Normal rubbish: deviant patients in casualty departments


  • 1

    . T. Parsons, The Social System, New York, The Free Press, 1951, pp. 435–9.

  • 2

    . See for example, the British Orthopedic Association, ‘Memorandum on Accident Services’, Journal of Bone and Joint Surgery, Vol. 41B, No. 3, 1959, pp. 457–63; Nuffield Provincial Hospitals Trust, Casualty Services and their Setting, London, O.U.P., 1960; and House of Commons Fxpenditurc Committee, 4th Report, Accident and Emergency Services, London H.M.S.O. 1 974. A fuller survey of this literature can be found in 11. Gibson Rules, Routines and Records, Ph.D. thesis, Aberdeen University, 1977.

  • 3

    . See e.g. the summary in World Medicine, February 1 972, p.11.

  • 4

    . Reported in the Fxpenditure Committee Report, op. cit. pp.xii-xiii.

  • 5

    . This is similar to Freidson's distinction between client control and colleague control: see E. Freidson, Patients Views of Medical Practice, New York, Russell Sage Foundation, 1961.

  • 6

    . J. Roth, ‘Some Contingencies of the Moral Evaluation and Control of Clientele: The case of the Hospital Fmergency Service’, A.J.S. Vol. 77, No. 5, March 1972. The studies of medical students which are relevant are: H. Becker et al., Hoys in White, Chicago, University of Chicago Press, 1961; and R. K. Merton et al. (eds), The Student Physician, Cambridge, Harvard University Press, 1957.

  • 7

    . P. Strong and A. Davis, ‘Who's who in paediatric encounters: morality, expertise and the generation of identity and action in medical settings’, in A. Davis (ed), Relationships between doctors and patients, Westmead, Teakfield, 1 978, pp. 51–2.

  • 8

    . H. Gibson, op. cit., chapter 9.

  • 9

    . A. H. Godse, ‘The attitudes of Casualty staff and ambulancemen towards patients who take drug overdoses’, Social Science and Medicine, Vol. 1 2, 5A, September 1978, pp. 341–6.

  • 10

    . This case, while not as spectacular as one reported by Sudnow, does suggest a general level of depersonalisation in British teaching hospitals rather higher than in American hospitals. Sec D. Sudnow, Passing On, New York, Prentice-Hall 1968.

  • 11

    . I am using normal in the sense that Sudnow uses, in 1). Sudnow, ‘Normal Crimes’, Social Problems, Vol. 1 2, Winter 1 965.

  • 12

    . This topic recurs in the reports referenced in note 2 above, and in most of the research reports on casualty case-loads in the medical press. In an attempt to discourage casual altenders the Ministry of Health changed the title of the departments from ‘Casualty’ to ‘Accident and Emergency’ during the 1960s. However, most of the staff continued to call it Casualty (and I have followed their usage) and there is no evidence that the change of name has altered the nature of the case-load.

  • 13

    . See E. Goffman, Asylums, Harmondsworth, Penguin, 1968, especially the section ‘Notes on the Vicissitudes of the Tinkering Trades’.

  • 14

    . Gibson (op. cit. pp. 164–86) discusses the ways in which ‘drunk’ fails as a medical category since a wide variety of careers and treatments are associated with drunk patients, which tends to support the argument that this is essentially a moral category.

  • 15

    . Godse (op. cit.) suggests that there is generalised hostility towards all drug overdoses, but he elaborates his discussion with respect to three types. One of these - deliberate suicide attempts or gestures - fails to distinguish between what I call ‘normal’ overdoses and those believed by the staff to be serious suicide attempts. Gibson (op. cit. pp. 186–94) also reports that staff presumed that most, if not all, cases of self-poisoning were seen as acts of self-injury, wilfully and directly caused, rather than as attempts to commit suicide.

  • 16

    . Sudnow, ‘Normal Crimes’, op. cit.

  • 17

    . P. Strong and A. Davis, op. cit., p.52.

  • 18

    . The research of a similar kind carried out by the author in Pakistan, doctors were both less interested in good patients and less bothered by rubbish: similarly, they had less autonomy over their working conditions.

  • 19

    . T. Parsons, op. cit. Although Parsons never says where he developed the sick role model from, it is plausible that it comes from his discussions with doctors in his Boston study, and from his course in psychotherapy (see his footnote 2, pp. 428–9). If so, and if we reformulate the sick role in the way that I have, this may overcome some of the problems which have been pointed out by other writers: for example, the inapplicability of the sick role to chronic illness. That is, there is indeed a preference by doctors for an illness which is temporary, transitory and curable, and part of the reason for the low prestige of work with geriatric or chronic patients is that doctors are uneasy dealing with patients who do not conform to this pattern.

  • 20

    . P. McHugh, ‘A commonsense conception of deviance’, in H. P. Dreitzel (ed.), Recent Sociology No. 2, New York, Crowell Collier Macmillan. 1968.

  • 21

    . Similar uncertainty has been reported from America amongst a general population and amongst social workers. See H. A. Mulford and D. F. Miller, ‘Measuring Community Acceptance of the Alcoholic as a Sick Person,’ Quarterly Journal of Studies in Alcoholism, Vol. 25, June 1964; and H. P. Chalfont and R. A. Kurtz, ‘Alcoholics and the Sick Role: Assessments by Social Workers’, Journal of Health and Social Behaviour, Vol. 12, March 1971.

  • 22

    . C. Bagley, The Sick Role, Deviance and Medical Care,’ Social and Economic Administration, Vol. 4, 1971.

  • 23

    . This is the sort of argument made by Becker et al., op. cit., in discussing the sources of negative evaluations by medical students.

  • 24

    . E. Freidson, Profession of Medicine, New York, Dodd Mead, 1970. He advances similar arguments in ‘Disability and Deviance’, in M. B. Sussman. (ed), Sociology and Rehabilitation. Washington DC, ASA 1966.

  • 25

    . R. Dingwall, Aspects of Illness, London, Martin Robertson. 1976.


Summary This paper describes typifications of good and bad patients made by staff working in three English hospital Accident and Emergency departments, commonly known as Casualty departments. The staff explain or defend their behaviour and their hostile evaluations by accounts which in many respects parallel the classic description by Parsons of the sick role.1 The data presented are most easily interpreted as cases where certain sorts of patients are unable to achieve entry into what is essentially the legitimate career of sickness, and this will lead into a disussion of the relationship between sicknesses and deviance.