Collyer 2015 Healthcare Choice. Bourdieu's Capital, Habitus and Field

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Current Sociology Monograph2015, Vol. 63(5) 685 –699

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DOI: 10.1177/0011392115590082

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Healthcare choice: Bourdieu’scapital, habitus and field

Fran M Collyer University of Sydney, Australia

Karen F WillisAustralian Catholic University, Australia

Marika FranklinAustralian Catholic University, Australia

Kirsten HarleyUniversity of Sydney, Australia

Stephanie D ShortUniversity of Sydney, Australia

Abstract

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 andexperience 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 regardeduncritically 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

Corresponding author:

Fran Collyer, Department of Sociology and Social Policy, R.C. Mills Building, A26, University of Sydney, New

South Wales, 2006, Australia.

Email: [email protected]

CSI0010.1177/0011392115590082Current SociologyCollyer etal.research-article2015

Social Processes

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686 Current Sociology Monograph 2 63(5)

must take greater account of the ‘field’ in which choices are made in order to better

explain the structuring of choice.

Keywords

Bourdieu, choice, healthcare services, inequality, rational choice theory

Introduction: Current conceptions of healthcare choice

The endorsement of patient ‘choice’ has become a key goal of healthcare planning for

many developed, and even developing, nations. Its popularity rose in opposition to the

publicly planned, and delivered, health and welfare systems of the advanced economies

of the postwar period: state systems based on the collectivist values of equity and com-

munity-defined needs, where a primary objective was to offer equal access according to

need (Fotaki, 2010: 900). For the plethora of countries where there is now a mixture of

private and public healthcare services, the promotion of patient choice has fundamen-

tally centred around state and corporate strategies to increase usage of private health

facilities: that is, assist patients to ‘make the choice to go private’. Such efforts have been

increasingly successful worldwide, resulting in the widespread privatisation of health-

care services in Australia (Collyer et al., 2015) and elsewhere (e.g. Hassenteufel et al.,

2010; Phua and Barraclough, 2011; Saltman, 2003).

The trend towards private healthcare is aligned with the philosophical origins of the

notion of choice as found in economic liberalism – and the latter’s concern with property

rights, individual autonomy and personal responsibility (Fotaki, 2010: 900). In its cur-

rent form, the notion of choice is encapsulated within rational choice theory, where pro-

ponents argue that health consumers are ‘rational actors’, acting purposively to maximise

individual outcomes.

Three basic assumptions about human behaviour underpin rational choice theory

(Patrick and Erikson, 1993: 426–427). First, the theory regards people as independent of

their social context and always acting with intention. Patients, reconfigured as ‘consum-

ers’, are encouraged to ‘shop around’, to actively evaluate the services of health profes-

sionals and go elsewhere if the service is unsatisfactory (Lupton, 1997). As consumers,

patients are encouraged to invest effort in acquiring information about price, quality of providers and other factors such as waiting times, and use this information to select

between available alternatives (Victoor et al., 2014). Second, individuals are assumed to

be stable and consistent in their choices even in the face of risk and uncertainty (Hechter

and Kanazawa, 1997: 194; Levin and Milgrom, 2004). The third assumption is that indi-

viduals prefer more rather than less choice, ‘that the more choice, the better, and that the

human ability to manage, and the human desire for, choice is unlimited’ (Iyengar and

Lepper, 2000: 995).

