Current Sociology

Policy discourse shaped by neoliberal ideology, with its emphasis on marketisation and competition, has highlighted the importance of choice in the context of healthcare and health systems globally. Yet, evidence about how so-called consumers perceive and experience healthcare choice is in short supply and limited to specific healthcare systems, primarily in the Global North. This special issue aims to explore how choice is perceived and utilised in the context of different systems of healthcare throughout the world, where choice, at least in policy and organisational terms, has been embedded for some time. The articles are divided into those emphasising: embodiment and the meaning of choice; social processes associated with choice; the uncertainties, risks and trust involved in making choices; and issues of access and inequality associated with enacting choice. These sociological studies reveal complexities not always captured in policy discourse and suggest that the commodification of healthcare is particularly problematic.

Women’s childbirth choices occur within contested discourses about medical, natural, and woman-centered births. All three perspectives, to slightly differing degrees, presume an autonomous female subject who makes childbirth choices. Thus informed choice is posed as a crucial corrective to the increasing medicalization of childbirth. This article employs a critical feminist analysis to examine how women learn about childbirth and make choices long before the moment of informed choice. Interviews with 40 pregnant and recently birthing women in two cities in Alberta, Canada illustrate how media, family and friends, and prenatal courses comprised core pre-birth knowledge systems informing women’s decision-making. The interviews exposed how medicalization is naturalized in these knowledge systems, so that women approached their actual births with an already-medicalized set of perceptions. This already-medicalized knowledge foreclosed women’s choices, a finding that complicates arguments over improving informed choice during childbirth as a means of reducing childbirth medicalization.

Chronic back pain is a major health and social problem in Australia, often concealed and given limited credibility vis-a-vis other health conditions. Care practices are diversified with allied health, biomedical and complementary and alternative medicine (CAM) practitioners regularly being consulted for help and care, often concurrently. While this differentiated ‘healthcare market’ may on one level be viewed as positive in terms of diverse therapeutic choices, there is also potential for difficulties with regard to care practices and negotiating competing therapeutic modalities. Drawing on qualitative interviews with 50 women aged 60–65 from the Australian Longitudinal Study on Women’s Health living with chronic back pain, this article explores their accounts of suffering and the experiences of engaging in pluralistic healthcare choices, with a particular focus on CAM. The findings reveal the ways by which healthcare pluralism is connected to the dynamics of suffering and relations of recognition.

This article analyzes the process of adoption of Ayurveda as a healthcare practice in Buenos Aires, focusing on sociocultural dimensions and material aspects which either facilitate or discourage the following of this foreign medical tradition. Ayurveda is an ancient Indian medicine whose popularity has been on the rise among the Argentinean middle and upper classes. Introduced as a ‘lifestyle’ medicine, it resonates with the new health consciousness of individual responsibility in health maintenance and improvement. Based on in-depth interviews conducted with 20 followers of Ayurveda in Buenos Aires, the article shows that it attracts New Agers, adherents to food-driven subcultures, and patients dissatisfied with the limitations of biomedicine. Followers develop new skills for self-understanding, self-healing, and wellbeing. As adherents to a foreign medical approach, however, they adopt Ayurvedic practices in flexible ways, and some even hold critical views on the elitist market niches of Ayurvedic specialists and products.

The promotion of choice is a common theme in both policy discourses and commercial marketing claims about healthcare. However, within the multiple potential pathways of the healthcare ‘maze’, how do healthcare ‘consumers’ or patients understand and experience choice? What is meant by ‘choice’ in the policy context, and, importantly from a sociological perspective, how are such choices socially produced and structured? In this theoretical article, the authors consider the interplay of Bourdieu’s three key, interlinked concepts – capital, habitus and field – in the structuring of healthcare choice. These are offered as an alternative to rational choice theory, where ‘choice’ is regarded uncritically as a fundamental ‘good’ and able to provide a solution to the problems of the healthcare system. The authors argue that sociological analyses of healthcare choice must take greater account of the ‘field’ in which choices are made in order to better explain the structuring of choice.

