Some Contingencies of the Moral Evaluation and Control of Clientele: The Case of the Hospital

Emergency Service
Author(s): Julius A. Roth
Source: American Journal of Sociology, Vol. 77, No. 5 (Mar., 1972), pp. 839-856
Published by: University of Chicago Press
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Some Contingenciesof the Moral Evaluation
and Controlof Clientele: The Case of the
Hospital EmergencyService1
JuliusA. Roth
Universityof California,Davis

One importantaspect of the controlof behaviorof patientsand

visitorson a hospitalemergency serviceis the moralevaluationof
theclientsmade by the staff.Such evaluationarisesfromthe appli-
cationof conceptsof social worthcommonin the largersocietyand
fromstaffconceptsof appropriateworkrole.The process,however,
is not a simplecause-effectmatter,but the productof a reciprocal
relationshipbetweenthe attributesof the clientand the categories
of the staff.Emergency-department staff,like otherserviceoccupa-
tions,attemptto establishmechanisms of controloverinappropriate
demandsforservice.

The moralevaluationof patientsby staffmembershas been exploredin

detailin thecase of "mentalillness"(Scheff1966,chap. 5; Strausset al.
1964, chaps. 8 and 12; Belknap 1956; Scheff1964; Goffman1961, pp.
125-70, 321-86; Hollingsheadand Redlich 1958; Szasz 1960). The
assumptionis made by some (especiallyThomas Szasz) that mentalill-
ness is a special case whichreadilyallows moraljudgmentsto be made
because thereare no technicalcriteriato be applied and because psychi-
atricconceptsin theirhistoricaldevelopment have been a pseudoscientific
replacement of moraljudgments.CharlesPerrow(1965) stresseslack of
technology as a factorwhichforcespsychiatric to fall back
practitioners
on commonsense conceptsofhumanitarianism whichopenthewayto moral
evaluationsof the clientele.
I contendthat the diagnosisand treatmentof mentalillnessand the
"care" of mentalpatientsare notuniquein incorporating moraljudgments
of theclientele,but are onlyobviousexamplesof a moregeneralphenome-
nonwhichexistsno matterwhatthehistoricaldevelopment or thepresent
state of the technology.Glaser and Strauss (1964) put forwardsuch a
notionwhentheydemonstrated how the "social worth"of a dyingpatient
affectsthenursingcare he willreceive.I wouldadd thatmoralevaluation
also has a directeffecton a physician'sdiagnosisand treatmentrecom-

1 The study on which this paper is based was supported by National Institutesof
Health grantsHM 00437 and HM 00517, Division of Hospital and Medical Facilities.
DorothyJ. Douglas, currentlyat the Universityof ConnecticutHealth Center,worked
with me and made major contributionsto this study.

AJS Volume 77 Number5 839

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AmericanJournalof Sociology

mendations. This is obviousin extremecases, such as whena monarchor

thepresidentof theUnitedStatesis attendedby teamsof highlyqualified
diagnosticiansto insurea detailed and accuratediagnosisand has out-
standingspecialistsflownto his bedsideto carryout the treatment. I will
discusssome aspects of this same processas it applies on a day-to-day
basis in a routinehospitaloperationinvolvingmore"ordinary"patients.
The data are takenfromobservationof six hospitalemergency services
in twopartsof thecountry-onenortheastern locationand one WestCoast
location.My co-workers and I spentseveralperiodsof time (spread over
two or threemonthsin each case) in the emergency department of each
of thehospitals.In one hospitalwe workedas intakeclerksovera period
of threemonths.At othertimeswe observedareas in the emergency unit
withoutinitiatingany interactionwithpatients,visitors,or personnel.At
otherpointswe followedpatientsthroughtheemergency servicefromtheir
firstappearanceto dischargeor inpatientadmission,interviewing patient
and staffduringthe process.During theseperiodsof observation,notes
werealso kepton relevantconversations withstaffmembers.
The hospitalemergencyserviceis a settingwherea minimumof in-
formation is availableabout thecharacterof each patientand a long-term
relationship withthepatientis usuallynotcontemplated. Even underthese
conditions,judgmentsabout a patient'smoral fitnessand the appropri-
atenessof his visitto an emergency serviceare constantly made,and staff
actionconcerning thepatient-includingdiagnosis,treatment, and disposi-
tionof thecase-are, in part,affected by thesejudgments.

