590082

research-article2015

CSI0010.1177/0011392115590082Current SociologyCollyer et al.

CS

Social Processes

Healthcare choice: Bourdieus

capital, habitus and field

Current Sociology Monograph

2015, Vol. 63(5) 685699
The Author(s) 2015
Reprints and permissions:
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DOI: 10.1177/0011392115590082
csi.sagepub.com

Fran M Collyer

University of Sydney, Australia

Karen F Willis

Australian Catholic University, Australia

Marika Franklin

Australian Catholic University, Australia

Kirsten Harley

University of Sydney, Australia

Stephanie D Short
University 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 and
experience 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 Bourdieus 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 regarded
uncritically 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: Fran.Collyer@sydney.edu.au

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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 community-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 fundamentally 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 healthcare 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 latters concern with property
rights, individual autonomy and personal responsibility (Fotaki, 2010: 900). In its current form, the notion of choice is encapsulated within rational choice theory, where proponents 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: 426427). First, the theory regards people as independent of
their social context and always acting with intention. Patients, reconfigured as consumers, are encouraged to shop around, to actively evaluate the services of health professionals 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 individuals 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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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 formers
judgement, making the neoliberal assumption of the rational and informed healthcare
consumer incongruous (Harley et al., 2011; Powers and Faden, 2006: 108). Such problems 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 influenced by how the choice is offered, how information is framed, and the context in which
choices 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 approaches
to 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 insurance 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 difficulties 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, accessibility to those services, and the support provided to patients to make healthy, more
informed, choices.

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Sociological approaches to healthcare choice

Collyers (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 and
2011 (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 19901999, to
12% of the papers in the period 20002011, suggesting a rising interest in the topic
across the field. Harley et al. (2012) interrogated Collyers 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 technologies figure prominently (e.g. Keleher, 1997; Magnusson and Ballis, 1999; Sikora
and Lewins, 2007). Others explore choices about the use of mainstream versus complementary 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 sociological 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 practitioners (GP) recommendation. 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 having 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 concerned the salience of consumer choice for the negotiation of identity in a modern risk
society (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 contemporary 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 conceptualising 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 sociologists 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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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 individualist 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 exemplar for sociological theorising.
Max Webers work helps situate the theorising of choice between the structuralist and
individualist paradigms of sociology. Webers mis-readings of Marx (Weber did not read
the latters 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
peoples choices about dress, marriage, eating, etc. contribute to the social reproduction
of status distinctions (social inequalities), but that these choices are themselves constrained 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 individuals 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). Webers 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). Bourdieus work extends Webers 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 habitus peoples 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 Bourdieus borrowings
from Weber, where the latter theorised the need to take into account the deployment of
resources 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 cultural 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 Bourdieus concept of capital and that of the equally wellknown James Coleman is that the former explicitly rejects the latters key presumption
that the actions of agents can be analysed and understood in terms of choices that maximise utility (Adkins, 2008: 1211). Indeed Bourdieu sought to offer an alternative to
Colemans 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 individually produced.
Bourdieus 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: 103104). In Bourdieus words, the field is a space of position-takings, a structured 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 Bourdieus concept of capital is not used in a descriptive and functional manner but understood in a dynamic sense and fundamentally as a class phenomenon. This means interpreting Bourdieus 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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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 specific communication styles or behavioural skills. Capital in various forms, particularly in
the form of knowledge and skills, is thus implicated in human action, it is employed for
all meaningful action, and is a key component in peoples 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 healthpromoting (Abel and Frohlich, 2012: 238). After all, nutritional knowledge is often
ignored 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 ones 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, differentially enabling or suppressing the realisation of various forms of power, and giving
shape 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 illustrate 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 (most
notably government subsidies) and penalties (e.g. taxation penalties) favourably position 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 peoples 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. Its just the way Ive
grown up (in Natalier and Willis, 2008).
Zadoroznyjs (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. Bourdieus 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 services (Zadoroznyj, 1999: 268). While social class differences are evident in the womens 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 wouldnt let me sit or be the way I
wanted, so I just screamed. My husband was so embarrassed but I thought, Well youre
going to get it because they wouldnt let me have my say (in Zadoroznyj, 1999: 281).
What is evident from this study is the way experiential knowledge may shift the dynamics 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 individuals 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 providing 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 cultural underpinnings of choice-related behaviours, and the manner in which social inequalities in health are perpetuated (e.g. Abel and Frohlich, 2012; Cockerham, 2005;

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Veenstra, 2007). This is because Bourdieus 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 Shims analysis is in pointing to the co-construction of choice through interaction between patient and healthcare provider (and extending it beyond patient stereotyping 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 services 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, with
the decisions made for them by their healthcare practitioner, and are, in all cases, constrained by the medical definition of the problem and its solution, and by the availability 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 Bourdieus fields are not just universes of belief,
they are arenas of practices where power operates. They are structuring structures, and
an aspect of Bourdieus 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 hierarchically
organised 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 sociological 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 services, 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 Australias 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 candidate at the Australian Catholic University and is researching how self-management goals are negotiated 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 siblings 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 Sydneys 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 Shorts 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).

Rsum
La promotion du choix est un thme courant aussi bien dans les discours politiques
que dans les arguments de vente au sujet des soins de sant. Toutefois, face aux
multiples parcours possibles quoffre le labyrinthe des soins de sant, comment
les consommateurs ou patients comprennent-ils les choix en matire de sant et
comment y sont-ils exposs ? Quelle est la signification de choix dans le contexte
politique et, plus important encore, comment ces choix sont-ils produits et structurs
du point de vue sociologique ? Dans cet article thorique, nous examinons linteraction
des trois concepts cls et interconnects de Bourdieu capital, habitus et champ dans
la structuration des choix en matire de soins de sant. Ces concepts sont proposs

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en tant qualternative la thorie du choix rationnel selon laquelle le choix est

considr sans rserves comme un bien fondamental mme de fournir une solution
aux problmes du systme sanitaire. Notre argument est que les analyses sociologiques
des choix en matire de soins de sant doivent davantage tenir compte du champ
dans lequel ces choix sont faits afin de mieux expliquer la structuration du choix.
Mots-cls
Bourdieu, choix, ingalit, services de soins de sant, thorie du choix rationnel
Resumen
La promocin de la eleccin es un tema comn tanto en discursos polticos como
en los reclamos comerciales sobre la asistencia sanitaria. Sin embargo, dentro de las
mltiples vas potenciales del laberinto de la asistencia sanitaria, cmo entienden
o experimentan la eleccin los consumidores de planes de salud o pacientes? Qu
se entiende por eleccin en el contexto de la poltica? y, especialmente desde una
perspectiva sociolgica, cmo se producen y estructuran esas elecciones a nivel
social? En este trabajo terico, consideramos la interaccin de los tres conceptos clave
interrelacionados de Bourdieu capital, habitus y campo en la estructuracin de la
eleccin del plan de salud. Estos se ofrecen como alternativa a la teora de la eleccin
racional, donde la eleccin se considera acrticamente como un bien fundamental y es
capaz de proporcionar una solucin a los problemas del sistema de salud. Argumentamos
que los anlisis sociolgicos de eleccin de los planes de salud deben tener ms en
cuenta el campo en el que las elecciones se realizan con el fin de explicar mejor la
estructuracin de la eleccin.
Palabras clave
Bourdieu, desigualdad, eleccin, servicios sanitarios, teora de la eleccin racional

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