Consuming healthcare: what's in a word?
Use of the terms “consumer” and “customer” has become widespread in discourse about healthcare among policy makers, managers, academics and advocacy groups. I was reminded of this phenomenon – and inspired to write this editorial – by a recent call by the policy branch of a provincial ministry of health for a “policy theme paper” on “consumer centredness” and “consumer choice.” Reflecting on the gradual, but seemingly relentless, shift from “patient” and “client” to “consumer” or “customer,” I wondered what might underlie this trend, what values and interests might be advanced or challenged (whether inadvertently or by intention) by use of these terms, and the extent to which healthcare users have come to see themselves as consumers of care. 
 
To sample the recent literature, I searched PubMed for editorials, letters and reviews published in the last five years that included the word “consumer” in the title or abstract. As I browsed this material, two distinct strands of meaning were apparent in the use of the term “consumer” – the consumer as empowered, informed, autonomous health decision-maker and the consumer as purchaser of healthcare goods and services. Some authors appeared to have only one strand in mind; others adopted both. 
 
The notion of healthcare users who are informed, empowered and autonomous, engage in self-care, participate in decisions about their health and have the right to receive care that is timely, culturally appropriate and responsive to their values and preferences is hard to quarrel with. What is curious is how these values came to be associated with the term “consumer.” No doubt the linkage is, in part, a reaction to the waning, but still present, paternalism (maternalism?) of medicine and nursing where the term “patient” is most firmly entrenched. Adoption of “consumer” declares a rejection of that traditional feature of the relationship between health professionals and healthcare users. But the term “consumer” carries baggage of its own. 
 
The concept of the empowered and informed healthcare consumer hardly squares with the reality of the marketplace from whence the term was imported. In that sphere, a bewildering array of goods and services are marketed based largely on image rather than information, conveyed through design, packaging and advertising – which Stephen Leacock characterized as “the science of arresting the human intelligence long enough to get money from it” (Leacock 1924). Unlike health professionals, producers, marketers and sellers of goods and services have no ethical imperative to act in the “customer’s” best interests; their primary allegiance lies elsewhere. In their world, the principle of caveat emptor prevails. Characterizing healthcare users as consumers seems completely at odds with Julian Tudor Hart’s inspired concept of patients and healthcare providers as “co-producers of health” (Hart 1992). 
 
How do healthcare users feel about all of this? Based on Canadian and international research (Lloyd et al. 2001; Nair 1998; Deber et al. 2005), they’re not at all enamoured of the consumer label. For example, in a Canadian study of people receiving care in breast cancer, prostate disease, fracture and HIV clinics, more respondents liked the label “patient” than any of the alternatives that were posed (consumer, customer, client, partner or survivor) (Deber et al. 2005). Among those attending the breast, prostate and fracture clinics, 90% moderately or strongly disliked and less than 5% moderately or strongly liked the label “consumer.” People living with HIV/AIDS were slightly more open to being referred to as consumers, with about 12% moderately or strongly liking the label. Imposing an identity on healthcare users that they reject seems like an odd form of empowerment. 
 
The second strand of meaning defines the consumer as an economic actor making choices in a healthcare marketplace. In a typical expression of this concept, George Lundberg, former editor of the Journal of the American Medical Association, writes: “Why not let individuals make the purchasing decisions directly, spending their own money, so as to inject free-market components into the otherwise skewed medical marketplace?” (Lundberg 2005). Although both strands of meaning conceptualize healthcare consumers as private actors, this second sense of the term poses a direct challenge to the communitarian view, long dominant in Canada, of healthcare as a collectively financed, social good that is made available based solely on need. What could be more “natural” for healthcare consumers than access to a wide variety of healthcare products and services available for purchase in keeping with one’s tastes and means. Whatever its other effects, characterizing citizens and healthcare users as “consumers” of healthcare seems likely to have a “softening up” effect in aid of efforts to expand private financing options for services currently included in the medicare basket. 
 
Where does this leave us? Those who favour marketization of healthcare will understandably (and with intent) continue to privilege the term “consumer.” For others, continued use of “consumer” to describe healthcare users may support a healthcare agenda that many Canadians reject. Perhaps the time has come to abandon this muddled and misleading terminology. Surely the laudable goals of citizen and patient empowerment can be pursued without recourse to the language of the market.