THE DESERVING AND THE UNDESERVING

The evaluationof patientsand visitorsby emergency-ward staffmay be

conveniently thoughtof in two categories: (1) The applicationby the
staffof conceptsof social worthcommonin the largersociety.(2) Staff
members'conceptsof theirappropriateworkrole. In this sectionI will
take up thefirstof these.
There is a popularmyth(generatedin part by some sociologicalwrit-
ing) that personsengaged in providingprofessionalservices,especially
medicalcare, do not permitthe commonlyaccepted conceptsof social
worthin our cultureto affecttheirrelationshipto the clientele.An on-
the-spotdescriptionof any serviceprofession-medicine, education,law,
social welfare,etc.-should disabuse us of this notion.There is no evi-
dencethatprofessional moral
trainingsucceedsin creatinga universalistic
neutrality(Becker et al. 1961, pp. 323-27). On the contrary,we are on
much safergroundto assume that those engagedin dispensingprofes-
sionalservices(or any otherservices)will apply the evaluationsof social
worthcommonto theircultureand willmodifytheirserviceswithrespect

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 The Hospital EmergencyService

to thoseevaluationsunlessdiscouraged fromdoingso by theorganizational

arrangements underwhichtheywork.Some such organizationalarrange-
mentsdo existon emergency wards.The rapidturnover and impersonality
of theoperationis in itselfa protectionformanypatientswho mightbe
devaluedif morewereknownabout them.In public hospitals,at least,
thereis a rule that all patientspresenting themselvesat the registration
desk mustbe seen by a doctor,and clerksand nursesknowthatviolation
of thisrule,if discovered,can get themintoserioustrouble.(Despite this,
patientsare occasionallyrefusedregistration, usually because they are
morallyrepugnantto the clerk.) Such arrangements restrictthe behavior
of thestaffonlyto a limitedextent,however.There remainsa greatdeal
of roomfor expressingone's valuationof the patientin the details of
processingand treatment.
One commonconceptof social worthheld by emergency-ward personnel
is thattheyoungare morevaluablethantheold. This is exemplified most
dramatically in the markeddifferences to resuscitateyoungand
in efforts
old patients(Glaserand Strauss1964; Sudnow1967,pp. 100-109). "Wel-
farecases" whoare spongingoffthetaxpayer-especiallyif theyrepresent
theproductof an immorallife (such as a womanwithillegitimate children
to support)-do not deservethebest care. Personsof higherstatusin the
largersocietyare likelyto be accordedmorerespectful treatment in the
emergency wardjust as theyoftenare in otherserviceor customerrela-
tionships,and converselythoseof lowerstatusare treatedwithless con-
sideration.(The fact that higher-status personsare morelikelyto make
an effective complaintor even filelawsuitsmay be an additionalreason
forsuchdifferential treatment.)
Of course,staffmembersvaryin the mannerand degreeto whichthey
apply theseculturalconceptsof social worthin determining the quality
of theirserviceto the clientele.The pointis that theyare in a position
to alterthenatureof theirservicein termsof suchdifferentiation, and all
of them-porters,clerks,nursingpersonnel,physicians-do so to some
extent.Despite some variations,we did in fact findwidespreadagree-
menton the negativeevaluationof some categoriesof patients-evalua-
tionswhichdirectlyaffectedthe treatment provided.Those who are the
firstto processa patientplay a crucialrolein moralcategorizationbecause
staffmembersat later stages of the processingare inclinedto accept
earliercategorieswithoutquestionunlesstheydetectclear-cutevidenceto
the contrary.Thus, registration clerkscan oftendeterminehow long a
personwill have to wait and what kind of treatment area he is sent to,
and, occasionally,can evenpreventa personfromseeinga doctorat all.
Some patientshave been morallycategorizedby policemenor ambulance
crewmenbeforethey even arriveat the hospital-categorizationwhich
affectsthepriority and kindof servicegiven.

