The second dimension is the extent to which patients are conceptualised as either consumers or citizens. Citizenship may be defined as a ‘collection of social rights and obligations that determine legal identity and membership of a nation-state, and function to control access to scarce resources’ (Turner 1999: 339), with health care comprising one of those scarce resources. As Turner (1999: 312) points out, the historical relationship between health services and citizenship has been challenged since the early 1980s by economic rationalism, privatisation and commodification. Accordingly, the overall trend both globally and
99 nationally is towards patients being conceptualised as consumers (that is,
customers) of health care services (see for example Mechanic 1996: 177-178). The notion of ‘patient as consumer’ is based on the assumption that patients are both willing and able to exercise choices about doctors in the same way that they exercise choice about restaurants, hairdressers or supermarkets. (Leavey et al.
1989: 737). This view, despite its growing prominence in many social and political arenas, is a problematic one as will be explained.
These changes are taking place within the wider context of the rapid and widespread growth of ‘consumer cultures’ (see for example Featherstone 1991; Miles 1998; Campbell (1987). At the personal level, consumption is established as ‘the main form of self-expression and the chief source of identity; as a reflexive practice and the standard by which individuals judge others and themselves’ (Waters 1996: 18 ; Waters 1995: 423). The commodification/marketization of health care involves the increasing need to buy medical services to achieve a better health status (White, 2000: 297): individuals ‘construct themselves’ through their consumption of health products and services (cosmetic surgery, personal training and the like) and their adherence to health regimens.
At the macrosocial level, health consumers may be organised into such pressure/lobby groups as the Consumers Health Forum (see for example Consumers Health Forum 1991) that emphasise patient rights and seek to improve the health care system. Such groups should themselves be seen in the context of a broader ‘consumer movement’ (see for example Irvine 1996; Coburn and Willis 2000: 378) which aims to raise awareness of power differentials between professionals and the lay public, grant patients greater autonomy in medical decision-making, and charge them with greater responsibility in the pursuit and
100 maintenance of health (Root Wolpe 1990: 918). Consumerism is fundamentally concerned with ‘rights’ (see for example Cook 2000: 13), and is based on the assumption of the health care consumer who is actively assertive, knowledgeable, critical and prepared to shop around for the best deal (see also Hindess 1987). As highlighted by the following extract, some doctors are unsettled by both the semantic changes and by the shift associated with the move from ‘patient’ to ‘consumer’:
Dr Allen: …well it’s a sort of pejorative word, ‘consumer’, isn’t it? It conjures up the picture of somebody carrying a placard or a subpoena or a writ or something…
Interviewer: Ok. So you don’t think of your patients as consumers, you think of them as…?
Dr Allen: I think of them as patients and I REFUSE to have my patients called ‘clients’.
Interviewer: Right. Ok, so what would that mean?
Dr Allen: Oh, I think lawyers and whores have clients, doctors have patients… (smiles)
The growth of consumerism in health that commenced in the 1960s (Coulter and Fitzpatrick 2000: 454) is associated with a new interest by the medical profession in the views and ‘satisfaction’ of patients. There is evidence of mounting interest in ‘patient satisfaction’ (in the form of surveys, in particular) both within the editorials studied and within the wider medical literature. Abercrombie (1994: 56) proposes that the process of commodification might be one way of explaining a shift of authority from producer to consumer, since producers will become more orientated to the needs and wishes of consumers ‘in
101 order to maximise sales’. The research suggests there is a perception among doctors that patient/public expectations are getting higher and ‘less realistic’, which is regarded as a problem because patients with unrealistic expectations are perceived as more likely to be dissatisfied and complain (or even sue) (Sitzia and Wood 1997: 1834; see also Abramowitz et al. 1987). This link between expectations, satisfaction and legal action is further explored in Chapter 7.
The notion of ‘patient as citizen’ is to some extent congruent with what many doctors regard as ‘the old style’ of doctor-patient relationship. This ‘paternalistic’ (as opposed to ‘consumeristic’) relationship is as exemplified by Parsons’ (1951) theory of the sick role, which is useful for our purposes in that it sets the parameters for what many doctors regard as the ‘old style’ of doctor- patient relationship. In particular, Parsons’ theory emphasises a set of shared understandings concerning the role of ‘patient’ as well as that of ‘doctor’. With respect to the latter, the doctor is expected to act selflessly for the welfare of the patient, act in accordance with roles for professional conduct, apply a high degree of skill and knowledge to curing the illness, and be objective and emotionally detached. With respect to the former, patients are expected to be motivated to get well, to seek out competent help, trust the doctor, accept the doctor’s superior knowledge and technical expertise, and obey the doctor’s instructions (See also Parsons 1951 and 1964; Nettleton 1995: 133). This language of ‘obligations’ has to some extent been displaced by a language of rights: patients’ rights have recently ‘taken on a new legitimacy and currency’ (Germov 1995: 55; see also Porter 1997: 690). Specifically, the rights of patients now include:
• the right to ‘shop around’ among possible providers – to be discussed under the heading ‘Choice of provider’ later in this chapter;
102
• the right to be informed and be involved in decision-making – to be discussed in Chapter 6; and
• the right to give or withhold consent to treatments, procedures or other aspects of care - to be discussed in Chapter 7.
