Skip to main content

Advertisement

SpringerLink
Log in

The Social Construction of Incompetency: Moving Beyond Embedded Paternalism Toward the Practice of Respect

  • Original Article
  • Published:
Health Care Analysis Aims and scope Submit manuscript

Abstract

This article illustrates the less-acknowledged social construction of the concept of ‘incompetency’ and draws attention to the moral concerns it raises in health care encounters in the south Indian city of Chennai. Based on data drawn from qualitative research, this study suggests that surgeons subjectively construct the idea of incompetency through their understanding of the perceived circumstantial characteristics of the patients and family members they serve. The findings indicate that surgeons often underestimate patients and family members’ capacity based on constructed assessments, which leads to paternalistic practice. In this article, I illustrate how these assessments influence the surgeons’ practices and provide the moral and practical justifications for their actions. The constructed knowledge becomes a source for drawing normative justification for surgeons’ actions and, in conjunction with socially enforced power relationships, results in patients and family members to be on the receiving end of disrespectful attitudes. Based on the data analysis and by drawing on philosophical analysis, I emphasize the need to focus on ‘respect for persons,’ to rethink the framework of ‘capacity,’ and to practice respect in hospital settings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Abernethy, V. (1984). Compassion, control, and decisions about competency. The American Journal of Psychiatry,141(1), 53–58. https://doi.org/10.1176/ajp.141.1.53.

    Article  CAS  PubMed  Google Scholar 

  2. Abernethy, V. (1991). Judgments about patient competence: Cultural and economic antecedents. In Competency (pp. 211–226). Springer.

  3. Alvarez, M. (2007). The causalist/Anti-causalist debate in the theory of action: What it is and why it matters. In A. Leist (ed.), Action in Context (103–123). Berlin/NY: De Gruyter.

    Google Scholar 

  4. Appelbaum, P. S. (2007). Assessment of patients’ competence to consent to treatment. New England Journal of Medicine,357(18), 1834–1840. https://doi.org/10.1056/NEJMcp074045.

    Article  CAS  PubMed  Google Scholar 

  5. Appelbaum, P. S., & Grisso, T. (1988). Assessing patients’ capacities to consent to treatment. New England Journal of Medicine,319(25), 1635–1638.

    CAS  PubMed  Google Scholar 

  6. Baru, R., Acharya, A., Acharya, S., Kumar, A. K. S., & Nagaraj, K. (2010). Inequities in access to health services in India: caste, class and region. Economic and Political Weekly, 49–58. https://www.jstor.org/stable/25742094

  7. Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics. New York: Oxford University Press.

    Google Scholar 

  8. Berg, J. W., Appelbaum, P. S., Lidz, C. W., & Parker, L. S. (2001). Informed consent: Legal theory and clinical practice. New York: Oxford University Press.

    Google Scholar 

  9. Berger, P., & Luckmann, T. (1966). The social construction of knowledge: A treatise in the sociology of knowledge. NY: Doubleday.

    Google Scholar 

  10. Blumer, H. (1986). Symbolic interactionism: Perspective and method. Berkeley: University of California Press.

    Google Scholar 

  11. Bourdieu, P. (1990). The logic of practice. Stanford, CA: Stanford University Press.

    Google Scholar 

  12. Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment. Journal of the Royal Society of Medicine,97(9), 415–420.

    PubMed  PubMed Central  Google Scholar 

  13. Buchanan, A. E., & Brock, D. W. (1989). Deciding for others: The ethics of surrogate decision making. Cambridge: Cambridge University Press.

    Google Scholar 

  14. Bullock, E. (2018). Paternalism and the practitioner/patient relationship. In K. Grill & J. Hanna (Eds.), The routledge handbook of the philosophy of paternalism (pp. 311–321). London: Routledge.

    Google Scholar 

  15. Buss, S. (1999). Respect for persons. Canadian Journal of Philosophy, 29(4), 517–550. Retrieved from https://www.jstor.org/stable/40232071.

  16. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative research. London: Sage.

    Google Scholar 

  17. Charmaz, K. (2017). The power of constructivist grounded theory for critical inquiry. Qualitative Inquiry,23(1), 34–45. https://doi.org/10.1177/1077800416657105.

    Article  Google Scholar 

  18. Coons, C., & Weber, M. (2013). Paternalism: theory and practice. Cambridge: Cambridge University Press.

    Google Scholar 

  19. Corbin, J. M., & Strauss, A. (1990). Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative Sociology,13(1), 3–21.

