Need, competence and compliance: Selective empowering in the distribution of medical technologies in the Norwegian health care system

Emil Øversveen

doi:10.1177/0001699320976745

Abstract

The development of medical technologies is often assumed to improve medical treatment, but may also reproduce health inequalities if their benefits are unequally distributed. Sociological studies have shown that social and moral evaluations matter for medical decision making, and that inequalities in access and outcome exist even in universal health care systems. This article uses the distribution of medical technologies in the treatment of type 1 diabetes as a case for examining the social production of health care inequalities. Drawing on observational data and in-depth interviews with physicians and nurses working in a Norwegian hospital, I demonstrate that medical staff evaluate patients based on a combination of medical, social and moral criteria. The concept of selective empowering is then elaborated and refined as a term for the practice in which medical professionals steer resources towards patients based on evaluations of need, competence and compliance. While previous studies of inequalities in medical care have often focused on medical staff’s cognitive dispositions, I argue that selective empowering may be interpreted as a reflexive response to increasing health care costs and a structural dependency on expensive and commercially produced medical technologies.

Highlights

The relationship between social inequality and health is a foundational theme of medical sociology, and has been the subject of empirical studies since the 19th century (Waitzkin, 2011)
Referred to as the ‘Nordic health paradox’, the persistence of health and health care inequalities in the Nordic countries challenges widely held assumptions in health inequality research, and highlights the need for studies examining the social production of health inequalities within formally egalitarian welfare systems (Mackenbach, 2012; Therborn, 2013)
Rather than a case of medical workers judging patients according to a fixed set of internalized expectations, I argue that the distribution of medical resources is an uncertain and often conflicted social practice in which medical staff reflexively respond to systemic pressures emerging from budgetary restraints, rising patient demand and an increased dependency on commercially developed technologies

Summary

Introduction

The relationship between social inequality and health is a foundational theme of medical sociology, and has been the subject of empirical studies since the 19th century (Waitzkin, 2011). To the extent that these moral economies are structured by general hierarchies of status and prestige, the distribution of medical resources may serve to produce, reinforce and justify health inequalities. By examining this issue, the study addresses the larger field of health inequalities research. The approach taken in this study seeks to explicate the practices through which medical resources are distributed, how these practices are structured by institutional and economic constraints, and how they may create or reinforce unequal outcomes. I elaborate the concept of selective empowering by specifying three logics through which patients are assessed and categorized by medical staff, and by demonstrating how these three logics may produce social inequalities in medical care

Methods and setting

Study design