Contesting dominant assumptions in rational choice theory

These three assumptions are contested by sociologists who regard choice as existing

within a complex sphere of interrelationships, vulnerabilities and interdependencies. It is


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Collyer et al. 687

argued that patients cannot readily be equated with the ideal model of the consumer

because it is difficult for individuals to make rational choices when they are at their most

vulnerable (Palmer and Short, 2014: 44), but also because of a fundamental asymmetry

in medical knowledge. In general, healthcare professionals hold more knowledge and

experience than patients about medical matters, and the latter tend to rely on the former’s judgement, making the neoliberal assumption of the rational and informed healthcare

consumer incongruous (Harley et al., 2011; Powers and Faden, 2006: 108). Such prob-

lems are compounded in situations where individuals are faced with selecting between

expensive or hard-to-evaluate products such as health insurance, for they are likely to

‘lack the skill and time to make choices based on a careful assessment of the relative

costs and quality of competing health plans, tending instead to choose on the basis of

anecdotal information, such as their friends’ experiences’ (Frank and Zeckhauser, 2009:

1135). Moreover, evidence suggests patient choices are far from consistent, and influ-

enced by how the choice is offered, how information is framed, and the context in whichchoices are made (Dixon et al., 2010). This means there is no such thing as the typical

patient: different patients make different choices in different situations and the same

patient makes different choices in different circumstances (Fotaki, 2006, 2014; Victoor

et al., 2012).

There is also little evidence that increasing the level of choice will raise the quality of

services, improve equity in the use of services or improve the efficiency of services (Fotaki,

2010). It cannot be assumed that rising healthcare costs are a product of unimpeded access

to services, nor its corollary, that paying for services provides a necessary ‘price signal’ to

ensure individuals will not ‘over-utilise’ services. On the contrary, sociological approachesto healthcare place the responsibility for rising healthcare costs elsewhere (e.g. the rise of

for-profit medicine, see Collyer et al., 2015; Richardson and Segal, 2004; or private insur-

ance systems, Shamsullah, 2011); regard healthcare services as a means to better health and

the alleviation of debilitating conditions or illness and hence argue they should be provided

liberally rather than restricted (Palmer and Short, 2014: 44); and consequently propose

user-pays systems and co-payments to be unethical because they restrict access to services,

particularly for the most vulnerable and poorest groups in the community.

Further, there is little evidence linking private, free-market medicine with better

health outcomes. Indeed, while there are almost insurmountable methodological difficul-ties comparing public with private provision, particularly in the Australian case (Collyer,

1996), evidence suggests better health outcomes are found in public systems of care,

where equity of access and universalism are more readily achieved (Davis et al., 2014;

Pollock and Price, 2011; Whiteside, 2011). Moreover, there is evidence of a growth in

the level of inequality in the healthcare systems of the world, indicating the increasingly

uneven distribution of services and significant constraints on access to existing services

for various social groups (Reibling and Wendt, 2012), including those in rural areas

(Sandall et al., 2009). Such studies indicate that ‘choices’ about health need to take into

account the socially constructed nature of decision-making (Pescosolido, 1992: 1096),

and show that choice cannot be adequately investigated without, at the very least, taking

into account the healthcare context: the cost and quality of available services, accessibil-

ity to those services, and the support provided to patients to make ‘healthy’, more

informed, choices.




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Sociological approaches to healthcare choice

Collyer’s (2012) mapping of the field of health sociology in Australia, Britain and

America indicates that the concept of choice/decision-making was one of several major

points of focus, employed in about 10% (86/842) of papers published between 1990 and2011 (Collyer, 2012; see also Harley et al., 2012).1 Additionally, relative to other topics,

the papers on choice and/or decision-making rose from 8% in the period 1990–1999, to

12% of the papers in the period 2000–2011, suggesting a rising interest in the topic

across the field. Harley et al. (2012) interrogated Collyer’s data further, finding that

43 (50%) of the papers on choice examined the patient experience of illness and patient

decision-making. These papers variously address the ethics and morals of the difficult

choices faced at the ‘end of life’ or at its beginning: abortion and the reproductive tech-

nologies figure prominently (e.g. Keleher, 1997; Magnusson and Ballis, 1999; Sikora

and Lewins, 2007). Others explore choices about the use of mainstream versus comple-mentary and alternative therapies (e.g. Raynor and Easthope, 2001; Tovey and Broom,

2008); screening and testing (e.g. Crompvoets, 2003; Lee and Sheon, 2008; Salant and

Gehlert, 2008); and the adoption (or otherwise) of healthy eating practices (e.g. Mallyon

et al., 2010; Pike and Colquhoun, 2009).