    Google Scholar 

  20. Creswell, J. W., Hanson, W. E., Clark Plano, V. L., & Morales, A. (2007). Qualitative research designs: Selection and implementation. The Counseling Psychologist,35(2), 236–264.

    Google Scholar 

  21. Dancy, J. (2000). Practical reality. New York: Clarendon Press.

    Google Scholar 

  22. Darwall, S. L. (1977). Two kinds of respect. Ethics, 88(1), 36–49. Retrieved from https://www.jstor.org/stable/2379993.

  23. Darwall, S. L. (2006). The second-person standpoint: Morality, respect, and accountability. New York: Harvard University Press.

    Google Scholar 

  24. Das, J., & Hammer, J. (2012). Health and health care policy in India: The case for quality of care. In Ghate, C.(ed.), The Oxford Handbook of the Indian Economy. New York: Oxford University Press.

    Google Scholar 

  25. Dean, R. (2009). The formula of humanity as an end in itself. In T. Hill (ed.), The Blackwell Guide to Kant’s Ethics (pp. 83–101). Oxford: Wiley-Blackwell.

    Google Scholar 

  26. Dean, R. (2013). Humanity as an Idea, as an Ideal, and as an end in itself. Kantian Review,18(2), 171–195.

    Google Scholar 

  27. Denzin, N. K., & Lincoln, Y. S. (2011). The Sage handbook of qualitative research. Thousand Oaks: Sage.

    Google Scholar 

  28. Elston, M. A. (2002). The politics of professional power: Medicine in a changing health service. In M. Bury, M. Calnan, & J. Gabe (Eds.), The sociology of the health service (pp. 68–98). London: Routledge.

    Google Scholar 

  29. Entwistle, V. A., & Watt, I. S. (2013). Treating patients as persons: A capabilities approach to support delivery of person-centered care. The American Journal of Bioethics,13(8), 29–39. https://doi.org/10.1080/15265161.2013.802060.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Epstein, R. M., Fiscella, K., Lesser, C. S., & Stange, K. C. (2010). Why the nation needs a policy push on patient-centered health care. Health Affairs,29(8), 1489–1495. https://doi.org/10.1377/hlthaff.2009.0888.

    Article  PubMed  Google Scholar 

  31. Estrada, S. (2017). Qualitative analysis using R: A free analytic tool. The Qualitative Report,22(4), 956.

    Google Scholar 

  32. Etherington, K. (2007). Ethical research in reflexive relationships. Qualitative Inquiry,13(5), 599–616.

    Google Scholar 

  33. Fateh-Moghadam, B., & Gutmann, T. (2014). Governing [through] autonomy. The moral and legal limits of “soft paternalism.” Ethical Theory and Moral Practice, 17(3), 383–397. Retrieved from https://www.jstor.org/stable/24478655.

  34. Finlay, L., & Gough, B. (2003). Reflexivity: A practical guide for researchers in health and social sciences. Oxford: Blackwell.

    Google Scholar 

  35. Fleming, P., & Spicer, A. (2007). Contesting the corporation: Struggle, power and resistance in organizations. Cambridge: Cambridge University Press.

    Google Scholar 

  36. Fochsen, G., Deshpande, K., & Thorson, A. (2006). Power imbalance and consumerism in the doctor-patient relationship: Health care providers’ experiences of patient encounters in a rural district in India. Qualitative Health Research,16(9), 1236–1251.

    PubMed  Google Scholar 

  37. Foster, C. (2019). The rebirth of medical paternalism: An NHS Trust v Y. Journal of Medical Ethics,45(1), 3–7. https://doi.org/10.1136/medethics-2018-105098.

    Article  PubMed  Google Scholar 

  38. Foucault, M. (1980). in Gordon, C. (ed.), Power/knowledge: Selected interviews and other writings, 1972–1977. New York: Pantheon.

  39. Foucault, M. (2002). The birth of the clinic. London: Routledge.

    Google Scholar 

  40. Fox, R. C. (1990). The evolution of american bioethics: a sociological perspective BT–social science perspectives on medical ethics. In G. Weisz (Ed.) (pp. 201–217). Dordrecht: Springer.

  41. Garfinkel, H. (1967). Studies in ethnomethodology. Englewood Cliffs, NJ: Prentice-HAll.

  42. Gergen, K. J. (1999). An invitation to social construction. New York: Sage.

    Google Scholar 

  43. Gerstenecker, A., Niccolai, L., Marson, D., & Triebel, K. L. (2016). Enhancing medical decision-making evaluations: Introduction of normative data for the capacity to consent to treatment instrument. Assessment,23(2), 232–239.

