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Since the 1980s, the use of the term health-care consumer as a synonym for patient (along with its doctor analogue, health-care provider) has become commonplace in the United States. For many observers today, especially physicians , this linguistic transformation has come to represent the worst consequences of American medicine’s growing market orientation. As one doctor quoted by the columnist Ellen Goodman quipped, “Every time a patient is referred to as a health-care consumer, another angel dies,” while another cited by William Safire observed, “The managed-care organizations call people consumers so they don’t have to think of them as patients” (Goodman 1999; Safire 2000; emphasis in original). Such visceral dislike of the term health-care consumer reflects not only the loss of physician autonomy that has accompanied the coming of managed care, but also a deeper sense of violation: a conviction that applying the base language of the marketplace to the sacred realm of the doctor-patient relationship is fundamentally wrong. In the introduction to his 1998 book Some Choice, George Annas makes a strong case against referring to patients as consumers on just such grounds. Market models of competition do not work when applied to health-care choices, he argues, “because patients are not consumers who pick and choose among physicians and treatments on the basis of price and quality.” The legal principles derived from the United States Constitution and the Bill of Rights are a surer foundation for protecting patient interests than any economic theory, Annas suggests; it has been in the courtroom and the legislature, not the marketplace, that entitlements to informed consent, privacy, emergency care, and the like have been most effectively secured. In contrast, consumer rights Patients or Health-Care Consumers? Why the History of Contested Terms Matters Chapter 4 Nancy Tomes 83 have focused “not on the context of diagnosing and treating patients, but on the purchase and sale of a health-care policy,” with far narrower and less beneficial results. Annas concludes, “Market language, with its emphasis on choice, tends to marginalize the sick and treat the practice of medicine as just another occupation, and medical care itself as just another commodity, like breakfast cereal” (xii). Such criticisms of consumer rhetoric are common among thoughtful health-care analysts today. While I share their concerns, I aim in this chapter both to dispute the widely held belief that managed-care advocates began the practice of referring to patients as consumers and to provide a broad historical perspective on this linguistic shift. In fact, it was patient activists, not market enthusiasts, who initially embraced the phrase health-care consumer in the 1960s and 1970s. They chose that language as a liberating alternative to a traditional doctor-patient relationship they believed to be hopelessly mired in paternalism. The 1970s concept of the empowered patient-consumer was part of a wide-ranging critique of both medical paternalism and the “new medicalindustrial complex” so famously described by Arnold Relman in 1980. Activists embraced a consumer-oriented rhetoric in order to redress the growing imbalance of power between patients and caregivers and to ensure that “people come before profits,” a favorite slogan of that era (Ehrenreich and Ehrenreich 1970). Thirty years later, it is tempting to dismiss the 1970s embrace of consumer rights as naive and misguided. But before throwing the consumer baby out with the managed-care bath water, we need better to understand why patient advocates adopted this rhetoric as well as why their grand visions of reform eventually failed. As policymakers continue to ponder how to cross the “quality chasm” toward a more patient-centered model of health care (Institute of Medicine 1999; 2001), the history of what might be termed the first consumer health revolution deserves a closer look. Such reflections are particularly timely, given the current enthusiasm in some policy circles for “consumer-oriented” or “consumer-driven” policy mechanisms such as defined-contribution health insurance plans and medical savings accounts (Herzlinger 1997; Gabel, LoSasso, and Rice 2002). While the historical analysis presented here helps explain the political appeal of such measures, it also provides little reason to hope that these consumer-driven mechanisms will succeed any better than their managed-care predecessors in transforming the troubled U.S. health-care system. My skepticism about the latest generation of so-called consumer-controlled policies reflects two conclusions based on my historical research. First, that modern 84 Nancy Tomes [3.144.143.31] Project...

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