ORI GIN AL ARTICLE

Situations of Choice: Configuring the EmpoweredConsumer of Hearing Technologies

Anette Lykke Hindhede

� Springer Science+Business Media New York 2013

Abstract Focusing on the largest and, arguably, the least visible disability group,

the hearing impaired, this paper explores present-day views and understandings of

hearing impairment and rehabilitation in a Danish context, with particular focus on

working-age adults with late onset of hearing impairment. The paper shows how

recent changes in perception of the hearing impaired patient relate to the intro-

duction of a new health care reform that turns audiological rehabilitation into a

consumer issue. Ethnographic and interview data from hearing clinics provides

evidence that the hearing technologies that are on offer stabilise in specific forms

through processes of negotiation among a variety of social actors representing the

interests of science, industry, government, and hearing-impaired people. The dis-

cussion critically considers the emergence of an ‘‘informed consumer’’ in audio-

logical practices.

Keywords Choice � Consumerism � Empowerment � Hearing technologies �Health research

Introduction

This paper focuses on the present-day heterogeneous processes and practices of

becoming a hearing aid user. Hearing problems affect a significant segment of the

Western population, as the proportion of hearing-impaired people is approximately

16 %. For people of working age, the proportion is approximately 11 % [25, 26].

However, only about 5 % of the population wear a hearing aid. As the numbers

indicate, there appears to be a large group who seem to be reluctant to acknowledge

their hearing impairment, or who seem not to consider audiological rehabilitation in

A. L. Hindhede (&)

Steno Health Promotion Center, Niels Steensens Vej 8, 2820 Gentofte, Denmark

e-mail: atlh@steno.dk

123

Health Care Anal

DOI 10.1007/s10728-013-0261-4

terms of a hearing aid to be a pertinent offer. The Scandinavian national healthcare

systems are to a large degree owned and managed by the state, financed from

general taxation and access to care is free for all citizens at the point of delivery. In

Denmark, all the examination and treatment of the hearing-impaired is free of

charge for all persons of fixed abode in Denmark, irrespective of age and income.

The most recent models of digital hearing aids and assistive devices are also

provided free of charge. Nonetheless, in calculating the costs to society in

connection with reduced hearing in the age group 50–64, hearing problems are

estimated to cause Denmark productivity losses of approx. EUR 360 million on an

annual basis. This is equivalent to a loss of 11.000 full-time jobs nationally [1].

Thus, in the year 2000 the Danish government decided to allow the subsidised

purchase of hearing aids in private hearing clinics. The Act of Private Hearing Aid

Treatment [20] was intended to reduce the pressure on public clinics, thus

stimulating competition between hearing health care providers and in turn giving

hearing-impaired people increased consumer choice and increased quality of care

provision.

Mobilising the Elective Consumer

We are dealing with a group that involves different nomenclatures. In the UK, the

term ‘‘deaf’’ is often used to include both totally deaf and hard-of-hearing people.

‘‘Hearing impaired’’ is the commonly used term to describe inclusively deaf and

hard-of-hearing people. However, in other parts of the world, e.g. in North America,

the use of the expression ‘‘hearing impaired’’ is a derogatory term: people are

categorised as either ‘‘deaf’’ or ‘‘hard of hearing’’. They are also ‘‘patients’’,

‘‘clients’’ and ‘‘users’’ and—in Denmark from year 2000—also ‘‘consumers’’.

Words inevitably bring meanings along with them, and the preferred choice of the

word ‘‘patient’’ and ‘‘hearing impaired’’ in the paper may bear negative associa-

tions; however, this is how they are addressed—in the news, in the health care

system, by the politicians.

The shift in conceptualization of the group in question is more than rhetorical

though, as it signals a shift in the nature of hearing health care and the trajectory of

health and social policy more generally where concepts of self-care, patient

empowerment and choice have become increasingly important. One fictive

perspective is rendered through the rhetoric of the technologically empowered

citizen who engages in new forms of participation, collaboration and self-care.

Another fictive perspective encompasses a different view where patients self-

organise and collaborate in order to compete with traditional medical understand-

ings of patients and their diseases. They both signal various processes of becoming

and some are already performed and acted out (in present audiological practices)

whereas others are imagined and idealised (in hearing health policies). However, in

this paper on the basis of the empirical findings of this research the author argues

that the health care policies intended to empower hearing impaired individuals may

not just transform, but in fact also diminish intended agencies and powers of at least

some of the newly diagnosed hearing impaired patients. The ability of the patient to

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embrace the ethos of ‘‘empowered consumer’’ has been problematized by various

writers [4, 18, 27]. Mol [21], for example, describes that in the civic version of

consumerism health professionals are not considered as selling the patient a product

in the consultation room. Instead, the relationship is based on a form as a contract

where the health professional and the patient are equal. The problem is though, that

by definition citizens are not troubled by their bodies, but patients are. Thus, in the

civic version of consumerism the body has to be subjugated [21, p. 74]. This means

that the logic of choice and the logic of care are profoundly different modes of

thinking. Mol demonstrates that ‘‘autonomy’’ and ‘‘choice’’ can be rewritings for

social practices of neglect, as responsibility is placed on the individual for his/her

care. This paper considers what happens when they get mixed together as they do in

audiological practices.

