“Health Is Better Than Wealth”: Controversies of the Marketization of Vital Goods (The Case of the Moscow Dental Market). Summary

Elena Berdysheva

Keywords: market, commodity, morality, values, calculation, oral health, medical service, dentistry

Introduction

In this article I advance the idea that if marketization is extended to the realm of vital goods, it becomes a moral problem. Turning goods which are absolutely essential for individuals and closely related to “sacred” entities—human life, death, the body, intimate relationships, and so on—into a market commodity causes conflict with social and cultural norms that distinguish between goods which can be supplied through the market and those which should be available for free. Contemporary western culture establishes a boundary between the world of unique human beings, who always should be the goal and not the instrument of social action, and the world of material things able to be easily transformed into standardized market commodities (Kopytoff 1986). Marketization requires the calculation of value in money. In relation to the value of vital goods, this calculation may discount the unique value of human life, and, a result, those who undertake it may face social censure (Espeland and Stevens 1998). One threat emphasized in this context is that marketization might lead to a total objectification and standardization in society, converting unique social values into depersonalized commodities. This may open the door for the exploitation of one man by another.

Today’s sociologists reread Karl Marx and show that objectification and standardization following marketization can take place without alienation and dehumanization (Timmermans and Almeling 2009:26). At the dawn of economic sociology, the marketization of goods of high social value was an object of criticism. Now it has become an urgent matter for sociological research. There are many social spheres where the question of commodification and marketization of vital goods has been worked out in practice; my task here is to understand how and with what practical effects. I focus on the market of dental services in Moscow taking it as an example of a market dealing in human health—a “substantive” value.

There are at least three reasons why the marketization of medicine (including dentistry) is often criticized. Health is an absolute human right and should be available to everyone. Moreover, medical markets face the hazard of professional opportunism: following their pecuniary interests, practitioners may use their expert position in order to induce additional demand and profit (Newhouse 1970). Furthermore, today healthcare systems have been criticized for the increasing standardization and objectification of their approach to patients (Anspach 1988; Timmermans and Almeling 2009:21). Since these characteristics are basic aspects of marketization, these tendencies promise to accelerate the alienation and mechanization of the doctor-patient relationship. I set out to explain how actors in the Moscow dental market sustain a balance between the profit orientation of their business and social expectations related to health and healthcare. Relying on the methodology of grounded theory (Glaser 1992; Charmaz 2006), I base my argument on 25 interviews with managers and doctors working in Moscow’s commercial dental clinics and on the results of a qualitative content analysis of 184 Moscow dental clinics’ websites.

I begin the paper by outlining the contradiction between medicine and commerce—the key moral dilemma dental market actors face in connection with the marketization process. Then I examine the ethical principles that help them to cope with this ambivalence. Following this, I describe the notion of dental health as it is interpreted today in the Moscow dental market. To conclude, I discuss how the marketization of dental services—an example of the commodification of goods related to human health—has become possible.

Medicine or trade? The controversial marketization of dentistry

Medical markets in Russia function in parallel with a public healthcare system in which people can visit doctors without incurring direct costs. Public healthcare is based on a civic logic: the availability and affordability of medical services are a primary social guarantee, and responsibility for human health is the core function of medicine as a social institution. When health becomes a market commodity with a price, access to it becomes a question of money. This is seen as a threat to social order and social fairness. Market logic contradicts civic logic. As a mode of distribution of medical services, this market faces a crisis of legitimacy within society. According to the results of my study, in the dental medical market this crisis is expressed in terms of a conflict between the categories of medicine and trade. The choice between medical and commercial logics here is not a question of free choice or subjective taste but a forced decision which must be made by each actor in this socially entangled market. There are several principles, described in the following section, which allow them to undertake this decision.

Overcoming the dilemma of marketization: lessons from the Moscow dental market

My study revealed a number of principles that help dental market actors to reduce the tension arising when the professional services of doctors are offered for money.

The first principle supposes that, despite the existence of a profit motive, the desire to help and care for a patient and his or her health should be the highest priority for a commercial clinic. The humanitarian core of dental business is highlighted. Clinics avoid raising the suspicion of sacrificing patients’ interests for their own financial well-being. According to my respondents, they are concerned about the slippery slope leading from treatment-for-pay to extortion. Hence, they take care to carefully substantiate their prices and avoid seeking extra profit. The main task of a clinic is to persuade their patients that the value of the treatment they receive is much higher than the price paid for it. The peculiar nature of health, as the base of the demand for dental services, prevents market participants from perceiving their commodity as completely decoupled from social values and makes them take into account its moral content.

The second principle that increases the legitimacy of commercial dentistry is to focus on quality instead of quantity. The categories of quality and quantity are closely related to the controversy between medicine and trade. The lack of time available for the treatment of each patient constituted the main problem of Soviet dentistry. Time constraints generated poor outcomes both in the quality of treatment and in the satisfaction of doctor and patient with the results of dental care. Commercial clinics today emphasize the category of quality. Patients must pay money for doctors’ attentions, but this outlay is made up for by the patient-oriented treatment environment. Money is necessary for allowing “quality” treatment. The substitution of health with quality of service helps market actors to shield the sacred nature of health and to downplay the moral hazards of their daily practice.

