Consuming Health

The Commodification of Health Care

Sara Henderson, Alan Petersen

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781134512089
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

In our post-welfare society, health is increasingly viewed as a commodity and individuals are defined as 'health care consumers'. At the same time, the notion that the state should care for the health of its citizens is being replaced by an expectation that citizens should play a more active role in caring for themselves. These developments are by no means uncontentious.
Consuming Health explores the diverse meanings and applications of the term 'consumer' in the field of health care and the implications for policy-making, health care delivery and experiences of health care. Contributors are well-known innovative researchers and lecturers from the Australia, the UK and Canada. Between them they cover a wide range of topics - from the medicalisation of the menopause to the participation of consumer groups in the national policy process - to create an original and thought-provoking text for students and practitioners in the field of health care.

Part I
Consumerism in context

Theoretical perspectives and policies

Chapter 1

What’s wrong with medical consumerism?

Arthur W. Frank

The juxtaposition of two images of medicine begins to suggest what has changed. The first is a late nineteenth-century painting (later an engraving) by Sir Luke Fildes, entitled ‘The Doctor’. Physician Alfred Tauber, who chose it as the cover for his recent meditation on medicine and its ethics, describes the painting and its significance as an icon of medicine:

This Victorian pastoral drama shows a country doctor sitting contemplatively [leaning forward at a 45 degree angle, one hand supporting his chin; the figure is utterly still yet poised to move forward] at the bedside of a sick child, whose parents look on in dismay and fear. Portraying the medical reality of that period just before the explosion of scientific medicine, Fildes’s evocation of the empathic doctor, helpless in the face of nature’s ravage and yet steadfastly committed to remaining with his young patient, both reflected the sentimentality of that era and also stated clearly the ethical relationship of the physician to his charge … Today, the painting still occupies a prominent place at the Tate Gallery in London, and I think it commands attention not so much for its large size and effective naturalism but more so because Fildes captured a human relation that is of time immemorial, and we respond instinctively to his depiction of this relation. The painting is a powerful image of my own philosophy of medicine – not the posture of a helpless physician watching the relentless scourge of nature, but the physician as empathic witness.

(Tauber 1999: 106–7)

I once saw Fildes’s painting presented as a slide at a medical meeting, and the audience response leads me to generalize Tauber’s interpretation. To physicians dealing with the restraints of managed care on the one hand, and the expanding frontiers of medical services on the other, the painting offers nostalgia for a medicine in which technical practices may have been primitive by contemporary standards but goals and ethics can seem uncomplicated in their idealism.

Disease in Tauber’s gloss of the painting is ‘nature’s ravage’ and ‘the relentless scourge of nature’. The patient is most emphatically not a ‘consumer’ in any sense of that world; her life is in danger. The physician opposes nature with few resources at his (the appropriate pronoun for the time) disposal, but what he lacks in interventive technology he makes up in ‘empathic witness’. Tauber realizes that many contemporary physicians would regard the painting as ‘the posture of a helpless physician’, and he deflects this interpretation. For him the primacy of the caring relationship occasioned by human vulnerability to nature is the enduring significance of the painting. Medicine is founded on the recognition of human suffering: when the physician can no longer cure, he continues to care.

The history of Tauber’s own relationship to the painting does not exactly undercut his interpretation but suggests the fragility of his version of the image. His father, also a physician, was given a reproduction of ‘The Doctor’ by ‘a pharmaceutical house’. ‘Knowing my attachment to this lithograph hanging in his waiting room,’ Tauber writes, ‘he gave me a small three-dimensional porcelain facsimile of the scene – also supplied by the drug company’ (1999: 106). The caring relationship of father to son mirrors that of physician to patient, yet a third party has intervened: the drug company that produced both reproductions and distributed them as gifts to physicians. New pharmaceuticals would render the fever watch of Fildes’s physician (happily) obsolete, but writing a prescription would increasingly (and perhaps less happily) replace the ‘empathic witness’ that Tauber idealizes. In distributing the image as a publicity give-away, the drug company commodified nostalgia for a kind of medical practice that it itself was instrumental in ending, for better and for worse.