Situations of Choice for the Hearing Impaired

The Government’s inclination to develop patients’ attitude of consumerism by the

introduction of the private hearing aid treatment act in 2000 follows on from the

assumption that consumerism is about choice. The Act [20] was intended to reduce

the pressure on public clinics and to give hearing impaired patients the choice

between a public and a private dispensation of hearing aids: ‘‘For hearing aids, the

applicant may, if he does not want to use the public county’s supplier, choose a

private, approved hearing aid supplier in accordance with the Social Services Act

sec. 97 [5, 20]’’. It is commonly believed that offering patients’ choice makes them

feel free, empowered and more in control. Within audiological practice the

consumables are hearing aids; highly technological products which need to be

adjusted to the changing and often subjective requirements of the individual user.

Research has shown that many hearing-impaired persons do not continue to use

their hearing aids after the fitting, and those who do continue to report

communication difficulties in everyday life [10, 14, 28].

The aim of this paper is to take forward notions of ‘‘choice’’, ‘‘empowerment’’,

‘‘active patients’’ and ‘‘consumerism’’ as part of an overriding discursive

formation and explore how these are played out as part of the market-type

reforms in Danish audiological practices. The author considers this an example of

the dawning of a new patient role within audiology—at least from the point of

view of the health care systems managers, policy makers and manufacturers of

hearing technologies. It focuses on the space of enactment and ordering of hearing

disability and how ‘‘active’’ patients negotiate biomedical ‘‘expertise’’ and manage

the blurred boundaries between empowerment and compliance. As argued by Mol

[21] choice is a specific mode of organizing action and interaction and of

understanding people and daily lives. In the logic of choice not only the autonomy

is regarded as an ethical good, but in addition ‘‘in the logic of choice making

normative judgments is the moral activity par excellence, and it is this activity

that this logic endorses’’ [21, p. 74]. In contrast, ‘‘the logic of care has no separate

moral sphere. Because ‘values’ intertwine with ‘facts’ and caring itself is a moral

activity, there is no such thing as an (argumentative) ethics that can be

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disentangled from (practical) doctoring’’ (ibid, p. 79). Data collected illustrates the

way in which audiological practices are accompanied with diverse and contra-

dictory discourses. Thus, rather than focusing on patients’ ability to choose, the

discussion concentrates on what Mol [21, p. 7] calls ‘‘situations of choice’’ as

these are not self-evidently given. The paper examines potential benefits of patient

responsibility thereby acknowledging that empowerment, even in its neo-liberal

guise, might be a positive development in some cases for some hearing impaired

people.

The paper is divided into four sections. Firstly, a description of methods is

provided. This is followed by an analysis of the configuring of the active patient in

audiological practices. The analysis focuses on ‘‘situations of choice’’ when

soundscapes are configured in clinical audiological examinations and tests in order

to assess patient’s hearing. In addition, it also focuses on the construction of

techniques of ‘‘cure’’ are constructed which involves an identification of the

repositories of the relevant knowledge in these encounters. Finally, the emergence

of an ‘‘informed consumer’’ in audiological practices is critically considered.

Sources

The empirical material presented is part of a larger study of the rehabilitation of

working age people with adult onset hearing impairment where participative

observations, video recordings, and interviews were conducted [9]. A total of 41

people from audiological encounters in two outpatient hearing clinics in different

hospitals in outer Copenhagen were recruited. Participants ranged in age from 20 to

70 years, with a mean age of 56, and a range of gender and socioeconomic

backgrounds were represented. They were diagnosed as hearing-impaired with

acquired hearing loss where a physician had decided that the provision of a hearing

aid was the appropriate treatment. The criteria were that they were first-time users,

of working age, and could speak and read Danish. There were no criteria as to

degree of hearing impairment. Some were classified as having mild to severe

hearing impairment, while others had hearing impairment that differed for each ear.

The functional and biological issues associated with hearing impairment are

inconsequential to this project, as the focus was on patients’ subjective experiences.

In addition, it is well established that self-perceived hearing disability has little

relationship to measurable hearing thresholds [5].

Besides 6 months of participatory observation in the hearing clinic of the

everyday practice in the hearing clinic and physician/patient interactions the data

used in this paper concerns all 41 patients and were constructed as follows:

1. The same day of the dispensing: Prefitting interview (lasting 10–20 min)

2. Immediately after the prefitting interview: Video recordings (nonparticipant

observation) of the dispensation of the hearing aids (lasting approx. 45 min)

3. 6 weeks after the dispensing: Postfitting interview (lasting 20–60 min)

4. 1 year after the dispensing: Follow-up survey regarding patients’ use of post

requisition offers

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Prefitting Interview

Prefitting interviews were conducted with the patients in the time right before

dispensation of the hearing aids. In these interviews, the researcher sought to learn

about the patients’ decision about their commitment to, and experience of, the

rehabilitation programme on offer.

Video Recordings (Non-Participant Observation) of the Dispensation

of the Hearing Aids

The hearing-aid fitting is where the patients are provided with hearing aids with the

aim of reconstructing their soundscapes. Research recordings examined the situated

complexity of interactions as they are embedded and enacted within the hearing

clinic setting. This provided an opportunity for the researcher to further enhance her

understanding of how the body and physical objects are featured and the

sociomaterial conditions under which those sentences will have a definite truth

value and thus are capable of being uttered.

Post-Fitting Interview

The postfitting interview was conducted 6 weeks later, following the fitting and

dispensation of the hearing technology. In these interviews patients were questioned

regarding the use of the hearing aid, benefits, problems, etc. The video recordings

were used as an opening for the interview to stimulate patients’ reconstructive

accounts of the encounter events: Which components were experienced as useful to

the patient? Were the aids used? How and when? What were their experiences of the

possibly shared decision-making in the rehabilitation process?