The third principle for overcoming the contradiction between medicine and trade claims that clinics should follow a professional logic of work and not yield to the temptation of arranging their work as though it were a form of mass production. Such a temptation is not a fantasy but an empirical fact. According to my data, two possible ideal types of clinics exist on the Moscow dental market. I describe them as “professional” and “mass production” clinics and suppose that they reflect the contrasting poles of the medicine-business dilemma. Professional clinics were founded by dentists with professional training who relied primarily on their connections within medicine and developed their dental business through professional intuition. Today, they maintain a professional focus, work with regular patients, do not spend much money on advertising but work on preserving their reputation and obtaining new patients through referrals. “Mass production” clinics have a different profile. Clinics of this type were started as investment projects and were often headed by people without a medical background. Hired doctors helped them to set up the business, but the main motive was profit. Medical knowledge was used instrumentally. Professional ideas, motives, and ethics did not play a crucial role in such clinics. Today, clinics of this type tend to model their practices on principles of business economics, seeking above all financial efficiency. This organizational format is often adopted by chain clinics. With the emergence of insurance companies, mass production logic has gained in popularity. Insurers provide clinics with such a large number of patients that they often have to shorten the time reserved for each one and, consequently, may sacrifice the quality of treatment. According to my data, this tendency is ruining the dental services market and is frequently condemned by market actors.

The forth principle that softens the moral tension between health and trade requires the separation of medical and business aspects from each other within a single clinic. Medical workers delegate the discussion of all commerce-related questions to managers—actors responsible for the economic effectiveness of clinics. Thanks to this separation of roles, doctor-patient relationships can develop within a purely medical frame. Furthermore, my data demonstrate that doctors and managers interpret the content of dental services differently. Dentists speak about it in terms of professional duty and care, as an embodiment of doctors’ talents and medical art. Managers, on the other hand, see dental treatment as they would any other service.

Even when working in commercial dental clinics, the respondents described feeling of concern about the disjuncture between market and social values. The effects of marketization look potentially dangerous: market logic, with its profit orientation, seems to threaten medical standards and ethics, patient health, and the quality of medical treatment. To neutralize these threats they use a vocabulary of medical standards, professional ethics, prioritizing patient interests, and quality of care as the sentinel principles of their commercial activity. Protection against the negative effects of marketization is also supported by advancing an image of dental services as a market product.

Dental service as a market product: determinants of quality

To understand why dental services would be positioned as a market product, one must begin with a description of the notion of dental health as it exists today on the Moscow market. I have traced the transformation of notions about dental health in different historical periods.

Russian dentistry began as a surgical subspecialty. In the Soviet period, dental health services guaranteed that toothaches would not interfere with the working activity of the population. Diseased teeth had to be extracted. Later, dentistry developed techniques for the preservation and rehabilitation of teeth. This was supported by the development of dental therapy. In the 1990s Russian dentistry got access to implantology, orthodontics, and cosmetic dentistry. Dentists were now able to make teeth straight and snow-white rather than just save them from extraction. A “Hollywood smile” represented the dental dream of that time. The beauty of healthy teeth was a man-made, artificial beauty. Today this model is undergoing changes. If dentistry is not able to save natural teeth, it tries to replace them with synthetic ones that look natural. Dental health today integrates nature and aesthetics. To have healthy teeth in the Moscow dental market means to feel and look as if your teeth are perfect and pristine.

The parameters of dental services as a market product were identified by means of a content analysis of Moscow dental clinics’ websites. Clinics use their websites to articulate their competitive advantage, which helps to reveal their interpretations of quality. Websites highlight professionalism and an individual approach to each patient as the core of quality dental services. These sites convey that clinics care about the value and uniqueness of the human body. Quality dental service also means that doctors will pay sufficient attention to patients and spend enough time on their treatment. It also means that the treatment will be conducted safely and without causing pain, using modern biocompatible materials and the best technologies in a comfortable atmosphere without long queues. On the whole, all these aspects enable patients to expect that paying money for dental services will be worth it because they will receive, in return, perfect teeth. This helps to balance out prejudices against the market.

Conclusion

The mechanisms and limitations of the marketization of vital goods remain a relatively new topic in economic sociology. In this paper, I tried to fill in some of its gaps using the example of the Moscow dental market where demand for services is paired with a demand for health. I tried to understand how a vital good, necessary for every member of society, enters into money-mediated market exchange. In short, the findings of my research are as follows: although Moscow dental market actors deal in health, they understand it in a particular way, without putting exaggerated emphasis on its substantive value. In contrast to many other medical fields, commercial dentistry rarely copes with issues of human survival. Oral health centers on the functionality of teeth and the aesthetics, beauty, and performance of the human body. This alleviates the tension between the incommensurable value of human health and dental services as a commensurable market product. The moral hazards of marketization in commercial dentistry can be reduced if clinics focus on upholding professional medical standards and ethics, on quality of treatment over quantity of patients, on maintaining a professional approach to the business instead of a “conveyor belt” logic of mass production, and if they manage to separate medical and commercial frames in their relationships with patients.

My study provides evidence that casts doubt on the idea that the marketization of medicine inevitably dehumanizes and depersonalizes it. For example, in the commercial dentistry market, the context of long-term-care relationships prevents alienation between a doctor and a patient. As soon as a client’s illness becomes a potential source of income for the supplier of medical services, the latter has to make a special effort to establish trust in their interactions. Attention to the value of the human body and health in commercial medicine is a prerequisite of market relationships. Monetary value, when ascribed to vital goods by the market, suddenly turns out to be a warranty of their social value.