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SOCIAL DIVISION OF HEALTH CARE 253

emotions and bodies are laid bare (indeed, it patient in a hospital, or is it something that
is frequently easier for the acts of care to take the hospital as a whole accomplishes? Or
place between strangers, than between again, is it the rich totality of the many rela-
friends or kin where issues of taboo or loss of tions and processes constituted by a society’s
status arise – see Twigg, 2000: 73–4). Care health care ‘system’ as a whole? The answer
work is the production of the trust without is all of the above. As Pat Armstrong (2004)
which the other aspects of care as process puts it, one needs both to lump and to slice,
and outcome could not happen. that is., to try to deploy concepts dialectically
As the production of trust, in the context of as a way of seizing phenomena in their
which intimate and even painful practices unity-within-difference.
may be performed in order to restore health
or reduce pain, care is also tied to consent.
For example, states have enacted laws and
professional bodies have created protocols THE RELATIONS OF PRODUCTION
governing consent by care recipients or those IN/OF CARE – SOME INITIAL
who represent them. Consent is based on trust, CONSIDERATIONS
and also on information and understanding,
on a sharing of objectives and values. Care is The key question to be addressed is: who
thus reflexive work, ‘entailing loops in which cares and under what circumstances do (can)
recursive knowledges, emotions, and value- they do so (Armstrong and Kits, 2003)? If
judgements can be reinvested in the relation- care is work, then it can be the object of a
ship between producer and user’ (Maheu and labour process analysis, that is., an analysis of
Bien-Aimé, 1996: 190 [my translation – the relations of production (classic contribu-
PLB]; Offe, 1985). tions include Braverman, 1974, Burawoy,
Care in the abstract cannot be an adequate 1979, 1985; Hales, 1980; recent ones include
description of every concrete example of care O’Doherty and Willmot, 2001; Smith and
work; nor will every specific task abstracted Thompson, 1998). Such an analysis can be
from the whole display every feature of summed up in three questions. Who decides
labour. Taken singly, in isolation, the vast what is to be done? Who performs the work
number of practices, organizations and insti- needed to execute what has been decided
tutions that make up health care, from hospi- upon? Who enjoys the fruits of this work?
tals to the home, from surgery to sitting with Imagine an abstract model of care in
Alzheimer’s sufferers, from dialysis to diag- which all parties to the care relationship
nostic tests, might seem to involve little or no shared in the positing of its goals, made an
intervention in the body (psychological equal effort to execute the tasks required to
counselling) or emotional work (analyzing a achieve those goals, and enjoyed the fruits of
blood sample). It is essential, however, to that work, the bodies of all involved being
bear in mind that such specific examples are the objects of labour. In such a situation of
the product of a given division of labour. As perfect co-production, in which all parties
such they may display at best some aspect of, actively built the relationship with each
and some connection to, care in general, not other, engaging in emotion work in order to
care as such. It is only when they are taken as enhance each other’s well-being, there would
a whole that we can grasp their interrelations be a virtuous circle of reciprocity, a spiral of
and commonalities. Does health care occur giving in which each party, rather than seek-
on the micro-sociological level of individual ing to abolish the debt through payment of its
practices and interactions or on the equivalent, instead perpetuated the mutual
macro-sociological level of collective pro- indebtedness by continual giving to the other
ductive processes and institutions? Is it, for (Godbout, 2000). The wealth produced
example, performed between a nurse and a by care would consist, to be sure, of the