Neoliberal policies are shaping the healthcare landscape by emphasizing individual choice. End-of-life care is a case in point as patient choice, through advance care planning, is a key conceptual framework for motivating service development and provision. Based on qualitative ethnographic research in England, this article describes what choice is and how it is enacted in the context of end-of-life care. Within policy, choice represents individual autonomy and is a goal to strive towards. In order to enable choice, healthcare professionals are to openly discuss dying with patients and in turn, patients are expected to express their preferences. However, by focusing on two case studies, the article demonstrates how people struggle to articulate choice in these ways and the preferences expressed represent the complex contexts in which care is performed. Although death is certain, the possibility of control alluded to by choice rhetoric is not realized in practice.

Thaler and Sunstein’s behavioural-economics theory of ‘Nudge’ aims to achieve beneficial outcomes for individuals and the society through designing the contexts in which choices are made rather than relying on traditional policy levers of restrictions, penalties and education. This article examines Nudge strategies to increase registration as a deceased organ donor among minority ethnic groups based on 22 focus groups that were held with Black and South Asian minority ethnic groups in London, UK. The article identifies ways in which minority ethnic groups’ habitus appears to limit awareness and knowledge of the system of organ donation and shapes attitudes to registration, with the varying influence of faith/culture and trust in the system reflecting differences in prior contexts and experience. This questions a key requirement of Nudge in terms of its libertarian dimension and suggests that focusing on the immediate choice context and neglecting individuals’ prior dispositions may not achieve desired outcomes for socially heterogeneous populations.

This article seeks to extend understandings of the ways in which trust is integral to analysing ‘choice’ within healthcare contexts, while also reappraising choice and its salience for grasping the nature of trust. Interrogating processes of ‘choosing to trust’, the authors describe various mechanisms through which ‘decisions’ are constrained while emphasising enduring agency to (dis)trust, even amid contexts where choice would appear annihilated by patients’ vulnerability. Drawing initially on Greener, Luhmann and Giddens, the article develops an analysis of how features of vulnerability, time and consciousness function in bounding choices and trust. Multiple structurations of choosing and trusting, alongside continuing agency, help further illuminate various power dimensions within clinical encounters. This theoretical analysis is illustrated using qualitative interview data from two studies across contrasting service settings in Australia and England, enabling recognition of further system and contextual influences upon patients’ vulnerability, dependency and trust, as these characterise processes of ‘choice’.

Implementation of the Affordable Care Act (ACA) in the United States changed the available options of healthcare coverage and providers. Through a comparative case study methodology, this article analyzes variations and trends in choice of provider and/or health plan and implications for consumers. Choice is explored at the national and state level for public and private health insurance options. This includes employer-based insurance, marketplace options, and the public Medicare and Medicaid programs. Findings indicate that too much choice can create confusion and lead to economically inefficient plan selection. Employer structuring of choice retains a wide choice of providers, but passes more cost on to employees. ACA marketplaces come short of structuring managed competition where choice drives efficiency. While the previously uninsured have far better options under reform, the system-wide range, degree, and complexity of choice tend to favor insurers over consumers.

This article explores the views of frontline research staff in different Sub-Saharan African contexts on the notion of choice in biomedical research. It argues that the current emphasis on individual choice, in the conduct of biomedical research, ignores significant structural and contextual factors in resource-limited settings. These factors severely constrain individual options and often make biomedical research enrolment the most amenable route to healthcare for the world’s poorest. From the position of frontline research staff, local contextual factors and structural issues narrowly frame the parameters within which many prospective participants are asked to choose, to such an extent that individuals are effectively presented with an ‘empty choice’. The article draws on ethnographic and interview data and insights gained through graphic elucidation techniques. It demonstrates that for frontline research staff, macro-level structural factors and their bearing on everyday realities shape what choice in biomedical research participation means in practice.