This analysis indicates that while choice has not been a neglected topic in the socio-

logical literature on healthcare, there is still insufficient interrogation of the concept

itself. For instance, few studies investigate the decision-making of doctors or other health

workers, or indeed whether patient choices should be extended in the healthcare arena.

There are a few exceptions, for instance Propper (2010) suggests that extensive choice is

unnecessary, as patients may be happy with less choice as long as the service they receive

is good enough, and are often content with their general practitioner’s (GP) recommen-

dation. And it has been pointed out that having ‘unlimited options can also make people

more dissatisfied with the choices they make: a point referred to by Schwartz (2000) as

“the tyranny of choice” ’ (cited in Dixon et al., 2010: 14). Even more pertinently, there is

little investigation about the way patients make choices, and of the social structuring of

patient choices. As Boyle (2013: 21) suggests, ‘meaningful choice’ is not just about hav-

ing the right information, but also the right support, confidence and the ability to take

part in joint decision-making. Instead, the primary direction of current research has con-

cerned the salience of consumer choice for the negotiation of identity in a modern ‘risksociety’ (e.g. Eckermann, 2006; McDonald et al., 2007: 448; Warin et al., 2008), which

carries an underlying message about the necessity and value of choice to the contempo-

rary citizen. This approach relies heavily on the theorisation of risk by Beck (1992, 2009)

and Giddens (1991), which fails to engage effectively with social structures such as class

(e.g. Atkinson, 2007; Brannen and Nilsen, 2005; Goldthorpe and McKnight, 2006;

Mythen, 2005; Simpson, 2012), and is therefore particularly unsuitable for conceptualis-

ing the structuring of healthcare choices.

The literature on choice, then, is clearly in need of both elaboration and theorisation.

This is particularly the case given the way neoliberalist discourse encourages sociolo-gists – as it does all individuals – to reject the very possibility of structural constraints on

our individuality and the choices we make as modern subjects. It may well be the case

that modern life in western societies is characterised by a compulsion to make choices,




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Collyer et al. 689

to demonstrate our capacity and competence in rational decision-making, and undertake

our duty as modern citizens by choosing healthy options (Moore and Fraser, 2006: 3037).

Nevertheless this context makes it even more imperative for the notion of ‘choice’ to be

examined critically, and for sociologists to resist the pressures of neoliberalist discourses

to shape the very sociological knowledge about choice itself.Theorising choice is rendered difficult also by the fact that the analysis of the social

shaping of decision-making perches perilously between two dominant paradigms of

sociological theory: the structuralist approach, which tends to ignore or minimise the

importance of human agency in the creation of structures; and the interactionist or indi-

vidualist approach, which rejects or underestimates the determination of action by social

structures. Engagement with either one of these traditions in isolation can produce only

partial insights into the investigation of choice. If we take it as axiomatic that choices are

structured and organised by conditions of the social context but that there is always some

room for individual agency, then choice about health and healthcare becomes an exem- plar for sociological theorising.

Max Weber’s work helps situate the theorising of choice between the structuralist and

individualist paradigms of sociology. Weber’s mis-readings of Marx (Weber did not read

the latter’s work) produced an alternative to a determinist, wholly structuralist approach

to the analysis of the rise of capitalism (Weber, 1958). Weber (1978) later proposed that

people’s choices about dress, marriage, eating, etc. contribute to the social reproduction

of status distinctions (social inequalities), but that these choices are themselves con-

strained by both the material and non-material resources and rules of the community.