All interviews were audio-recorded and fully transcribed. The transcripts were

analysed for recurring discourses and for ways of constructing points of view and

meaning regarding issues pertinent to consumerism in the hearing clinic. The quotes

presented represent only a select few taken from the many pages produced. They are

chosen for their exemplary quality in support of the arguments about ‘‘situations of

choice’’.

Follow-Up Survey Regarding Patients’ Use of Post-Requisition Offers

By use of a database at the hospital, the number of patients that had contacted the

hearing clinics a year after the provision of hearing aids was tracked.

Observational recording is fruitful not only in terms of who says what but also in

terms of the sociomaterial conditions under which those sentences will have a

definite truth value and thus are capable of being uttered. It may be considered as

objectifying. There is no doubt that the cameras had an impact on the dynamics of

the interactions. For instance, the recordings showed that the audiologist reacted to

the camera’s presence by looking directly into the lens from time to time, indicating

that he/she might have felt the need to act more ‘correctly’ were the appointment not

have been video-recorded. A way to cross this objectifying divide was to use the

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videos as a reflexive approach to communication with health professionals as a

collaborative tool for practice improvement.

Configuring the Active Patient in Audiological Practices

The dispensing of the hearing aids is based on informed choice and this is where the

‘‘Act of Private Hearing Aid Treatment’’ takes on a social life. Empowerment is

about strengthening the capacity of the individual to play the role of actor in his or

her own life [19, p. 106]. Engagement with the impairment and the disability by

means of improved knowledge of his or her condition might support patient’s self-

management and in this sense, becoming an expert can be seen as a radical,

democratising process, giving the patients control over their options. In the hearing

clinic patients file into particular rooms depending on their stage in the process,

hearing science technology and what is thought to constitute an ‘‘appropriate’’ or

‘‘accurate’’ testing environment. These norms are inscribed in the technologies on

offer. Decisions taken by the physician to place the patient on the waiting list for

hearing technologies are made according to the categorisation of hearing thresholds

which differentiate the normal from the pathological [7]. These regulations are

outlined in guidelines from the National Board of Health which is the supreme

health care authority in Denmark. Hearing loss that results in the prescription of a

hearing aid is dealt with in a specific technical, rational and chronological way

where everything is connected: When a person has been individually assessed with

examination of the ear (otoscopy), audiometry (measurement of hearing) and is

considered a hearing aid candidate by a physician, the patient is placed in a

‘‘situation of choice’’ of where to go for the dispensing and the fitting of the hearing

aid. In the pre-fitting interviews, the researcher asked the patients to state why they

chose the public hearing clinic instead of the private alternative and why this

specific clinic. Half of the patients stated economic reasons for choosing a public

clinic. The rest stated a lack of trust in the privatisation of health care. Few of the

patients stated that they had made an active choice to go to a specific public

hospital. Instead, they reported that they were referred there by their audiologist.

Thus instead of challenging the traditional distribution of authority choice interacts

with a historically accumulated set of understandings about how health care is to be

delivered.

The participant observations revealed another ‘‘situation of choice’’ which is

squeezed into tight hospital routines: at the point of the diagnosis and within a

4–5 min consultation with the physician the patient is expected to participate in the

decision about which hearing aid should be provided. Choosing a suitable hearing

aid traditionally has been a task performed by the physician. The positions to which

they are assigned dictate that they make the choice. They know that some hearing

aids are small and rather discrete, whereas others are larger and easier for older

people to handle. While some of the physicians negotiated the structural constraints

by passing on their experiences from patient to patient others just told the patient

where he/she fell on the hard-of-hearing continuum and then left the patient to make

the decision alone.

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The ideal hearing impaired patient concerns an individual who is no longer

passive but thanks to the internet has not only access to relevant and adequate

information about hearing aids and hearing loss but also to a possible active online

involvement with other hearing impaired patients. This ideal patient inscribed in

actual hearing health care policies and in hearing technology advertisements is the

knowledgeable, well informed patient, rich in experience and skills. Elementary to

achieve real patient empowerment is the dissemination of information on every

aspect involved in the health and care path of the (potential) patient. However,

scholars have raised ethical concerns about trustworthiness of information sources

and channels of dissemination, damage to the doctor-patient relationship, privacy

and confidentiality, and health disparities [17].

Thus, in order to examine clients’ information practices across a range of

different sources they were asked if they had informed themselves on the internet,

TV and such about types of hearing aids. Only two of them, both working in the

health care sector answered yes. The 39 remaining patients had not informed

themselves in advance and asserted that they did not want to exercise choice but

preferred to place faith and trust in the physician to make the right decisions: ‘‘The

doctor said that it would be best for me to have the type that fits behind the ear (…)

and so far I think she is the wisest in this respect’’. Thus, as my data suggest prior to

entering the hearing clinic very few of the patients appeared to have much insight

into the nature of the hearing-aid treatment regimen.

Patients were then asked if they knew the outcome of the talk with the physician

they had had 6 weeks earlier; whether they were given information about the types

of hearing aids available, and if they knew which model they were about to receive.

Three of the 41 patients had no idea; the rest knew whether it was a hearing aid that

would fit behind the ear or in the ear canal. It does seem that when confronted with

tight schedules and when invited to be a ‘‘partner’’ in decision-making as well as a

‘‘consumer’’, many of the patients are not prepared to do either. The following

example illustrates the way in which many patients do not subscribe to the hearing

aid consumer role:

Audiologist I have some hearing aids for you. They are (brand and model

mentioned) and are very small which means that there is no room for

a telecoil. But you have talked to the doctor about this?