    PubMed  Google Scholar 

  44. Grisso, T., & Appelbaum, P. S. (1995). Comparison of standards for assessing patients’ capacities to make treatment decisions. American Journal of Psychiatry,152(7), 1033–1037.

    CAS  PubMed  Google Scholar 

  45. Groll, D. (2014). Medical paternalism—Part 2. Philosophy Compass,9(3), 194–203. https://doi.org/10.1111/phc3.12110.

    Article  Google Scholar 

  46. Hacking, I. (1999). The social construction of what?. Cambridge: Harvard University Press.

    Google Scholar 

  47. Hansen, H., Holmes, S., & Lindemann, D. (2013). Ethnography of health for social change: Impact on public perception and policy. Social Science & Medicine,99, 116–118. https://doi.org/10.1016/j.socscimed.2013.11.001.

    Article  Google Scholar 

  48. Hermann, H., Trachsel, M., & Biller-Andorno, N. (2015). Physicians’ personal values in determining medical decision-making capacity: A survey study. Journal of Medical Ethics,41(9), 739–744.

    PubMed  Google Scholar 

  49. Hill, T. E. (1991). Autonomy and self-respect. Cambridge: Cambridge University Press.

    Google Scholar 

  50. Hill, T. E. (2000). Respect, pluralism, and justice: Kantian perspectives. Oxford: Oxford University Press.

    Google Scholar 

  51. Huang, R. (2014). RQDA: R-based qualitative data analysis. R Package Version 0.2--7. Retrieved November 18, 2015 from http://rqda.r-forge.r-project.org.

  52. Jacob, K. S. (2014). Informed consent and India. The National Medical Journal of India,27(1), 35–38.

    CAS  PubMed  Google Scholar 

  53. Jones, C., & Porter, R. (2002). Reassessing foucault: Power, medicine and the body. London: Routledge.

    Google Scholar 

  54. Lamont, S., Jeon, Y.-H., & Chiarella, M. (2013). Assessing patient capacity to consent to treatment: An integrative review of instruments and tools. Journal of Clinical Nursing,22(17–18), 2387–2403.

    PubMed  Google Scholar 

  55. Lindenbaum, S., & Lock, M. M. (1993). Knowledge, power, and practice: The anthropology of medicine and everyday life. New York: University of California Press.

    Google Scholar 

  56. Macklin, R. (1999). Against relativism: Cultural diversity and the search for ethical universals in medicine. New York: Oxford University Press.

    Google Scholar 

  57. Manson, N. C., & O’Neill, O. (2007). Rethinking informed consent in bioethics. Cambridge: Cambridge University Press.

    Google Scholar 

  58. Miller, F., & Wertheimer, A. (2009). The ethics of consent: Theory and practice. New York: Oxford University Press.

    Google Scholar 

  59. Mocherla, S., Raman, U., & Holden, B. (2011). Clinician-patient communication in a glaucoma clinic in India. Qualitative Health Research,21(3), 429–440.

    PubMed  Google Scholar 

  60. O’Neill, O. (2003). Some limits of informed consent. Journal of Medical Ethics,29(1), 4–7. https://doi.org/10.1136/jme.29.1.4.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Pigg, S. L. (2013). On sitting and doing: Ethnography as action in global health. Social Science & Medicine,99, 127–134. https://doi.org/10.1016/j.socscimed.2013.07.018.

    Article  Google Scholar 

  62. Rose, N. (1999). Powers of freedom reframing political thought. Cambridge: Cambridge University Press.

    Google Scholar 

  63. Rush, F. (2004). Conceptual foundations of early critical theory. In F. L. Rush (Ed.), The Cambridge companion to critical theory (pp. 6–39). Cambridge: Cambridge University Press.

    Google Scholar 

  64. Ryan, M., Kinghorn, P., Entwistle, V. A., & Francis, J. J. (2014). Valuing patients’ experiences of healthcare processes: Towards broader applications of existing methods. Social Science & Medicine,106, 194–203.

    Google Scholar 

  65. Schneider, C. (1998). The practice of autonomy: Patients, doctors, and medical decisions. New York: Oxford University Press.