These structural aspects are the life chances, which determine the probability of indi-viduals achieving their goals, and thus shape individual choices (Abel and Frohlich,

2012: 237). This Weberian approach has been taken up in the recent sociological health

literature to analyse the interrelations between health behaviours and their social shaping

(e.g. Cockerham, 2005). Weber’s work is also arguably the basis of the Bourdieusian

approach to health inequalities and behaviours (e.g. Abel and Frohlich, 2012; Fotaki,

2010; Shim, 2010). Bourdieu’s work extends Weber’s theoretical framework into an

even more explicit concern with the structuring of agency and the agentic production and

reproduction of structure.

Using Bourdieu to analyse healthcare choice

For Bourdieu, three interlinked concepts enable the analysis of the relations between

agency and structure: habitus, capital and field.

Habitus is employed to bind the ‘objective’ with the ‘subjective’ social world. It

explains how it is that people act and think in accordance with the social context without

those ideas, beliefs and practices being fully determined by social structure. In the habi-

tus people’s experiences become embodied, and through these experiences they develop

a ‘feel for the game’, learning the rules that become second nature to them (Bourdieu,

1994: 63). Thus, in their daily lives, individuals act unconsciously according to their

habitus and sometimes make choices and develop strategies as they engage with various

social fields, gathering and deploying forms of capital.




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Capital , the second of the concepts, is used by Bourdieu to refer to the kinds of

resources actors bring to social interaction or else to the products of those interactions.

These resources may be used consciously or unconsciously, and can take an economic,

cultural or social form. The different forms of capital indicate Bourdieu’s borrowings

from Weber, where the latter theorised the need to take into account the deployment ofresources of a less directly economic kind, including social prestige and status. Economic

capital is essentially about material resources such as income or property, and Bourdieu

sees this as the basis of all other types of capital (Bourdieu, 1986: 252). Social capital in

contrast refers to the resources linked to the ‘possession of a durable network of mutual

acquaintance and recognition’ (Bourdieu, 1986: 248). Cultural capital concerns the cul-

tural competencies individuals develop through socialisation and learn over time.

Cultural capital can be incorporated as skills and knowledge, objectivised in books or

tools, or institutionalised as degrees or certificates (Abel and Frohlich, 2012: 238). A

crucial difference between Bourdieu’s concept of capital and that of the equally well-known James Coleman is that the former explicitly rejects the latter’s key presumption

that ‘the actions of agents can be analysed and understood in terms of choices that max-

imise utility’ (Adkins, 2008: 1211). Indeed Bourdieu sought to offer an alternative to

Coleman’s rational choice sociology, proposing that capital is not simply a characteristic

of the individual but a class phenomenon, and that ‘choice’ is therefore socially, not indi-

vidually produced.

Bourdieu’s third concept, the field , refers to a social space (such as an academic field

or a healthcare field), but also a configuration or network of relations with a specific

distribution of power. A field is always a site of struggle and contestation (Collyer, 2014),and is dominated by the logics of the economic field where the production and exchange

of capital reproduces unequal class relations and its structures of inequality (Moore,

2008: 103–104). In Bourdieu’s words, the field is a space of position-takings, a ‘struc-

tured set of the manifestations of the social agents involved in the field … [it] is a field

of forces, but it is also a field of struggles tending to transform or conserve this field of

forces’ (Bourdieu, 1983: 30, emphasis in the original). The healthcare field, for example,

can be understood as characterised by contests between the dominant ‘position-takings’

or claims of medicine (where health is defined as the absence of pathology), those of the

corporations of capitalism (where health is defined as a product for market exchange and profit), the capitalist state (where the medical definition of health and the need to support

capitalist medicine sit somewhat uncomfortably alongside political goals to mediate the

effects of the inequalities of the capitalist market on the health of the population), and

those of subordinate actors with a plethora of competing and diverse position-takings, for

example, patient rights, public health or complementary and alternative medicine.