I move forward more than a century to a very different image: an advertisement on the inside back cover of a new Australian-American magazine, The Art of Cosmetic Beauty, which had its inaugural issue in Summer 2000. The magazine is 8.5 inches by 11.5 inches, printed on high-quality paper providing excellent resolution to its graphics; its price and production values elevate it above supermarket check-out ‘beauty’ magazines.

The advertisement is for the services of Dr R, Plastic and Reconstructive Surgery.¹ The centre of the image, 7.5 inches, is a portrait of Dr R. He looks straight at the camera with a slight smile, hands on hips, wearing bright blue surgical scrubs (looking fresh from the laundry) with a surgical cap and mask (open, worn around his neck). On the upper border (just under 2 inches) is the copy: ‘When the eye of a gifted artist and the hand of a skilled surgeon come together, every part of you can be more beautiful.’ Down the side borders (with Dr R’s elbows blocking parts of some images) are six photographs of parts of women’s bodies: eye, hip, abdomen, shoulder and breast (discretely in shadow), full face, and nose and mouth. The bottom border specifies his name, Board Certification, services (‘Facial Rejuvenation, Breast Augmentation, Liposuction, Endermologie(TM)’), address, and – a ubiquitous feature of such advertising – his website. The bottom line of the image says, all in capitals: ‘Call to schedule your complimentary consultation.’

The last line is particularly interesting since, in another article, readers are warned by Dr Harlan Pollock, identified as ‘chair of the Public Education Committee of the American Society of Plastic Surgeons’, that ‘Free consultations are a gimmick that are used in obtaining patients and they’re worth about what they cost … . They are an opportunity to sell an operation and serve very little purpose’ (Bishop 2000a: 87). The apparent contradiction between this caveat in the text of an article and the advertising image is typical of magazines generally and of The Art of Cosmetic Beauty particularly. The editorial introduction to the first issue specifies, ‘Never far from our articles will be the message that surgery is surgery and any reputable surgeon will tell you that procedures can enhance the way one looks but it [sic] doesn’t alter the person’ (Grujovic 2000: 6). That message is repeated throughout even as it is undercut by advertising copy such as that on the back cover: ‘Celebrate a reflection of the true you by scheduling a consultation with Dr W … medical professionals dedicated to helping you discover your beautiful side.’

In the transition from Fildes’s doctor to the cosmetic surgeon, the image of medicine shifts from Tauber’s empathic witness to the ‘gifted artist’ with the surgical skills to shape the human body to his aesthetic vision. ‘Nature’, as the object of the physician’s work, ceases to be what Tauber calls ‘ravage and scourge’ and becomes instead the raw material awaiting the human intervention that will perfect it.

Fildes’s physician gazes at his sleeping patient, alert to whatever he can do – probably nothing – that might affect the outcome. Dr R, the cosmetic surgeon, is surrounded by fragments of beautiful women. In the synecdoche of these images, the perfection of each fragment creates the imagination of a plenitude that includes not only perfect bodies but perfect ‘lifestyles’. There need be no direct statement specifying that the photos of women surrounding Dr R are the outcome of his work; this association is less than crucial. The message is that the body’s wholeness and happiness lies in the perfection of each of its parts. In beauty the ‘true you’ is simultaneously released and invented. Thus the surgeon no longer contemplates human suffering; rather he perfects contingent imperfection. Fildes’s physician seems to wonder what he can possibly do; Dr R stands ready to show his next patient how much he can do.

What is to be made of this juxtaposition of images? Critique risks lapsing into a moralism (whether neo-Marxist or neo-Calvinist) that can become what psychiatrist Peter Kramer (2000) calls ‘the valorization of sadness’. Kramer, it should be noted, is author of the best-selling Listening to Prozac in which he coined the term ‘cosmetic psychopharmacology’. He builds a compelling case that there is a long-standing critical bias that identifies the serious (in whatever cultural field) with the sad. Happiness, in itself, is often regarded as trivial.