Patient No, I have not

Audiologist It looks like (points at patient’s journal) it was the size of the hearing

aid that was most important?

Patient Yes it was because I don’t feel that I am that—hearing impaired—so-

well (gesticulates) I just don’t feel that. Well of course there are

things that I cannot hear, right? Or which irritates me that I cannot—

for instance when I’m together with other people and such, right?

As the above quote illustrates, the hearing health professional can only attend to

people who define themselves as being in the need of help. Thus, hearing health

practices depend on active hearing impaired patients. As argued elsewhere for many

in this group, a reluctance to acknowledge the onset and ongoing experience of

hearing difficulties is characteristic, which means that there often is a lengthy period

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of five to 15 years before they seek medical help. Some patients embark on the

process of getting a hearing aid and come to the hearing aid fitting as a response to

social pressure from relatives or colleagues, or they can relate to particular

situations (hearing impairment is not a general disability but can be problematic in

certain situations, however, the patient rarely feels ill).

Configuring Soundscapes as a Means of Empowerment

The hearing-aid fitting is the encounter with the audiologist where the hearing aid is

dispensed and fitted to patient’s individual audiogram. The audiological technol-

ogies used in the measurement sets the agenda for the meeting. They are referred to

as something that gives the audiologist visual and audible evidence of a patient’s

hearing impairment and are the entities upon which the audiologist’s attention is

fixed most of the time. The audiologist programmes the hearing aid with an external

computer temporarily connected to the device. While wearing the fitted hearing

aids, the patient will be tested for word understanding. The patient will also be

checked for how well he or she hears tones. The aim is then to set the hearing aids to

appropriate levels for the patient’s hearing needs. It is a ‘‘situation of choice’’ where

technology, sound, and the ‘‘normal’’ clearly have a bearing with the kind of

auditive subjectivity to which the hearing aid use gives rise.

In these accounts some forms of knowledge are considered as ‘‘viable’’, whereas

others are considered ‘‘unviable’’ or ‘‘unnecessary’’. The video recordings demon-

strated that the audiologists are saying the same things over and over, regardless of

who sits in front of them: ‘‘wait and see’’, ‘‘we can always fine-tune’’, ‘‘you have to

get used to’’. The words ‘‘are responsible for’’ and ‘‘your obligation’’ are recurring

motifs. Patients’ subjective experiences are not of interest in this specific context. At

the same time, it can be considered a ‘‘situation of choice’’ where the patient learns to

distinguish between what’s fitting well or not.

One of the perspectives on the hearing aid consumer encompasses the view that

patients self-organize and gather together through social networks and in this way

collaborate and challenge traditional medical approaches to disease and treatment.

This perspective implies a renegotiation of the terms on which empowerment and

patient participation takes place. Many patients, especially those with long-term and

chronic diseases, it is argued, benefit from finding others in similar situations on the

internet to share useful information and experiences with. However, less than 1 %

of the Danish hearing impaired are members of the official patient group, far fewer

than are members of other social activist movements [2]. Hence, there appears to be

no struggle to resist oppressive accounts of their identity. Instead, groups are

organized by various sorts of ‘‘proxies’’ for patients. It means that this particular

patient group does not necessarily represent the ‘‘public understanding of hearing

impairment’’ but instead functions as a specific and concrete entity. As described

elsewhere this might be due to the segregation that underlies these types of support

groups. Hearing aids are digital tools with connotations of ageing and anomaly.

Identification with a group of the hearing disabled might easily separate the

individual further from the normal hearing world. For these patients, there are

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powerful positive effects from maintaining silence around an attribute that could be

expected to attract stigmatization.

The following example of a ‘‘situation of choice’’ is from the fitting encounter.

Before the actual fitting, the clinic has received the hearing aids from the

manufacturer who has adjusted them according to the audiometry carried out at an

earlier appointment. The audiologist has inserted the hearing aids into the patient’s

ears, connected the hearing aids to the computer. The computer emits sounds that

measure the response in the patient’s ear canal:

Patient I am curious to find out if the buzzing sound disappears when you

disconnect me from these leads because this is a nuisance. Otherwise,

when I am working on my computer, which is quiet, I will not tolerate

that. I would tear them off

Audiologist But in the beginning you should pull yourself together and tolerate

this. Otherwise it will not be stored (pointing at the brain). So you

have to be persistent in the beginning even though it is annoying.

Because suddenly it is part of everyday life and it will be normal

This patient seemed most frustrated by the unnatural quality of the sounds

coming through the hearing aids and the difficulties she had explaining why they

were wrong. The audiologist, on the other hand, seemed to have difficulties in

persuading the patient of the positive effects of the hearing aids that would accrue to

them if they could get through this phase. As argued by Kort et al. [13] Mol’s notion

of ‘‘calibration’’ seems fruitful to describe the way patients are in a process of trying

out, evaluating, and adjusting rather than weighing up and managing when taking

decisions.

Ihde [12] has explored the (post) phenomenology of hearing and the role of

technical artefacts in sensory experiences. According to Ihde [12, p. XI], we are our

body, in the sense of our motile, perceptual, and emotive being-in-the-world. We

can directly touch, see, hear, and smell the world around us. Ihde considers

technology as a mediator through which we can experience the world. Following

Ihde, hearing aids can be considered as an extension of the body, enabling hearing-

aid users to further engage as hearing individuals in their everyday life. This

corresponds to Latour [16, p. 192] and his description on the interchangeability of

humans and nonhumans: ‘‘a body corporate is what we and our artefacts have

become’’. However, the idea of the hearing impaired being and the technology as

interwoven was not present in material gathered during this research. On the

contrary, quite a few users saw it as a relief to remove the hearing aids during and

after the fitting encounter, thus considering the hearing aids as a foreign object.