This triad of concepts – habitus, capital and field – can assist with theorising health

choices, as long as Bourdieu’s concept of capital is not used in a descriptive and func-

tional manner but understood in a dynamic sense and fundamentally as a class phenom-

enon. This means interpreting Bourdieu’s concept of capital not just as a passive resource

within a predetermined field, but as a form of power or capacity to act, that is, as the

‘energy’ that drives the development of a field through time (Moore, 2008: 105). The

emphasis, then, must be on this more dynamic definition of capital, on the way forms of

capital can be transformed, under specific conditions, into other forms of capital, and




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Collyer et al. 691

thus gain social and financial advantage for the actors involved. After all, as Abel and

Frohlich (2012: 238) argue from their reading of Bourdieu, the different forms of capital

are dependent and conditional on one another. For instance, the acquisition of social

capital necessitates cultural capital, as membership of a given social group requires spe-

cific communication styles or behavioural skills. Capital in various forms, particularly inthe form of knowledge and skills, is thus implicated in human action, it is employed for

all meaningful action, and ‘is a key component in people’s capacity for agency, including

that for health’ (Abel and Frohlich, 2012: 238).

It is also important to note that it is not simply the acquisition of capital that confers

individual or group advantage and produces a hierarchical, unequal society with marked

health inequalities and differential capacity to choose: capital must be activated,

employed and engaged with. Individuals do not simply consume or own resources, they

must acquire and actively deploy health-relevant capital if their actions are to be health-

promoting (Abel and Frohlich, 2012: 238). After all, nutritional knowledge is oftenignored and abundant income may easily be spent on health compromising behaviours:

… inequality goes beyond just the unequal distribution of capital … there is considerable social

inequality also in the chances and ability for people to have the different forms of capital

consistently support and complement each other with the end result of their interaction being a

health advantage. (Abel and Frohlich, 2012: 239)

Health choices can be understood in this way as the processes of agency in action.

However, these choices must also be shown as socially structured. The structuring of

health choices can be understood in Bourdieusian terms when the three concepts are

brought together into an interlinked and dynamic schema. Health choices are structured

within the habitus, which is both a ‘structured and structuring structure’ (Bourdieu, 1984:

171). This occurs through the interplay and interaction of the various forms of capital

where individual practices are aligned with those of one’s social group or class. But the

habitus and its dispositions are in turn structured by the dynamics of the field. The field

gives the habitus structure (Bourdieu and Wacquant, 1992: 127), for it is the mechanism

through which the various capitals are produced and socially distributed (Moore, 2008:

105). In this way the logics and forces of the field structure the capacities of actors, dif-

ferentially enabling or suppressing the realisation of various forms of power, and givingshape to the kind of choices that can be made.

Studies of choice in healthcare

Studies of the choice to purchase private health insurance (PHI) can potentially illus-

trate the dynamics of habitus, field and capital. In the Australian context, PHI is an

optional addition to the universal health insurance system of Medicare and provides

individuals with some financial assistance to access services in the rapidly growing

private healthcare sector (see Collyer et al., 2015). A series of policy incentives (mostnotably government subsidies) and penalties (e.g. taxation penalties) favourably posi-

tion the choice to purchase PHI within the healthcare field. Harley et al.’s (2011) study

of PHI marketing illustrates how companies draw on shared meanings and concerns to




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influence individuals to purchase their product, and use their positioning in the field to

construct a particular form of consumption by individuals. Another study has focused

on the value people place on having PHI, finding that it is valued even where it is not

utilised in the Australian context (Natalier and Willis, 2008). (There is no requirement

in Australia to use PHI, with all citizens retaining the right to be treated as public patients in public hospitals and covered by Medicare.) Moreover, these values can be

transmitted from generation to generation within families, and have been found to

impact on participants’ choices about the purchase of insurance. Participants who have

grown up in families with PHI, even if they have low economic resources themselves,

may value it sufficiently to put in place strategies to purchase it, indicating that while

economic capital is important, other forms of capital need to be examined in order to

explain people’s healthcare choices. This finding demonstrates the largely unconscious

shaping of behaviour through the habitus. As one participant stated when discussing his

reason for choosing PHI: ‘Everyone is still on it in my family. It’s just the way I’ve grown up’ (in Natalier and Willis, 2008).