At the level of rhetoric, at least, this takeover is all but complete. However, the extent to which consumerism has actually entered the doctor-patient relationship at the microsocial level (Lupton 1997b: 480); that is, the extent to which individual patients actually conform to the ideal type of sovereign consumer outlined above, continues to be the focus of debate within sociological circles. A separate, though related debate concerns the extent to which doctor- patient interactions themselves can be reconstructed as simply the exchange of services between a ‘consumer’ and a ‘provider’ in a market for services. This idea of consumerism in medicine has both strong supporters and strong critics (see for example Logan et al. 1989). The interviews also demonstrate the complex and sometimes contradictory ways that doctors understand ‘consumerism’ generally and “patients’ rights” more specifically. Note the stark contrast between the following comments on the topic of ‘consumerism’:
Dr Stephens: I’m actually believe in consumerism, because I’m a big believer in patients taking as much responsibility for their health as they can… and taking pride in their future, knowing their drugs, knowing their medical conditions, and them being in charge.
Dr Connors: And this is where consumerism is really bad, because the idea that people who know nothing about medicine can judge it is crazy. It would be like if I went to the Ford factory and said to old Mr Ford that the motor he put in his cars was wrong, because I didn’t like the colour or the shape or the way the bonnet sat. And this is where you have people who have no knowledge of biological sciences, no knowledge of
103 psychology or anything, making judgments about medicine.
Some doctors are joined by economists and others in arguing that the view of the patient as consumer and health care as a commodity is ‘fundamentally flawed’ (see for example Sitzia and Wood 1997: 1830). Objections include that ‘health care is different from other commodities ‘in that a patient is rarely free to make an informed choice over what operation, which set of pills, or what laboratory tests she or he should purchase. Furthermore, patients participate in the medical market ‘out of necessity and ignorance’ (Kaufmann 1994: 388).
Visiting a doctor is not like taking a broken clock to be fixed. In the case of the broken clock, the owner can obtain quotes from various repair shops outlining what they will charge to fix the broken clock. On the basis of those quotes and other criteria, the repair shop offering the best ‘value for money’ (which may or may not be the one offering the lowest price) may be selected to undertake the repair work. The owner can be certain that the clock will not be fixed if they do nothing (that is, it will not ‘heal itself’). It is possible for the owner to judge whether or not the repair man/woman has ‘done a good job’ by whether or not the clock works again when it is collected. If the clock does not work, it is appropriate to refuse to pay the bill since the owner ‘did not get what they paid for’.
Although the above illustration is oversimplified and somewhat frivolous, it does serve to convey some of the problems associated with the view of ‘patient as consumer’ and ‘medicine as a market’. Of fundamental importance is the issue of consumers ‘judging’ the care they receive. There is widespread agreement among doctors that consumers are in a position to judge such ‘superficial’ aspects of care (the equivalent of the 'colour of the car' example cited above)
104 as the interpersonal skills of the doctor, the availability of convenient appointments, and time spent in the waiting room. However, opinion is divided as to whether consumers’ judgment can realistically extend to other aspects of care. As argued by Leavey et al. (1989: 738) a fundamental problem with the view of ‘patient as consumer’ is that medical care ‘is only an imperfect means to the desired end’ since the ‘commodity’ sought by patients is health, not medical care
per se. While patients may be the best judges of the commodity of health, they may not possess the necessary competence to judge the quality of care provided. This situation is exacerbated by the very nature of illness itself:
A bad outcome for a patient does not necessarily mean that the doctor treating them is incompetent. Treatments have side- effects and risks, particularly surgical procedures. Many patients suffer adverse side-effects, even when they are given the best treatment (Walton 1998: 142; see also Fox 2000: 415).
What is at issue here is the ability of the patient to judge whether or not the doctor ‘has done a good job’ (Mooney 1986: 29). As Walton suggests above, an ‘adverse outcome’ (such as failing to improve, a worsening of the condition, experiencing anticipated or unanticipated side-effects of treatment, or even the death of the patient) may or may not be related to, or caused by, ‘poor quality care’. For this reason, the ability of the consumer to assess ‘value for money’ in the market for medical care is highly problematic.