The following example is of a 65 years old divorced woman with 2 grown up

children who works as a lithographer. She does not think she has a hearing problem.

But her friends and her ex-husband keep on saying ‘‘You’re deaf’’ because she often

wants them to repeat what has just been said. She hopes that her hearing aids will

make her stop asking people around her to repeat everything ‘‘because it is annoying

for my social circles’’. When calling her 6 weeks after she was provided with

hearing aids she explained that she had only worn them two times lasting less than

1 h. This is the beginning of the postfitting interview:

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Researcher How has it been with your hearing aids?

Patient It was irritating in my ear canal—when wearing them I continuously

fiddle them and my friend says ‘‘For God’s sake, leave them alone’’.

‘‘But this is new to me’’ I answer. But really, I’ve only worn them

twice. For me it seems futile to wear them because I actually hear well

enough. Everybody else said ‘‘Take a hearing test’’ and ‘‘You need

hearing aids’’. And you sort of get tired of listening to that, right?

In the hearing clinic her hearing problem is disentangled from her tangible,

physical body and becomes an object that can be moved through computer networks

and across space and time. Rather than teaching her how to get along in everyday

life with a reduced hearing sense there seems to be a strict focus on one particular

body part—the physical ear—and on the technology intended to normalise that body

part. What she needs involves offers of consolation and encouragement in order for

her to disentangle her from collectives (such as families or friends) that influence

her needs, choices and capacities in adverse ways and what Mol [21, p. 2] describes

as good care silenced incorporated in practice and something that does not speak for

itself.

Repositories of Relevant Knowledge for the Hearing Impaired Patient

The continued rapid technological advancement in hearing aids aims to facilitate

improved communicative functions. These include pre-programmed sound levels

that fluctuate to compensate for the amount of background noise, so that they

function more sensitively in quiet rooms and less so at parties, etc. Digital hearing

aids can also cancel out feedback,1 and use directional microphones that tune out

competing sources of sound. Medical and acoustic knowledge resides in the

technologies (such as the computer software used when fitting the hearing aids or

the other technical equipment). The increased complexity of equipment impacts on

the patient-audiologist relationship as the audiologist has limited room to improvise

and has to rely on the producers and their software when conducting the hearing-aid

fitting. Thus, the producers have become the repositories of the relevant knowledge

in these encounters; knowledge that rests outside the reach and control of both staff

and patients.

Although patient involvement and participation in the rehabilitation processes in

many way varied from the ideal consumer some hearing impaired were surprised by

the agency to which the hearing aids had given rise, e.g. ‘‘I did not realise how deaf

I was’’. Pickering [23, p. 567] describes how: ‘‘the trajectories of emergence of

human and material agency are constitutively enmeshed in practice by means of a

dialectic of resistance and accommodation’’. Material agency of a modern hearing

aid thus articulates in the way in which it is able to both amplify and suppress sound

1 A hearing aid has one input: the sound comes in through the microphone. It has one output: the sound

goes out of the speaker into the ear drum. But sound moves in all directions unless something blocks it.

Feedback occurs when sound coming out of the speaker travels back into the microphone and is amplified

again. Feedback results in annoying whistling or squealing sounds.

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simultaneously, and it has built-in programmes for different soundscapes.2 Thus,

many of the hearing aids provided are closed systems. These products emphasise

user-friendliness in terms of simplicity of use. Patients are told that when they adjust

the volume, the hearing aid remembers and registers what the programme and

environment readings were at the time of the manual change. If the hearing aid

experiences a consistent pattern of manual change, it will adopt the volume

adjustment into the programme. This means that once the hearing aid has learned

the patient’s listening comfort levels in all environments, it will adjust to this so that

the patient no longer needs to adjust the volume. Where some patients described

how they considered this an advantage, others felt objectified by the hearing aid and

instead wanted to regain agency through a remote control device.

Put a different way; for the patient, agency is delegated to the experts in the

hearing clinic and from these to the hearing aids; thus, agency is delegated from

humans to artefacts. The hearing aid wearer must rely on the expertise of the

professional who has adjusted and fitted the hearing aids and will have to become

accustomed to what they perceive and in turn, eventually what the hearing aid

perceives. This also means that if the patient wishes to have the hearing aid

modified, an audiologist must reprogramme the unit by means of special software.

Herein lays the ambiguity of today’s welfare policy, a policy that seeks both to

reduce and at the same time is dependent on professional expertise. Thus, while the

empowered service user is introduced in Danish hearing health policy, in practice

the patient is positioned as a more or less passive receiver of a piece of technology.

Some of the patients informed the researcher in the post-fitting interview that

they, 6 weeks after the dispensing—still found it stressful or even painful to listen to

the world through their hearing aids. For most patients awareness of the body is due

to inadequacies or changes that have occurred. However, in this case the hearing

loss has taken place over a number of years and therefore is no longer sensed,

although its loss is probably ‘‘alerted’’ or ‘‘activated’’ as a possibility in certain

contexts. They sense their loss when they experience the nuisance of hearing high-

pitched frequencies or the discomfort of having a foreign object in the ear. The

problem with increased sensitivity which for some has the consequence that they

choose not to wear it also has the impact that it decreases the patient’s capacities for

being active in other places and at other times. As Mol [22, p. 1757] puts it:

‘‘Technologies are not only demanding, but also rarely do what is promised on the

package. Instead, they do more, or less, or something entirely different’’.

