Pretenders and performers: Professional responses to the commodification of health care

How do professionals respond to the commodification of health care? Using an interactionist perspective, we answer this question by referring to the findings of five qualitative studies of hospital surgeons, mental health-care professionals, emergency and ambulance personnel, and youth workers in the Netherlands. We find that differential levels of professional autonomy, dominance and discretion spawn different combinations of the logics of the market, bureaucracy and professionalism. We discern five new ways of enacting professionalism: (1) entrepreneurialism: embracing commodification as integral part of professionalism; (2) activism: rallying against encroachment on the profession; (3) bureaucratization: seeking reassurance in procedures; (4) pretending: faking compliance to protect autonomy; and (5) performing: upholding the profession through conscious and skillful management of appearance in the eyes of patients and the public. Hidden strategies of opposition, however, support commodification since most professionals outwardly play by the rules and mix the Logic of care with those of the market and bureaucracy, rendering alternative courses of action and solidarity more difficult. Uncertainty is increasing for all professionals, leading to feelings of insecurity and reflexivity but also to creativity. Professionalism is increasingly 'disembedded', called into question, and de-routinized.