Zadoroznyj’s (1999) study of choice in Australian maternity services is illustrative of

the potential to explore the dynamic nature of field and capital. Yet, while she uses a

Bourdieusian framework to link social class and health-related behaviour, further work

is needed to illustrate how the field structures choices and the exchange of capital beyond

the initial placement of individuals into social classes. Bourdieu’s symbolic world is

evident in this study in the way the decision to purchase PHI for coverage for childbirth

is linked not just with income but with social ideals of having the ‘best care’, reflective

of the current framing of ‘both the idealisation and character of possible birthing ser-vices’ (Zadoroznyj, 1999: 268). While social class differences are evident in the wom-

en’s narratives, Zadoroznyj also found experiential knowledge, or up-skilling, serving to

shift positionings in later birthing choices. Zadoroznyj gives the example of ‘Chris’, a

participant of limited economic and cultural resources, who was dissatisfied with her

first birth experience. Chris drew on her experiential knowledge to take greater control

when birthing with her second baby, by delaying going to hospital when in labour; and

once there by expressing her dissatisfaction. ‘They wouldn’t let me sit or be the way I

wanted, so I just screamed. My husband was so embarrassed but I thought, “Well you’re

going to get it” because they wouldn’t let me have my say’ (in Zadoroznyj, 1999: 281).What is evident from this study is the way experiential knowledge may shift the dynam-

ics of some choices made about, and interactions with, healthcare providers. However, if

these processes were analysed with greater reference to the structures of the field, it

would become clear that there are severe constraints on the individual’s capacity to

deploy capital in a manner which might change the structures of decision-making – that

is, the material conditions under which childbirth choices are made.

Fully utilised, a Bourdieusian approach to understanding healthcare choices can bring

together the key concepts, rather than focus on a single determinant, potentially provid-

ing a richer analytical account of health behaviours that extends beyond individual

choices in the context of their capital resources (see e.g. Edwards and Imrie, 2003;

Lunnay et al., 2011). Some such studies have brought a better understanding of the cul-

tural underpinnings of choice-related behaviours, and the manner in which social ine-

qualities in health are perpetuated (e.g. Abel and Frohlich, 2012; Cockerham, 2005;




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Collyer et al. 693

Veenstra, 2007). This is because Bourdieu’s approach interrogates the intersection of

both material and symbolic factors which condition and structure the social context

within which choices are made. However, even within studies that adopt a Bourdieusian

approach, very few focus on the field itself as a mechanism to structure choice and its

effects on the operation and functioning of capital.Shim (2010) offers a rare example of a study that sheds light on the interactions

between capital and field. In this, her focus is on cultural capital, specifically her concept

of cultural health capital. Shim (2010: 12) draws on Bourdieu to demonstrate the way

‘social structural inequality manifests in clinical encounters’. Cultural health capital is

accumulated in various practices concerning embodiment, cultivated consumption (or

experience) and interactions with healthcare providers so that ‘patients can continually

develop the cultural resources to manage and navigate healthcare’ (Shim, 2010: 8). The

value of Shim’s analysis is in pointing to the co-construction of choice through interac-

tion between patient and healthcare provider (and extending it beyond patient stereotyp-ing by providers); and then at another level, recognising how such interactions may be

constrained by broader interactions in the field. For example, payment systems aligned

with consultation time reinforce and reward particular communication capacities and

styles that privilege those with some health knowledge or other social advantages. Shim

also points to the differential exchange value of cultural health capital which may vary

according to social grouping and situation.

