Academic journal article Journal of Sociology

Birth and the `Reflexive Consumer': Trust, Risk and Medical Dominance in Obstetric Encounters

Academic journal article Journal of Sociology

Birth and the `Reflexive Consumer': Trust, Risk and Medical Dominance in Obstetric Encounters

Article excerpt


For some decades now, the so-called `consumer' movement in health care has grown in Australia and overseas and become increasingly significant in a range of areas of health care provision including obstetrics (Bastian, 1991; Consumers' Health Forum, 1992, 1996; Grace, 1994). Not only has the development of this movement been seen to have an impact at the `macro' level of health policy, but also at the `micro' level of doctor-patient interactions which, some have argued, have the potential to disrupt the dominance of medicine (Gabe et al., 1994; Haug, 1979; Haug and Lavin, 1981; Little, 1995; Wiles and Higgins, 1996). At the `macro' level, there is little conceptual difficulty with the organization of actual or would-be `consumers' into pressure/lobby groups. However, the extent to which doctor-patient interactions themselves can be reconstructed and recast as simply the exchange of services between a provider and a `consumer' in a market for services is of course debatable, and despite some proponents of this view (e.g., Logan et al., 1989) it is a contentious one (Germov, 1995; Lloyd et al., 1991; Lupton, 1997a).

There are many reasons for this. Some of the most notable particularities of the doctor-patient relationship identified by Talcott Parsons nearly half a century ago still pertain today: the asymmetry in knowledge and hence power is of course still significant, though, some claim, the gulf between consumer and provider has been reduced in important ways. These include the rise in general educational level, in self-help groups which develop an extensive knowledge base about coping with particular conditions, and in the use of alternative medicines and information age technology that allow individuals to access alternative sources of information about, and approaches to, health conditions (Easthope, 1998; Haug, 1979; Haug and Lavin, 1981; Kelleher, 1994; Saks, 1994). Nor is the asymmetry simply between two parties; much has been made of the changing employment patterns of many medical practitioners rendering them employees of sometimes large organizations (Starr, 1982), and of the constraints that can be imposed on medical practice by not only employer organizations but also by insurance companies providing medical malpractice insurance (Cook and Easthope, 1996; Hay, 1992). Despite these developments, fundamentally the asymmetry in knowledge and power between doctors and their patients remains tilted in the favour of the doctors.

Many other characteristics of the doctor-patient relationship render it, at best, a rather particular case of a `consumer/provider' relationship. It is often anxiety and distress which bring people to medical encounters; Parsons referred to this as the patient's `vulnerable and emotional state', an important feature which differentiates this encounter from most others in the marketplace. Patients seek medical encounters on the basis of need more than on the basis of want, as in the case with simply market exchange, and this to Parsons was another feature of the doctor-patient relationship which differentiated it from business relationships (Bury, 1997; Parsons, 1951). In addition, many have noted the `confessional' characteristics of the therapeutic encounter which can involve laying bare the soul and often the body (Foucault, 1973; Gerhardt, 1987).

So, consumerism in health is clearly an important phenomenon of the contemporary era, but its impact, significance and meaning for the doctor-patient relationship is obviously quite complex. Indeed, in recent years a number of analysts have argued that constructing the patient qua consumer has gone too far (Germov, 1995; Lupton, 1997a), and that Parsons' insight from psychoanalytic theory, that the adoption of a dependent, passive patient stance has therapeutic value, is one that ought to be maintained in considerations regarding consumerism in health (Lupton, 1997a, 1997b).

The research reported in this article makes some contribution to the debate regarding the significance and meaning of the phenomenon of consumerism in health. …

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