While being fit with the hearing aids, the patient must make judgments and report

likes/dislikes to the audiologist for immediate changes and choose if the fitting is ok.

What patients can say is clearly grounded in and circumscribed by the meanings

available to them in this discursive, material, and technological environment.

2 Often hearing aids have listening programmes stored in the hearing aid circuit. Each programme is

intended for specific listening situations. These comprise master programmes, music programmes, TV

programmes, telecoil programmes, etc. A telecoil is a special circuit inside the hearing aid. It is a small

coil of wire designed to pick up a magnetic signal. While the microphone on a hearing aid picks up all

sounds, the telecoil will only pick up an electromagnetic signal. It turns off the hearing aid microphone,

picks up the signal and the hearing aid converts it to sound. This magnetic signal is created from hearing

aid compatible telephones and assistive listening systems.

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Assessment and treatment occurs without leaving the clinic. Instead, different

listening situations are simulated. These simulations are done in order for the

audiologist to try to define the everyday life in which the patient is about to be

reintegrated:

Audiologist Well now I have turned the sound on. Now I want you to listen

to a lady’s voice. All the technical stuff is over and I want you

to listen to whether it is too high or too low or what it is

Patient At the moment it is way too high

Audiologist Yes your own voice?

Patient Yes. It sounds horrible

Audiologist But you have lived with your own voice until now and you will

continue to live with it (…) what is supposed to sound natural is

what I say or what the lady says. Your own voice will sound

odd just like if you watch yourself on video or listen to yourself

on tape-recorder. Then you think: ‘‘Who is that idiot talking out

of my mouth?’’, right?

Patient Yes?

Audiologist That is part of what you are experiencing. Of course not quite

the same because even though we strive towards making this an

open fitting, if you could say so, that means you don’t have an

ear mould in your ears then the space in your head has been

made smaller and you can compare with putting two fingers in

your ears and then say something—this is probably part of the

experience you have now, right?

Patient Yes

Audiologist

(pointing towards

the loudspeaker)

Well but what is not supposed to sound strange is her voice so

listen to her for a while

The audiologist turns on the loudspeaker and leaves the room for 5 min.

The desirable outcome of this kind of interaction is to give the patient an

experience of sound. Thus, what happens is that—due to the difficulties about how

to render experiences of hearing understandably in intersubjective terms means that

rather than something that grows out of collaborative attempts to attune knowledge

and technologies to the disabled body and the complex life of the patient, the

technology is the main decision-maker in audiological practices and patient’s body

is subjugated. At the end of each fitting session the patient is told that he/she has

3 months trial. If it does not work out well the patient can come back and have them

exchanged to another type. The patient then receives a few pamphlets with

information about different services offered. As for communication problems that

remain after the hearing aid fitting, the patient receives a pamphlet with information

about the services offered by the educational sector. If the hearing aid-fitted person

feels the need for further pedagogical rehabilitation, or an additional need for other

assistive listening devices, he or she has to initiate the contact accordingly. This

policy of post-acquisition contact can be considered to be an educational tool used

to impress responsibility and the ability to live within one’s physical means on

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patients. It is not something typical of Denmark or Scandinavia, as audiological

rehabilitation in most European countries is predominantly restricted to the fitting of

a hearing aid [14].

Twelve months after receiving their hearing aids, one out of the 41 patients in

this study had contacted the communication centre for additional education and

eight patients had contacted the hearing clinic for the readjustment of their hearing

aids, thus the number of follow-up visits initiated by patients was limited to a

minimum. The reason for patients not using the rehabilitation service offered could

be considered as active deselection: they were not seeking further hearing health

care because they were happy living their everyday lives as hearing aid wearers.

However, out of the 41 patients only 15 claimed that they used their aids on a

regular basis, 11 did not use them at all, and the rest used them occasionally i.e.

1–2 h per week. This kind of ‘‘non-compliance’’, however, should not necessarily

be treated as a choice. Choice does not make space for many of these patients.

Rather, choice alters everyday living in ways that does not necessarily fit well with

the intricacies of patients’ hearing disability. The reasons given for not wearing the

hearing aids provided, or using them less than prescribed, included disappointment

that these apparently very advanced hearing aids were not able to restore their

hearing; that they could not get used to the abnormal sound of their own voice; that

there was a poor fit of the ear mould; and that there were communication problems

despite amplification etc. It is important to acknowledge that the socio-material

environment has the power to both enable and disable the hearing impaired. For

them to change their situation is to risk further stigmatisation by disrupting every

social interaction in which they engage: having people change the way they sit or

stand, altering the pace at which they speak, restructuring what they say, and even

suggesting that people be told to shave off their beards [11, p. xiv]. It means

rearranging rooms and furnishings and restaurant seating arrangements. It means

developing a repertoire of skills, attitudes, behaviours, and technologies that work

for them both in the technical as well as the social sense [11, p. 44]. Rather than

letting everyone know that you are hearing impaired it might be easier to try to pass

as normal. The hearing aid technology is aimed at the better control of symptoms

and at making the hearing impairment less noticeable so that it deflects stigmatizing

responses from others. In reality, however the hearing impaireds’ condition is

manifested by the appearance of the same hearing aids).