The road ahead: Navigating the healthcare maze

This brief foray into the notion of choice has suggested a need for a greater focus on the

field of healthcare, its institutions and organisations, its payment systems, gaps in ser-

vices and barriers to access; but also the way patient choices within the system are shaped

by the decisions and practices of its ‘gatekeepers’: the healthcare providers, managers,

administrators, policy-makers and significant others in the institutions and organisations

of both private and public healthcare. Such a focus would entail paying much greater

attention to the producers of healthcare, as Bourdieu himself did in investigating the

cultural production of art (Bourdieu, 1996). There is an even greater imperative for this

in the healthcare field, because patient ‘choices’ coincide, in the majority of cases, withthe decisions made for them by their healthcare practitioner, and are, in all cases, con-

strained by the medical definition of ‘the problem’ and its ‘solution’, and by the availa-

bility and accessibility of specific treatment options and services. The latter, which we

refer to as the ‘healthcare maze’, has been constituted historically through political and

corporate action, through the struggles of professionalisation and specialisation, and

reflects the ideas and practices of the institutions of medicine within a context of both

state and corporate activity.

The healthcare ‘field’, like all fields as conceived by Bourdieu, is clearly a ‘universe

of belief’. It is an arena of action where cultural products are fought for and valued and

given value (Bourdieu, 1996: 229). Yet Bourdieu’s fields are not just universes of belief,

they are arenas of practices where power operates. They are ‘structuring structures’, and

an aspect of Bourdieu’s theoretical framework that has been least investigated in the

sociology of health literature. Yet patient ‘choices’ between, for example, treatment with




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surgery, chemotherapy, radiation therapy or even traditional medicine therapies, are

shaped not just by the cost of each option or the availability of each service in their local

area (though each of these can be very important), but through the ongoing competitive

practices between the differing specialities of medicine. Each speciality seeks to define

the ‘problem’ and its appropriate ‘solution’, and positions itself in the hierarchicallyorganised field with its claims for legitimate medical knowledge and is supported – or

not – by its relative proximity to the poles of economic and cultural power. These are the

processes through which choice is structured, and they are a fertile field for future socio-

logical analysis.

Acknowledgements

The authors acknowledge the support of the School of Social and Political Sciences and the Faculty

of Health Sciences at the University of Sydney.

Funding

This work was supported by an Australian Research Council Discovery Grant (DP130103876)

‘How Australians navigate the healthcare maze: The differential capacity to choose’.

Note

1. The study was based on a context-content analysis of 842 published manuscripts from key

journals in the sociology of health and medicine. The methodology is fully explained in

Collyer (2013).

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Author biographies

Fran Collyer is Associate Professor and sociologist at the University of Sydney in the Department

of Sociology and Social Policy. She is senior editorial advisor to Health Sociology Review, and

series editor for Anthem Books. Her research interests include the privatization of healthcare ser-vices, the sociology of the healthcare system, the history of sociology, disciplines and institutions,

and the sociology of knowledge. Current funded research projects focus on the experience of

patients within Australia’s mixed private and public healthcare system, and the formation and




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inequalities of global networks of expert knowledge. Recent books include Mapping the Sociology

of Health and Medicine (2012), for which she won the Stephen Crook Memorial Award for the

best Australian monograph 2014, and the Palgrave Handbook of Social Theory in Health, Illness

and Medicine (2015).

Karen Willis is a health sociologist and qualitative researcher. Professor Willis is currently lead

chief investigator on the Australian Research Council Project, Navigating the HealthCare Maze –

The Differential Capacity to Choose; and has just commenced a further study examining goal

setting for people with chronic health conditions. Her work aims to bring together the field of

individual decision-making with broader social and policy forces. In pursuing this research interest

she has examined the choice to participate in mammography screening, the reasons people take out

private health insurance, and the actions fishers and farmers take to maintain good health. She is

also Associate Dean, Learning and Teaching in the Faculty of Health Sciences at Australian

Catholic University.

