Abstract
How do contemporary American hospitals reconcile what seem to be contradictory values and goals, such as medical professionalism, patient care, and the efficient use of scarce resources (not to mention medical education and community involvement)? To explore this question, Adam Reich logged two hundred hours of participant observation and conducted over one hundred interviews with administrators and health workers of three California hospitals, which he calls PubliCare, HolyCare, and GroupCare. The three hospitals were founded in different historical periods; and despite more recent changes in ownership, their original missions shape their responses to the moral contradictions they are facing. In addition to an introduction, which situates the work theoretically, Selling Our Souls: The Commodification of Hospital Care in the United States consists of three empirical parts, each focusing on one of the hospitals, while making frequent references to and comparisons with the other two.
PubliCare was originally an almshouse-type institution. It continues to define its mission for health provision in terms of a social right and is largely at odds with the marketization of care. As a result, PubliCare tends to attract a disproportional share of patients who are poor, uninsured, or underinsured and who, in turn, also prefer PubliCare to other hospitals because they are treated much better by the staff. Doctors and nurses at PubliCare are in a more egalitarian relationship with each other, but they treat patients in a paternalistic manner (the poor are less likely to challenge their authority) and the hospital environment is rather disorganized, with many resources not used efficiently.
HolyCare was a voluntary private hospital established and managed by the Sisters of St. Francis. The mission of hospitals like HolyCare was defined initially in opposition to the dehumanizing realities of almshouses, to which early voluntary hospitals could juxtapose meaningful and dignified care (open, however, only to the “deserving” poor and, later, to privately paying patients). The sisters’ unique position in society allowed them to combine “vocational devotion with shrewd political and economic calculations” (p.72). But the recent departure of the last remaining sisters has brought the contradictions between care as a “sacred encounter” and care as a luxury product to the forefront. HolyCare amenities do look more luxurious than in the other two hospitals, and it attracts a higher percentage of insured and well-to-do patients. It also offers more opportunities to doctors to act in more entrepreneurial and individualistic terms, which results in a lack of coordination in patient care and in profit-driven overtreatment.
The hospital views its mission as stewardship of valuable resources aimed at providing care imbued with meaning. In light of the hospital’s spiritual roots, finances and the market are viewed as the means to promote the ministry. But Reich argues that “the relationship between means and ends was [at best] ambiguous” (p.93) and that itwas frequently the mission that was used to promote HolyCare’s success in the market.
GroupCare is the newest hospital of the three and was established by a managed care organization. Its mission is overcoming uncertainties and inefficiencies inherent in healthcare provision with modern tools of organizational management—bureaucracy, standardization, and technical infrastructure. In terms of a workplace, GroupCare is the most hierarchical and bureaucratized institution, requiring doctors to sacrifice professional identity and entrepreneurship but in return offering salaried arrangements and limited workweeks. And while GroupCare is, perhaps, the most successful in “taming” the market, it, too, faces a deep moral contradiction: scientifically based rationalizing of care delivery across a population of patients inevitably rations care in the cases of individual patients. GroupCare leadership does not see this as a moral dilemma, however, and instead considers it a purely technical problem that evidence-based medicine coupled with cost-benefit analysis can help solve.
These brief summaries do not do justice to the richness of ethnographic and historical data and analytical rigor that puts this book in line with other medical ethnography classics like Forgive and Remember and Deciding Who Lives. But what makes this book particularly appealing is that the author is equally comfortable with medical sociology (professions, medical settings, healthcare) and economic sociology (markets and morality, commodification) literatures. These two subfields of sociology are rarely placed in dialogue; the notable exception is the work of Donald Light and, more recently, Roi Livne. Those coming from the medical sociology field will find a very useful literature review problematizing morals and markets in medical care in ways that extend beyond the usual focus on the loss of professional autonomy in the face of corporate and bureaucratic pressures. Economic sociologists will find an already familiar set of theories, but it is the application of these arguments to health care, and particularly a comparison of three different organizational settings each with its own deeply rooted organizational culture, that they will find of high interest.
While I do not have any major criticisms, I have to point out that the book does not give any voice to patients and does not address their role in the processes it describes. Where are the proverbial empowered patient-consumers? They may not be the typical users of PubliCare, but I imagine that HolyCare and GroupCare patients may try to shape medical decisions concerning their health. But, in defense of the book, its focus is on contradictions experienced by health care organizations and their employees. I do, however, have an issue, perhaps a bit frivolous, with the title. While Reich frames the book as a study of moral contradictions and refrains from favoring one hospital’s practices over the others or laying blame, the title, Selling Our Souls, is unexpectedly damning, suggesting that what follows will be a strong critique of commodification. I found the argument much more nuanced and multilayered than the title may suggest. In fact, Reich managed to humanize most if not all of his respondents, so that while the dilemmas are clearly apparent, none of them has any clear solutions in sight and the reader most of the time can be swayed by good arguments on both sides. For instance, while rationing surely sounds unappealing, rationalizing care across the population may be the only (and only fair) solution given the realities of resource scarcity. The alternative—making decisions about the use of scarce resources on a case-by-case basis—directly frames patients’ lives in economic terms and makes some patients’ lives worth more. The title also leaves open a question of who “we” are in this case and whose souls are in danger of being sold: patients’ or medical professionals’. Perhaps this was intended as double entendre; in any case, titles are often insisted upon by publishers, who are driven by market consideration much more than authors. So perhaps this is an appeal for not judging the book by its cover.
These minor musings aside, this excellent book is a must-read for anyone interested in contemporary healthcare debates, particularly the impact of market-based healthcare on doctors, patients, and communities. It is empirically rich and analytically rigorous and is written in engaging, accessible language. It is a true achievement of an astute observer of the ongoing transformation of the U.S. healthcare system.
The book would be a great addition to advanced undergraduate or graduate seminars in medical sociology, health and healthcare, qualitative sociology, or ethnography, as well as the more specialized courses on professions, medical settings, work, and organizations.