Conclusions and Discussion

This paper has considered the ways in which present-day audiological practices and

the patients who embark on the process of getting a hearing aid can be considered as

a specific assertion of the empowered consumer. The recent change in the

organization of Danish hearing health services and patient treatment with private act

of hearing aid dispensation reflects the development within other parts of health care

systems in Western countries. Within the audiological practices situations are being

reshaped so that choices are called for and patients are called upon to make those

choices. The empowered hearing aid consumer chooses treatment and chooses

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healthcare provided. The empowered hearing aid consumer is able to bridge the

knowledge gap between the patient and the hearing health care provider; to interact

with the physician and audiologist in a better manner than before the Act. In the

hearing clinics, the responsibility for the rehabilitation project is shouldered by the

patient alone. Empowerment becomes a matter of purely dispensing as rehabili-

tation is restricted to the fitting of the hearing aid, and patients have to take the

initiative themselves as regards any kind of follow up.

As a consequence, the hearing clinic is not the place where patients are taught

how to communicate subjective hearing in words. This is not the place where they

are guided in becoming aware of needs and aspirations for hearing aids. When

hearing aids are dispensed, this is not the place where procedures are offered to the

patient for subsequent domestic assessment. This means that issues that could be

considered part of the logic of care—such as learning to understand hearing loss,

developing communication strategies and learning to listen with and manage

amplified sound are toned down to a matter of handing out a pamphlet, allowing the

patients to come to their own informed decisions. Thus, patients are not educated in

what to expect from the hearing aid or how to identify potential obstacles for

optimal use and whether there may be room for further refinements available

concerning its programming. They have to attain that knowledge elsewhere.

Hearing clinics have an inevitable material dimension, and, in the course of time,

subjects produce and reproduce the material dimensions of these clinics. The

process of employing technology to make hearing visible (quantifiable, measurable,

a thing able to be visually understood via charts and graphs) is—in other words—

what constitutes audiological rehabilitation. Thus, the consumer discourse does not

challenge the medical idea of hearing impairment as being something that only

concerns the physical ear. Rather, hearing loss is transformed from a troublesome

bother in the patient’s everyday life to something measurable on a curve, indicating

an anatomical characteristic bringing it into a field of visibility where it is compared

against an established norm that then governs what kind of treatment is offered.

To understand how technologies enable and constrain social interaction, it is

important to consider both how technologies could be different from how they present

themselves and how social interaction built around technologies could also differ [6].

In other words: the challenge becomes to understand how technical objects themselves

are bound up with their social uses. As argued by Pinch [24: 471] ‘Technologies (…)

acquire meanings in the social world, and these meanings shape and constrain their

development’’. For audiology and other medical specialisations, standardisation

entails routinized social actions. The capacity to operate, modify and fix technologies

when they break down or fail has been shown to be of great importance, not as a simple

technical matter but as a powerful way of bringing a resolution to debates

encompassing the different social meanings of a technology [15].

The patient entering the hearing clinic meets a system that invites individuals to

voluntarily conform to the clinic’s objectives in the interests of their hearing health.

To benefit from hearing aids requires adaptation on the part of the user, senses must

be rediscovered, and daily routines must change. The clinic is not providing the

hearing impaired with information on how to do this. It is the individual who must

conform to the technology and not the other way around. There is thus an

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interdependence of objectification3 and agency. To be sure, objectification in one

context can enable subjectivity in others. For many of these patients, the experience

of agency might be related to the extent to which the rehabilitation offered manages

to maintain a link between ears, hearing aids, and everyday life. The audiological

encounter is cut off from yet connected to patients’ everyday life. It is cut off due to

constraints of time as it consists of only a short visit that for most is not followed up

by a revisit. The question of patients’ agency has to be assessed according to sites

and situations beyond the audiological encounter. The real ‘test’ for the hearing aids

is delocalised from the consultation to patients’ homes. At the same time, it is

connected, because attending audiological rehabilitative services means complying

with the wishes of significant others, children, colleagues, and for some, gaining

access to a rehabilitation programme that can prove helpful in their everyday lives.

Strategies for managing hearing impairment are thus rooted in local, experience-

based, and context-specific knowledge about what works in everyday life. The

rehabilitative challenge is that there is not one everyday life but many; there is not

one pattern of reaction to being diagnosed as hearing impaired but many, there is not

one single understanding of hearing impairment and hearing disability but many.

However, at present, the audiological field is dominated by the medical model

with medical experts who conceptualise hearing disability as an impairment of the

normal body function. The state is involved in the reproduction of medical

dominance by regulating the conditions for the licensing of medical practitioners,

thus it remains the medical practitioners’ privilege to conceptualise hearing

problems and formulate solutions. Within the consumer discourse, the hearing

impaired are empowered by choice, however, the choice is limited to saying ‘‘yes’’

or ‘‘no’’ to an already existing product range. It is choice constrained by specific

temporal, spatial, institutional, and medical situations in which the experience,

knowledge, and aspirations of the hearing-disabled patients themselves are not

considered. The implications of the ideal consumer are that new understandings are

produced which make governing possible. The liberal ideology of choice goes hand

in hand with the rationalisation of care. The rubric of ‘‘consumer freedom’’ is used

to justify cuts in state care and to legitimise the private sector.

Does it make sense to talk of ‘‘choices’’ in relation to living with a disability?

Having a disability is not something we choose in the first place. Mol [21] argues

that the active patient is a contradiction in terms and that good care has little to do

with ‘‘patient choice’’. Therefore, creating more opportunities for patient choice will

not improve health care. Impaired hearing means that the impairment—due to a loss

of a sense—interferes with daily practice for many people and for those with whom

they interact, because often their way of communicating does not follow the

prescribed rules for everyday activities. To ask for things to be repeated attracts

anger and insult, and one is identified as incompetent for breaching the social

assumptions about everyday communication [8]. The potential for people to take

more control of their impaired hearing by understanding and managing their

disability could lead to an improved quality of life. The promise is that by making

3 I contend that the self is formed by the subject as thinking and acting being through the modes of

subjectivation and objectivation [3].

