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9781412934633-Chap-17 1/10/09 10:19 AM Page 259

SOCIAL DIVISION OF HEALTH CARE 259

understood as doing so out of their own These are the classic features of reification
goodness as people. Management may or (Lukács, 1971): the fragmentation of the
may not tolerate these deviations from work- unity of human action by a division of labour
ing to rule. The fact remains that the ‘extras’ driven by a will to impose an instrumental
are not remunerated and are seen as a ‘labour rationality of control; the consequent
of love’ that workers do as a result of being replacement of that unity in the consciousness
intrinsically good people (Aronson and of the agents by a series of binary categories
Neysmith, 1996; Hochschild, 1983: 167; (rational–irrational, objective–subjective,
Twigg, 2000: 121). social–natural, etc.); the reduction of the rela-
Fully commodified labour is a sum of dis- tions produced by complex collective labour
crete, identifiable tasks; incompletely com- either to aspects of an objective, bureaucrati-
modified work is greater than the sum of its cally imposed, process or to aspects of the
parts, never reducible to a set of operations subjective nature of the individual workers;
prescribed in a contract. In a holistic concept the opposition between active producers and
of care, ‘extras’ would be recognized as an passive consumers, between those who do
integral part of the work and be part of the and those who receive. As a result of reifica-
overall work plan, not left to personal whim. tion, there is conflict between care as a dia-
By splitting the labour process asunder, logical, reciprocal process of co-production,
rationalization reduces formal care to a set of and as a service distributed or sold to individ-
rationalized, costed services, making much ual recipients.
of care on the ‘supply side’ not only informal
and invisible, but also, in a sense, an ‘irra-
tional residue’, like weeds growing in a man-
icured garden. ‘NECESSARY’ AND ‘SURPLUS’
On the ‘demand side’, those in need of LABOUR
care are constructed – either as passive
patients and clients or as active, empowered What seems like exploitation, waste or
consumers of products and services. As pas- superfluity in the logic of commodity
sive clients, they are no longer conceived as exchange, and like irrationality in the logic
co-producers; as active consumers, they may of redistribution – doing more than was
be, but in the context of a contractual, market demanded, giving more than was expected,
relation, in which they may act as employers. donating without expectation of a return – is
In many cases, however, those in need of the epitome of sensible behaviour in the logic
care, and their kin, are mobilized as agents of of reciprocity. Furthermore, while the person
their own care and made to act as substitutes who gives without receiving the equivalent
for paid workers who are no longer present appears as the loser in the logic of the
or no longer have time. As the home increas- market, the opposite would tend to be the
ingly becomes the site of post-acute care, case in the logic of giving: the person who
patients and their kin are trained by time- does not give back remains in debt and thus,
crunched professionals to effect a range of potentially, in a position of inferiority. As an
technical tasks. This work transfer, driven by employee, the worker’s relationship with the
the financial imperatives of the public sector, employer is governed by the logic of the
remains largely invisible and unrecognized. market; as a caregiver, her relationship with
What were identified in the first section as the person for whom she cares is governed by
essential aspects of care, namely its co- the logic of reciprocity.
production by ‘workers’ and ‘users’, and its This juxtaposition of the commodity and
union of physical, emotional and intellectual gift forms makes it possible for the worker to
work, are eclipsed by the working of the be subject to the dual imperatives of the
social division of care. employer’s will and the complex requirements