The critique of medical consumerism is not about the triviality or authenticity of the individual lives of people who seek and purchase these services. The object of critique is the society in which these services are offered as they are. Sociological interpretation begins from the counterintuitive presupposition that the effects of medical consumerism may ultimately be as great, and possibly greater, on those who do not themselves receive these services but who live in a society of which these services are a part. What counts is how common-sense perception of bodies and lives are affected by the publicizing of available services.

Most discussions of medical consumerism take a should-they-or-shouldn’t-they perspective. Individual decisions to seek or not to seek commodities were understood by Georg Simmel (in his 1903 essay, ‘The Metropolis and Mental Life’) as part of a historical tendency by which ‘individuals who had been liberated from their historical bonds sought now to distinguish themselves from one another’ (1971: 339). ‘Regardless of whether we are sympathetic or antipathetic with their individual expressions,’ Simmel concluded, ‘they transcend the sphere in which a judge-like attitude on our part is appropriate.’ What counted for Simmel was to study ‘the totality of historical life to which we belong’. The point is neither ‘to complain or to condone’ individual acts but ‘to understand’ their place in that totality (1971: 339). Thus my concern is not with the true motives of individual consumers, but rather with consumption as an increasingly prevalent social discourse that legitimates a variety of attitudes and practices (Wernick 1991).

Simmel’s rejection of complaining or condoning does not, as I read him, imply abandoning critique. How society complains about and condones medical consumerism seems crucial in the future of the historical totality that I will follow others in calling neo-liberalism. If the most salient characteristic of neo-liberal society is its capacity to assert itself as not having any viable alternative (Bourdieu 1998), then developing a critique of medical consumerism is a crucial demonstration of the continuing possibility of critique itself.

In asking what’s wrong with medical consumerism I present attempts to purchase cosmetic beauty as my primary examples with the recognition that these practices may become an increasingly minor part of the medical consumerist future. Genetic interventions seem poised to be the dominant form of consumerism and are the issue of concern among leading bioethicists (Buchanan et al. 2000) as well as disability activists (reviewed by Parens and Asch 1999). If the promissory notes of the new genetics have any validity, we can imagine a clinic advertisement in the next decade or two that might read: ‘When the dreams of parents and the right genetic technology come together, your child can enjoy every opportunity life offers.’ The question of this future has high stakes for medicine and for society. Economic interests and technical possibility will create this future, but perhaps critiques can act – in Weber’s famous metaphor of 1913 – as switchmen, deflecting the course of this future slightly but consequentially (Weber 1958: 280).

Beauty as medical commodity

We would hardly expect to find the word ‘consumerism’ in The Art of Cosmetic Beauty, but what is surprising is how completely the whole aspect of payment for products and services is rendered invisible. Even articles specifically devoted to the promotion of ‘products’ (‘face, body, hair, makeup’ and later, dental) do not mention prices. One of the few places where dollar signs can be found is in a fascinating set of ‘recommendations’ for the age (by decade) when different ‘skin changes’ occur and what interventions are recommended; thus: ‘30s Blotchiness, frown lines, crow’s feet, forehead wrinkles. Treatment: Use Botox, approx. $500’ (Muzik 2000: 66; prices presumably in US dollars). An article comparing the benefits of ‘Blue Peel treatment’ to laser resurfacing ($200–$800 versus $2,500–$5,000; Bishop 2000b: 70) and a couple of mentions of spa treatments are, on my perusal, the only other places where it is suggested that payments are made. Thus, at the high end of consumerism, what for Simmel was the underlying form of the activity – the money economy – is set discretely out of view.²

In medicine as elsewhere, first-world consumerism is often most explicit when viewed in the mirror of third-world adaptations; thus to locate the act of consuming I turn to a recent report of cosmetic surgery in Iran. ‘So a cool thing to do in Tehran these days is to get a nose job,’ reports The New York Times.

So cool that unlike women in many places, who hide the chiseling and sawing and stretching done to their faces, Iranian women wear their post-surgical bandages like badges of honor, or at least indicators of a certain wealth.