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choices patients will be freed from the passivity in which hearing health

professionals have kept them trapped. The use of ‘‘the empowered patient’’ and

the ‘‘health care consumer’’ in hearing health care policy signals certain underlying

attitudes and beliefs about hearing disabled patients that are inconsistent with what

is known about the difficulties of becoming a hearing aid wearer and thus a true

disregard for the complexity and magnitude of the challenges these patients face in

getting good help and care and making the most of it. These are not simple tasks,

and the help patients need to get along in their everyday life with hearing

impairment is not a simple task. Throwing a few bits of information and describing

patients with shiny new words will not do the trick.

References

1. Christensen, V. T. (2006). Hard of hearing? Hearing problems and working life. Copenhagen: The

Danish National Institute of Social Research.

2. Epstein, S. (2008). Patient groups and health movements. In E. J. Hackett, O. Amsterdamska, M.

Lynch, & J. Wajcman (Eds.), The handbook of science and technology studies (pp. 499–539).

Cambridge: MIT Press.

3. Foucault, Michel. (2000). Foucault. In J. Faubion (Ed.), Michel Foucault, aesthetics, method, and

epistemology: Essential works of Foucault 1954–1984 (Vol. 2, pp. 459–463). London: Penguin.

4. Fox, N. J., Ward, K. J., & O’Rourke, A. J. (2005). The ‘expert patient’: empowerment or medical

dominance? The case of weight loss, pharmaceutical drugs and the Internet. Social Science and

Medicine, 60(6), 1299–1309.

5. Garstecki, D. C., & Erler, S. F. (2001). Personal and social conditions potentially influencing

women’s hearing loss management. American Journal of Audiology, 10(2), 78–90.

6. Haraway, D. (1991). Simians, cyborgs, and women: The reinvention of nature. New York: Routledge.

7. Hindhede, A. L. (2010). Everyday trajectories of hearing correction. Health Sociology Review, 19(3),

382–395.

8. Hindhede, A. L. (2012). Negotiating hearing disability and hearing disabled identities. Health, 16(2),

169–185.

9. Hindhede, A. L. (2012). Disciplining the audiological encounter. Health Sociology Review, 19(1),

100–113.

10. Hickson, L., & Worrall, L. (2003). Beyond hearing aid fitting: Improving communication for older

adults. International Journal of Audiology, 42, S84–S91.

11. Hogan, A. (2001). Hearing rehabilitation for deafened adults: A psychosocial approach. London,

Philadelphia: Whurr Publishers.

12. Ihde, D. (2002). Bodies in technology. Minneapolis, MN: University of Minnesota Press.

13. Kort, S. J., Pols, J., Richel, D. J., Koedoot, N., & Willems, D. L. (2010). Understanding palliative

cancer chemotherapy: About shared decisions and shared trajectories. Health Care Analysis, 18(2),

164–174.

14. Kramer, S. E., Allessie, G. H. M., Dondorp, A. W., Zekveld, A. A., & Kapteyn, T. S. (2005). A home

education program for older adults with hearing impairment and their significant others: A ran-

domized trial evaluating short- and long-term effects. International Journal of Audiology, 44(5),

255–264.

15. Lindberg, K., Styhre, A., & Walter, L. (2012). Assembling health care organizations: Practice,

materiality and institutions. New York: Palgrave Macmillan.

16. Latour, B. (2002). A collective of humans and nonhumans. In Pandora’s Hope. Essays on the reality

of science studies (pp. 174–215). Cambridge, MA: Harvard University Press.

17. Lo, B., & Parham, L. (2010). The impact of web 2.0 on the doctor-patient relationship. The Journal of

Law, Medicine & Ethics, 38(1), 17–26.

18. Lupton, D., Donaldson, C., & Lloyd, P. (1991). Caveat emptor or blissful ignorance? Patients and the

consumerist ethos. Social Science and Medicine, 33(5), 559–568.

19. Miller, P., & Rose, N. (2008). Governing the present. Cambridge: Polity.

Health Care Anal

123

20. Ministry of Social Services. (2000). Act of private hearing aid treatment no 465. Copenhagen:

Ministry of Social Services, Government of Denmark.

21. Mol, A. (2008). The logic of care. Health and the problem of patient choice. London, NY: Routledge.

22. Mol, A. M. (2009). Living with diabetes; care beyond choice and control. The Lancet, 373(9677),

1756–1757.

23. Pickering, A. (1993). The mangle of practice: Agency and emergence in the sociology of science.

American Journal of Sociology, 99(3), 559–589.

24. Pinch, T. (2008). Technology and institutions: Living in a material world. Theory and Society, 37(5),

461–483.

25. Shield, B. (2006). Evaluation of the social and economic costs of hearing impairment. London: Hear-It.

26. Sorri, M., Brorsson, A., David, A., Mair, I., Myhre, K., Parving, A., et al. (2001). Hearing impairment

among adults. Report of a joint (Nordic-British) project. Helsinki: Finnish Office for Health Care

Technology Assessment.

27. Stacey, C. L., Henderson, S., MacArthur, K. R., & Dohan, D. (2009). Demanding patient or

demanding encounter?: A case study of a cancer clinic. Social Science and Medicine, 69(5), 729–737.

28. Stephens, D. (2001). Determination and classification of the problems experienced by hearing-

impaired elderly people. Audiology, 40(6), 294–300.

Health Care Anal

123