Dignity in Red Envelopes: Disreputable Exchange and Cultural Reproduction of Inequality in Informal Medical Payment

Abstract

Disreputable exchanges are morally disapproved and often legally prohibited exchanges that exacerbate and reproduce social inequality but remain ubiquitous. Although previous literature explains the phenomenon by material interests and structural relations, we propose a cultural approach based on three major conceptions of culture: culture in relations, culture in interactions, and culture in inequality. We illustrate this approach by a case study of China’s hongbao (the red envelope) exchange, a typical disreputable exchange through informal medical payment. Drawing on interviews with doctors and patients, we find that participants of the exchange mobilize items from their cultural repertoires, such as professional ethics, face, power, fairness, and affection, to redefine different situations of interactions and project positive self–images to render their problematic exchanges morally acceptable to each other. Moreover, as the participants’ responses to our vignettes show, they negatively evaluate the exchanges in general moral terms, such as equality and fairness, but culturally justify their own involvement. This discrepancy between saying and doing tends to legitimize the disreputable exchange amid enduring public outrage and institutional prohibition. These cultural processes contribute to the reproduction of unequal access to scarce health care resources. Findings of this research not only offer insights into understanding disreputable exchanges but also contribute to research on other cases of social problems in which deviant behaviors are morally and culturally justified.

WITHDRAWN: Culture or corruption: who gave red envelopes to the doctors in China?

“…The cause of medical red envelopes is complicated [2][3][4][5] due to the contradiction between the huge population and scarce medical resources in China [6]. An important reason why patients give doctors red envelopes, which is often overlooked, is a lack of trust between patients and doctors leading to insecurity [7].…”

“…It is widely believed that giving and taking red envelopes (informal payments [1]) is a common phenomenon in medical practices due to the contradiction between the huge population and scarce medical resources in China [2]. The cause of medical red envelopes is complicated [3][4][5][6]. An important reason why patients give doctors red envelopes, which is often overlooked, is a lack of trust between patients and doctors leading to insecurity [7].…”

Honor among Crooks: The Role of Trust in Obfuscated Disreputable Exchange

“…Similarly, homophily can facilitate cooperation by reducing social uncertainty (McPherson, Smith-Lovin, and Cook 2001; Melamed et al 2020), and this finding may extend to cooperation via obfuscated disreputable exchange. Likewise, socioeconomic status may be the basis of homophily, as with doctors who accept tactful, relationally embedded gifts and favors from the elite but deflect the clumsy, more overtly transactional, attempts of the lower class (Guo and Xu 2022).…”

“…Hoang (2018) shows how developers in Vietnamese real estate use different types of obfuscation, ranging from gifting designer handbags to hiring the children of public officials to working with politically connected law firms who broker payments. 2 Guo and Xu (2022) emphasize the element of tact and social class in “red envelope” side payments to doctors for concierge-level medical treatment in China. Jia, Markus, and Werner (2023) analyze how firms conceal their lobbying activities by outsourcing them to intermediaries or misrepresenting them in publicized statements, thus making it more difficult for audiences to recognize the link between the firm and the lobbying activity.…”

“…The economic sociology of obfuscation has produced insights into actors’ sensemaking (Hoang 2018; Mears 2020) and audiences’ moral judgments (Amengual and Bartley 2022; Guo and Xu 2022), but it has yet to delve deeper into the conceptually distinct issue of actors’ decisions of whether or not to engage in obfuscation in the first place. This involves a moral consideration: “Will I be ashamed to engage in an obfuscated disreputable exchange?” It also raises a pragmatic question: “Will I actually receive the goods or services I sought?” For instance, a man might seek sex by acting the part of a sugar daddy and accept the milder shame this implies than being a john, but he might worry the sugar baby could fail to reciprocate his expenditures with sex.…”