization,” or the tendency for the quality of life in inner cities to decline, was well worth any hassles, given the fact that suburbs tended to offer nicer and larger homes, better schools, less crime, and less pollution than cities provided. Today, suburbs continue to grow and develop. Many have become economic centers in their own right. Offices, hospitals, and factories coexist with shopping malls, sports complexes, and housing subdivisions. In this way, many suburbs have essentially become small (and, in some cases, not so small) cities. Demographically, sub- urbs tend to attract “whiter” and more affluent residents than do cities. Yet not all suburbs and suburbanites are alike. Even within a suburb, families of varying ethnic and religious backgrounds exist. 213 SOCIOLOGY POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 213 Because of all this growth, many suburbs have developed “urban” problems, such as air and water pollution, traffic congestion, and gangs. To escape these problems, some people have chosen to move to rural areas. Others have chosen to return to and revive their cities by renovating and remodeling buildings and neighborhoods. Such an interest in urban renewal (also called gentrification) has turned some slums into decent areas in which to live, work, and raise a family. The vast urban complex known as a megalopolis was created as suburbs continued to grow and merge with other suburbs and metro- politan areas. That is, some suburbs and cities have grown so large that they end up merging with other suburbs and cities, forming a vir- tually continuous region. One example of a megalopolis is the hun- dreds of miles of almost uninterrupted urbanization from Boston to Washington, D.C. The typical megalopolis consists of literally mil- lions of people. 214 C LIFFS Q UICK R EVIEW POPULATION AND URBANIZATION 8615-7 Ch15.F 6/23/00 9:51 AM Page 214 CHAPTER 16 CONTEMPORARY MASS MEDIA Mass media is communication—whether written, broadcast, or spo- ken—that reaches a large audience. This includes television, radio, advertising, movies, the Internet, newspapers, magazines, and so forth. The Role and Influence of Mass Media Mass media is a significant force in modern culture, particularly in America. Sociologists refer to this as a mediated culture where media reflects and creates the culture. Communities and individuals are bombarded constantly with messages from a multitude of sources including TV, billboards, and magazines, to name a few. These mes- sages promote not only products, but moods, attitudes, and a sense of what is and is not important. Mass media makes possible the concept of celebrity: without the ability of movies, magazines, and news media to reach across thousands of miles, people could not become famous. In fact, only political and business leaders, as well as the few notorious outlaws, were famous in the past. Only in recent times have actors, singers, and other social elites become celebrities or “stars.” The current level of media saturation has not always existed. As recently as the 1960s and 1970s, television, for example, consisted of primarily three networks, public broadcasting, and a few local inde- pendent stations. These channels aimed their programming primarily at two-parent, middle-class families. Even so, some middle-class households did not even own a television. Today, one can find a tele- vision in the poorest of homes, and multiple TVs in most middle-class homes. Not only has availability increased, but programming is increasingly diverse with shows aimed to please all ages, incomes, backgrounds, and attitudes. This widespread availability and exposure 215 SOCIOLOGY 8615-7 Ch16.F 6/23/00 9:51 AM Page 215 makes television the primary focus of most mass-media discussions. More recently, the Internet has increased its role exponentially as more businesses and households “sign on.” Although TV and the Internet have dominated the mass media, movies and magazines— particularly those lining the aisles at grocery checkout stands—also play a powerful role in culture, as do other forms of media. What role does mass media play? Legislatures, media executives, local school officials, and sociologists have all debated this contro- versial question. While opinions vary as to the extent and type of influence the mass media wields, all sides agree that mass media is a permanent part of modern culture. Three main sociological perspec- tives on the role of media exist: the limited-effects theory, the class- dominant theory, and the culturalist theory. Limited-effects theory The limited-effects theory argues that because people generally choose what to watch or read based on what they already believe, media exerts a negligible influence. This theory originated and was tested in the 1940s and 1950s. Studies that examined the ability of media to influence voting found that well-informed people relied more on personal experience, prior knowledge, and their own reason- ing. However, media “experts” more likely swayed those who were less informed. Critics point to two problems with this perspective. First, they claim that limited-effects theory ignores the media’s role in framing and limiting the discussion and debate of issues. How media frames the debate and what questions members of the media ask change the outcome of the discussion and the possible conclu- sions people may draw. Second, this theory came into existence when the availability and dominance of media was far less widespread. 216 C LIFFS Q UICK R EVIEW CONTEMPORARY MASS MEDIA 8615-7 Ch16.F 6/23/00 9:51 AM Page 216 Class-dominant theory The class-dominant theory argues that the media reflects and pro- jects the view of a minority elite, which controls it. Those people who own and control the corporations that produce media comprise this elite. Advocates of this view concern themselves particularly with massive corporate mergers of media organizations, which limit com- petition and put big business at the reins of media—especially news media. Their concern is that when ownership is restricted, a few peo- ple then have the ability to manipulate what people can see or hear. For example, owners can easily avoid or silence stories that expose unethical corporate behavior or hold corporations responsible for their actions. The issue of sponsorship adds to this problem. Advertising dol- lars fund most media. Networks aim programming at the largest pos- sible audience because the broader the appeal, the greater the potential purchasing audience and the easier selling air time to adver- tisers becomes. Thus, news organizations may shy away from nega- tive stories about corporations (especially parent corporations) that finance large advertising campaigns in their newspaper or on their stations. Television networks receiving millions of dollars in adver- tising from companies like Nike and other textile manufacturers were slow to run stories on their news shows about possible human-rights violations by these companies in foreign countries. Media watchers identify the same problem at the local level where city newspapers will not give new cars poor reviews or run stories on selling a home without an agent because the majority of their funding comes from auto and real estate advertising. This influence also extends to pro- gramming. In the 1990s a network cancelled a short-run drama with clear religious sentiments, Christy, because, although highly popular and beloved in rural America, the program did not rate well among young city dwellers that advertisers were targeting in ads. Critics of this theory counter these arguments by saying that local control of news media largely lies beyond the reach of large corpo- rate offices elsewhere, and that the quality of news depends upon good journalists. They contend that those less powerful and not in 217 SOCIOLOGY CONTEMPORARY MASS MEDIA 8615-7 Ch16.F 6/23/00 9:51 AM Page 217 control of media have often received full media coverage and subse- quent support. As examples they name numerous environmental causes, the anti-nuclear movement, the anti-Vietnam movement, and the pro-Gulf War movement. While most people argue that a corporate elite controls media, a variation on this approach argues that a politically “liberal” elite con- trols media. They point to the fact that journalists, being more highly educated than the general population, hold more liberal political views, consider themselves “left of center,” and are more likely to register as Democrats. They further point to examples from the media itself and the statistical reality that the media more often labels conservative com- mentators or politicians as “conservative” than liberals as “liberal.” Media language can be revealing, too. Media uses the terms “arch” or “ultra” conservative, but rarely or never the terms “arch” or “ultra” liberal. Those who argue that a political elite controls media also point out that the movements that have gained media attention— the environment, anti-nuclear, and anti-Vietnam—generally support liberal political issues. Predominantly conservative political issues have yet to gain prominent media attention, or have been opposed by the media. Advocates of this view point to the Strategic Arms Initiative of the 1980s Reagan administration. Media quickly charac- terized the defense program as “Star Wars,” linking it to an expensive fantasy. The public failed to support it, and the program did not get funding or congressional support. Culturalist theory The cultur