Marika Franklin, BA Psychology, is a researcher on the Australian Research Council funded project exploring healthcare choice in Australia at the University of Sydney. She is also a PhD candi-

date at the Australian Catholic University and is researching how self-management goals are nego-

tiated and enacted between people with chronic conditions and their healthcare providers. Her

experience is in evaluation and psychosocial research in social and health domains. Marika also

has an interest in the psychosocial needs of siblings of cancer patients and how the needs of sib-

lings can be addressed in current models of service delivery.

Kirsten Harley is an honorary lecturer in the Faculty of Health Sciences at the University of

Sydney. She is part of a team researching healthcare choice in the Australian context, a project

with particular personal significance since her diagnosis with motor neurone disease in early 2013.

Her recent publications include (with Gary Wickham) Australian Sociology: Fragility, Rivalry,

Survival (Palgrave Pivot, 2014) and (with Kristin Natalier) a special issue of the Journal of

Sociology, Teaching Sociology: Reflections on the Discipline (2013). She received the University

of Sydney’s inaugural Rita and John Cornforth Medal for PhD Achievement in 2011.

Stephanie Short is Professor and head of the Discipline of Behavioural and Social Sciences in

Health in the Faculty of Health Sciences at the University of Sydney. Professor Short’s research

interests concern health governance and public policy, both locally and internationally. She has

published widely in health sociology and policy, including the 5th edition of Health Care and

Public Policy: An Australian Analysis, as co-author (Palgrave Macmillan, 2014) and Health

Workforce Governance, as co-editor (Ashgate, 2012).

Résumé

La promotion du choix est un thème courant aussi bien dans les discours politiquesque dans les arguments de vente au sujet des soins de santé. Toutefois, face auxmultiples parcours possibles qu’offre le « labyrinthe » des soins de santé, comment

les « consommateurs » ou patients comprennent-ils les choix en matière de santé etcomment y sont-ils exposés ? Quelle est la signification de « choix » dans le contexte

politique et, plus important encore, comment ces choix sont-ils produits et structurésdu point de vue sociologique ? Dans cet article théorique, nous examinons l’interactiondes trois concepts clés et interconnectés de Bourdieu – capital, habitus et champ – dans

la structuration des choix en matière de soins de santé. Ces concepts sont proposés




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en tant qu’alternative à la théorie du choix rationnel selon laquelle le « choix » est

considéré sans réserves comme un « bien » fondamental à même de fournir une solutionaux problèmes du système sanitaire. Notre argument est que les analyses sociologiquesdes choix en matière de soins de santé doivent davantage tenir compte du « champ »

dans lequel ces choix sont faits afin de mieux expliquer la structuration du choix.

Mots-clés

Bourdieu, choix, inégalité, services de soins de santé, théorie du choix rationnel

Resumen

La promoción de la elección es un tema común tanto en discursos políticos como

en los reclamos comerciales sobre la asistencia sanitaria. Sin embargo, dentro de las

múltiples vías potenciales del ‘laberinto‘ de la asistencia sanitaria, ¿cómo entiendeno experimentan la elección los ‘consumidores’ de planes de salud o pacientes? ¿Quése entiende por ‘elección’ en el contexto de la política? y, especialmente desde unaperspectiva sociológica, ¿cómo se producen y estructuran esas elecciones a nivel

social? En este trabajo teórico, consideramos la interacción de los tres conceptos claveinterrelacionados de Bourdieu – capital, habitus y campo – en la estructuración de la

elección del plan de salud. Estos se ofrecen como alternativa a la teoría de la elecciónracional, donde la ‘elección’ se considera acríticamente como un ‘bien’ fundamental y escapaz de proporcionar una solución a los problemas del sistema de salud. Argumentamos

que los análisis sociológicos de elección de los planes de salud deben tener más encuenta el ‘campo’ en el que las elecciones se realizan con el fin de explicar mejor laestructuración de la elección.

Palabras clave

Bourdieu, desigualdad, elección, servicios sanitarios, teoría de la elección racional

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