    Google Scholar 

  66. Schroeder, M. (2008). Having reasons. Philosophical Studies,139(1), 57–71.

    Google Scholar 

  67. Schwandt, T. A. (1998). Constructivist, interpretivist approaches to human inquiry. In N. K. Denzin & Y. S. Lincoln (Eds.), Landscape of qualitative research: Theories and issues (Vol. 1, pp. 118–137). Thousand Oaks: Sage. Retrieved from https://www.researchgate.net/profile/Thomas_Schwandt/publication/232477264_Constructivist_Interpretivist_Approaches_to_Human_Inquiry/links/557048d908aeab777228bfef/Constructivist-Interpretivist-Approaches-to-Human-Inquiry.pdf.

  68. Shaikh, M., Miraldo, M., & Renner, A.-T. (2018). Waiting time at health facilities and social class: Evidence from the Indian caste system. PloS One,13(10), e0205641.

    PubMed  PubMed Central  Google Scholar 

  69. Shim, J. K. (2010). Cultural health capital: A theoretical approach to understanding health care interactions and the dynamics of unequal treatment. Journal of Health and Social Behavior,51(1), 1–15.

    PubMed  Google Scholar 

  70. Spike, J. P. (2017). Informed consent is the essence of capacity assessment. The Journal of Law, Medicine & Ethics,45(1), 95–105.

    Google Scholar 

  71. Subramani, S. (2018). The moral significance of capturing micro-inequities in hospital settings. Social Science & Medicine,209, 136–144. https://doi.org/10.1016/j.socscimed.2018.05.036.

    Article  Google Scholar 

  72. Subramani, S. (2019a). Practising reflexivity: Ethics, methodology and theory construction. Methodological Innovations,12(2), 1–11. https://doi.org/10.1177/2059799119863276.

    Article  Google Scholar 

  73. Subramani, S. (2019b). The Rhetoric of the ‘Passive Patient’ in Indian Medical Negligence Cases. Asian Bioethics Review,11(4), 349–366. https://doi.org/10.1007/s41649-019-00106-1.

    Article  Google Scholar 

  74. Thompson, G. A., & Whiffen, L. H. (2018). Can physicians demonstrate high quality care using paternalistic practices? A case study of paternalism in latino physician-patient interactions. Qualitative Health Research,28(12), 1910–1922. https://doi.org/10.1177/1049732318783696.

    Article  PubMed  Google Scholar 

  75. Vellinga, A., Smit, J. H., Van Leeuwen, E., Van Tilburg, W., & Jonker, C. (2004). Instruments to assess decision-making capacity: An overview. International Psychogeriatrics,16(4), 397–419.

    PubMed  Google Scholar 

  76. Verlinde, E., De Laender, N., De Maesschalck, S., Deveugele, M., & Willems, S. (2012). The social gradient in doctor-patient communication. International Journal for Equity in Health,11(1), 12.

    PubMed  PubMed Central  Google Scholar 

  77. Wasserman, J. A., & Navin, M. C. (2018). Capacity for preferences: Respecting patients with compromised decision-making. Hastings Center Report,48(3), 31–39.

    PubMed  Google Scholar 

  78. Wear, S. (1998). Informed consent: Patient autonomy and clinician beneficence within health care. Washington: Georgetown University Press.

    Google Scholar 

  79. Welie, J. V. M., & Welie, S. P. K. (2001). Patient decision making competence: outlines of a conceptual analysis. Medicine, Health Care and Philosophy,4(2), 127–138.

    CAS  Google Scholar 

Download references

Acknowledgments

I build my argument in this paper based on the data analysis of my doctoral study. I am grateful for the grant awarded by the University Grants Commission under a Junior and Senior Research Fellowship (2013-18) for the doctoral work. I also thank Swiss Excellence Postdoctoral Fellowship (2019-2020), it enabled me to access academic environment to write my papers and develop conceptual arguments at the Institute of Biomedical Ethics and History of Medicine, University of Zurich. I thank reviewers for their comments, and Aditya Narayanan and Sophie Gloeckler to their help with editing.

Author information

Authors and Affiliations

  1. Swiss Excellence Federal Scholar (ESKAS), Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland

    Supriya Subramani

  2. Department of Humanities and Social Science, Indian Institute of Technology Madras, Chennai, India

    Supriya Subramani

Authors
  1. Supriya Subramani
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Supriya Subramani.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 14 kb)

Supplementary file2 (DOCX 15 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Subramani, S. The Social Construction of Incompetency: Moving Beyond Embedded Paternalism Toward the Practice of Respect. Health Care Anal 28, 249–265 (2020). https://doi.org/10.1007/s10728-020-00395-w

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10728-020-00395-w

Keywords

Search

Navigation