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How the Patient Became a Consumer in Modern American Medicine UNIVERSITY OF CALIFORNIA, SAN DIEGO Curing Consumers: How the Patient Became a Consumer in Modern American Medicine A Dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Communication by Nancy Stark Lee Committee in charge: Professor Michael Schudson, Chair Professor Daniel Hallin Professor Robert Horwitz Professor Richard Kronick Professor Richard Madsen 2007 Copyright Nancy Stark Lee, 2007 All rights reserved. The Dissertation of Nancy Stark Lee is approved, and it is acceptable in quality and form for publication on microfilm: Chair University of California, San Diego 2007 iii With loving gratitude to my Mother and Father, 李沈秀娟 李 品 禮 Lee Shen Hsiu Chuan and Lee Pin Li. This is their work. iv TABLE OF CONTENTS Signature Page ..................................................................................................................... iii Dedication ........................................................................................................... iv Table of Contents ................................................................................................ v Acknowledgements ............................................................................................ vi Vita ................................................................................................................... viii Abstract .............................................................................................................. ix Chapter One: Introduction .................................................................................. 1 Chapter Two: A Historical Perspective on Consumerism ................................ 21 Chapter Three: Health Care and the Problem of Communication …................ 63 Chapter Four: “Be a Good Patient!” and Other Stories of Medical Paternalism, 1930-1969 ............................................. 102 Chapter Five: “Patient Power!”: The Patient as Health Care Consumer, 1970-2006 ............................................................. 164 Epilogue ........................................................................................................... 213 Bibliography .................................................................................................... 215 v ACKNOWLEDGEMENTS My deepest thanks and gratitude go to the chair of my committee, Michael Schudson. He has listened to my ideas, shared my concerns, and laughed at my jokes (the good ones, at least). He has guided this project from start to finish, and a better advisor I could not have found. My heartfelt thanks to my committee members, Dan Hallin, Robert Horwitz, Richard Kronick, and Richard Madsen. They are incredible scholars and more—I shall not forget their civility and kindness. My project has benefited from their wisdom. I am especially grateful to Professor Madsen for all the years he has listened and shared. I would also like to thank the people of the Department of Communication, colleagues and staff. They have made my years in the program some of the most memorable. Gayle Aruta deserves special thanks for supporting me and all the grads in so many ways. There are many at UCSD who helped make my work possible, too many to acknowledge fully here. But special thanks to Elliot Kanter for providing excellent library support. My thanks extend also to Martha Stacklin, Christina Lambert, and Arturo Galvez. They contributed to enriching my life at UCSD. My friends in the program have provided intellectual and moral support—and they’ve made these years in graduate school fun. The experience wouldn’t have been the same without Ge Jin (a.k.a. Jingle), Ricardo Guthrie, Nadine Kozak, Erin Malone, Antonieta Mercado, Fatma Mindikoglu, and Megan Pincus-Kajitani. I am particularly vi grateful to Regina Marchi for our friendship that has sustained me through the peaks and valleys of this long journey. To my parents, my brother John, sister-in-law Robin, and Vanessa, my niece, I owe the profoundest thanks for their love and faith in me. And to my husband, Jürgen, I save my sweetest thanks for last. His unshakable confidence in my abilities is remarkable. His patience, inspiring. vii VITA 1988 B.A., History, University of British Columbia, Vancouver, Canada 1999 M.A., Liberal Arts & Sciences, San Diego State University, San Diego, California 1989-1997; 1999 Communications consultant, writer and editor 1997-1999 Teaching Assistant, San Diego State University, San Diego 2000-2005 Teaching Assistant, University of California, San Diego 2001-2002 Editorial Assistant, Laboratory of Comparative Human Cognition, University of California, San Diego 2002-2003; 2004 Research Assistant, University of California, San Diego 2005 Teaching Consultant, Center for Teaching Development, University of California, San Diego 2007 Reader, University of California, San Diego 2007 Ph.D. in Communication, University of California, San Diego PUBLICATIONS “Telling Their Own Stories: Chinese Canadian Biography as a Historical Genre.” In The Chinese in America: A History from Gold Mountain to the New Millennium, edited by Susie Lan Cassel. Walnut Creek, CA: Alta Mira Press, 2002 (106-121). Review of Confronting Consumption, edited by Thomas Princen, Michael Maniates, and Ken Conca. Journal of Environment and Development 12 (June 2003): 268-271. viii ABSTRACT OF THE DISSERTATION Curing Consumers: How the Patient Became a Consumer in Modern American Medicine by Nancy Stark Lee Doctor of Philosophy in Communication University of California, San Diego, 2007 Professor Michael Schudson, Chair This dissertation addresses the widespread practice of calling the patient a consumer in contemporary discourses about health and medicine in the United States. Despite its common usage, little is known of the historical origins of this construct, how it entered popular discourse, and the symbolic and social significance of conceptualizing the patient as a consumer to current health care debates. Through historical research that spans the years 1930 to 2006, this study traces the patient- consumer metaphor to the patients’ rights movement of the 1960s. Ideas about patient empowerment and rights emerged only after that decade’s social and cultural ix transformations reduced the public’s trust in traditionally authoritative and paternalistic institutions such as medicine. Calling the patient a consumer was a rhetorical tactic first popularized by the 1960s social movements involved in expanding patients’ rights, including the consumer movement led by Ralph Nader. This periodization is supported by findings from a historical textual analysis of mainstream magazine articles on health and medicine from 1930 to 1969 that indicate the patient as an empowered health care consumer was not part of normative expectations of patienthood before the 1960s. Textual analysis of self-help literature, magazine and newspaper articles since the 1970s show how the patient-consumer metaphor’s connotations of empowerment and personal autonomy in health decisions were co-opted and reduced to simple messages about consumer sovereignty by the 1980s as the US health care sector became increasingly corporatized under successive neoliberalist administrations. This dissertation’s findings contributes to a more nuanced, historically based understanding of the ramifications of patient consumerism to better enable and support critiques of the American health care system. x CHAPTER ONE Introduction Americans today are reminded constantly by the media that individuals are the masters of their own health. Learning to make informed choices is the way to take control of health. And information is the key to making the best, most informed health decisions. That patients as “empowered consumers” have the right—and the responsibility—to make their own health decisions has become nearly taken-for- granted in American society. The patient is often called a consumer these days, yet the right to self-determination in health is a recent concept in the history of medicine in the United States, as is the idea that information and effective communication are central to making personal decisions about health. This dissertation addresses how the widespread practice of calling the patient a consumer in both popular and expert discourses represents a profound transformation of American ideas about patienthood and expectations of professional authority in medicine. These changes correspond to larger cultural and social transformations of American society since the 1960s that reduced the public’s trust in traditionally authoritative and paternalistic institutions such as medicine. As a result, a new paradigm emerged of the patient as an active, empowered consumer that upended traditional ideas about the patient as a passive dependent of her physician. Given this 1 2 historical context, this dissertation argues that the rhetorical figure of the patient- consumer represents contemporary ideas and expectations of freedom, choice, personal control and responsibility in matters of health, not all of which resulted from the influence of neoliberalism. In the past 25 years, the consumer metaphor lent itself readily to neoliberalist health policies that have promoted market expansion in the health care sector on the basis of greater consumer sovereignty and choice in health services and products. These developments, understandably, tend to obscure the fact that calling the patient a consumer was a rhetorical tactic first popularized by the 1960s and 1970s social
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