(Sciolino 2000)

The description points towards an operational definition of the dense keyword, consumerism. As the post-surgical bandages themselves become worth wearing, the surgical enterprise takes a reflexive twist. The surgery is not only the instrumental means to achieve a desired end; surgery itself is also a desired end, as a display of wealth.

The Iranian report also offers some remarkably candid statements of what is desired from surgery. In these we hear the voices of consumers, however ungeneralizable. I quote these women not to suggest that what they say reveals the truth of their motivations, but rather for these quotations’ expression of the discourse of consumerism. The quotation of these voices in The New York Times will doubtless be read differently by different readers: some will regard the Times engaged in a neo-colonialist deprecation of the Third World, other readers will find legitimation of their own attitude towards medical consumerism, and still others will read the quotations as I do, actually saying what Westerns act upon but are reticent to express.

The mother of a 17-year-old whose nose had been changed surgically said: ‘We did her nose so she could become more beautiful and enjoy her face for the rest of her life. I could see that she had a flaw in her face, and I was very glad we could get rid of it.’

‘Unfortunately, in my family everyone has bad noses’, said a 20-year-old called Haleh after she had had her nose shrunk. ‘This is a very, very serious flaw. Their faces change after the operation. They suddenly look beautiful. So all our family members are very sensitive about the shape of our noses, and everywhere we go we make comments about people’s noses.’

‘I want a smaller nose, like a doll’s nose’, [Ms Moghimi] said. ‘I’m willing to pay lots of money to a plastic surgeon to give me a new look. I don’t want to have any faults in my face. I’d like to look beautiful, like Marilyn Monroe.’

(Sciolino 2000)

These statements provide at least three parameters to consumerism in general. First is the pleasure of spending money. As these women are quoted, they seem somewhere between the ideal type that Simmer called the spendthrift, for whom ‘the pleasure of waste depends simply on the expenditure of money for no-matter-what objects’ (1971: 182) and Veblen’s ([1899] 1953) understanding of conspicuous consumption as acts of displaying wealth. There is pleasure in wearing the bandages as well as pleasure in the reconstructed face.

Second we can hear intimations of what Simmel called ‘the curse of restlessness and transience … every pleasure attained arouses the desire for further pleasure, which can never be satisfied’ (1971: 185). Reading what the Iranian women say, I am not alone in wondering how long it will be before other ‘flaws’ have to be got ‘rid of’. That the whole body awaits improvement – and, with age, constant improvement – is evident on one surgeon’s website (described by The Art of Cosmetic Beauty as ‘very reader friendly – fun and informative’ (McCloskey 2000: 34)) where the homepage features an idealized nude woman (simulated or real? a cartoon or the result of surgery? who can tell, and who bothers to ask?) with the invitation to click on part of her body to learn about surgery to that area. The Times quotes an Iranian cosmetic surgeon (American trained) saying: ‘What’s in fashion right now is getting the nose done. After that come face-lifts’ (Sciolino 2000).

The third parameter I want to single out – among others that could be observed – is that consumerism individualizes the bases and morality of action. The self is the sole referent. In particular the consumer defines money as his or her exclusive resource to expend as she or he chooses. In the following quotation, also from Ms Moghimi, quoted above, a narrative account that initially points in the direction of culture turns to focus on the isolated self:

‘Part of the reason for spending so much attention on the way I look is that it’s in our culture. … It’s in the nature of Iranian women to want to look beautiful. Part of the reason is that I don’t have anything else to do. My only job is to cook and take care of my home. So I spend time [and money, as stated in the earlier quotation of Ms Moghimi] on myself’.

(Sciolino 2000)

Neo-liberalism elevates consumer choice to the level of a right that society is organized to defend; the right of each to spend his or her own resources as he or she chooses is the organizing principle behind the privatization of government services. ‘Giving money back’ to taxpayer/consumers and allowing them to spend it as they choose is the recurring slogan of neoliberal political parties. Advertisements by cosmetic surgeons join this presumption of consumer right with psychotherapeutic imperatives to discover or liberate an inner self...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Acknowledgements
• Introduction
• Part I Consumerism in Context
• Part II Consumerism in Practice