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AmericanJournalof Sociology

In thepublicurbanhospitalemergency service,the clienteleis heavily

skewedtowardthe lowerend of the socioeconomicscale, and nonwhite
and non-Angloethnicgroupsare greatlyoverrepresented. Also, manypa-
tientsare in thepositionof supplicating thestaffforhelp,sometimes fora
conditionforwhichthepatientcan be held responsible. Withsucha popu-
lation,the staffcan readilymaintaina stanceof moralsuperiority. They
see thebulk of thepatients as people undeserving of the servicesavailable
to them.Staffmembersmaintainthattheyneed not tolerateany abuse or
disobediencefrompatientsor visitors.Patientsand visitorsmay be issued
orderswhichtheyare expectedto obey.The staffcan, and sometimes does,
shout downpatientsand visitorsand threatenthem with ejection from
the premises.The staffdemandsprotectionagainst possibleattack and
also againstthe possibilityof lawsuits,whichare invariablyclassifiedas
unjustified. Thereis no needto be politeto theclienteleand, in fact,some
clerksfrequently engagepatientsand visitorsin arguments. The staffalso
feelsjustifiedin refusing serviceto thosewhocomplainor resisttreatment
or refuseto followproceduresor make troublein any otherway. From
time to time the clientsare referredto as "garbage,""scum," "liars,"
"deadbeats,"people who "come out fromunderthe rocks,"by doctors,
nurses,aides, clerks,and even housekeepers who sweep the floor.When
we spentthefirstseveraldays of a newmedicalyearwitha new groupof
internson one emergency service,we foundthatan important part of the
orientation was directedtowardtellingthe internsthat the patientswere
notto be trustedand did nothave to be treatedpolitely.At anotherpublic
hospital,new registration clerksweretold duringtheirfirstfewdays of
workthattheywouldhave to learnnot to acceptthe wordof patientsbut
to treateverything theysay withsuspicion.
Despite thegeneralnegativeconceptionof the clientele,differentiations
are madebetweenpatientson thebasis of clues whichtheypresent.Since
thisis typicallya fleetingrelationship wherethe staffmemberhas little
or no background information about thepatient,evaluationsmustusually
be made quicklyon thebasis of readilyperceivableclues. Race, age, mode
of dress,languageand accentsand wordusage,and the mannerin which
theclientaddressesand respondsto staffmembersare all immediateclues
on whichstaffbase theirinitialevaluations.A littlequestioningbrings
out otherinformation whichmaybe used foror againsta patient:financial
status,typeof employment, insuranceprotection, use of private-practice
doctors,natureof medicalcomplaint, legitimacyof children,maritalstatus,
previoususe of hospitalservices.In thecase of unconsciousor seriouslyill
or injuredpatients,a searchof the walletor handbagoftenprovidesin-
formative cluesaboutsocialworth.
Some characteristics consistently turnstaffagainstpatientsand affect
the qualityof care given.Dirty,smellypatientscause considerablecom-

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 The Hospital EmergencyService
mentamongthe staff,and efforts are made to isolate themor get rid of
them.Those dressedas hippiesor womenwith scantyclothing(unless
thereis a "good excuse,"e.g., a womandrownedwhile swimming)are
frownedupon and are morelikelyto be kept waitingand to be rushed
throughwhentheyare attendedto. We observedhintsthatcertainethnic
groupsare discriminated to detectnowadays
against,but this is difficult
because everyoneis extremely sensitiveto the possibilityof accusations
If a womanwith a child is tabbed a "welfare
of racial discrimination.
case" (fromher dress,speech,and manner,or in the explicitformof a
welfarecard whichshe presents),the clerkis likelyto ask, "Is therea
fatherin thehouse?"whilebetter-dressed,better-spoken womenwithchil-
drenare questionedmorediscreetly.

ATTRIBUTES AND CATEGORIES: A RECIPROCAL RELATIONSHIP

On one level,it is trueto say thatthestaff'smoralevaluationof a patient

influencesthe kindof treatment he getsin the emergency room.But this
kindof causal explanationobscuresimportantaspectsof the networkof
interrelationships involved.On another,the definitionof devalued or
favoredcategoriesand the attributesof the patientreinforce each other
in a reciprocalmanner.
Take, forexample,patientswho are labeled as drunks.They are more
consistently treatedas undeserving than any othercategoryof patient.
They are frequentlyhandled as if they were baggage when they are
broughtin by police; thosewithlacerationsare oftenroughlytreatedby
physicians;theyare usually treatedonly for drunkenness and obvious
surgicalrepairwithoutbeing examinedforotherpathology;no one be-
lievestheirstories;theirstatements are ridiculed;theyare treatedin an
abusiveor jocularmanner;theyare ignoredforlong periodsof time; in
one hospitaltheyare placed in a roomseparatefrommostotherpatients.
Emergency-ward personnelfrequently commenton how theyhate to take
care of drunks.
Thus,it mightseemthatthestaffis applyinga simplemoralsyllogism:
drunksdo not deserveto be cared for,thispatientis a drunk,therefore,
he doesnotdeservegoodtreatment. But howdo we knowthathe is drunk?
By the way he is treated.Police take him directlyto the drunkroom.
If we ask whythepolicedefinehimas drunk,theymay answerthatthey
smellalcoholon his breath.But notall peoplewithalcoholon theirbreath
are pickedup by thepoliceand takento a hospitalemergency room.The
explanation mustcomein termsof somepartof thepatient'sbackground-
he was in a lower-classneighborhood, his style of dress was dirtyand
sloppy,he was unattendedby any friendor familymember,and so on.
Whenhe comesto the emergency roomhe has alreadybeen definedas a

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AmericanJournalof Sociology

drunk.Thereis no reasonforthe emergency-room personnelto challenge

thisdefinition-itis routineprocedureand it usuallyprovescorrectin so
faras theyknow.There is nothingto do fordrunksexceptto give them
routinemedicationsand let themsleep it off.To avoid upsettingthe rest
of the emergency room,thereis a roomset aside for them.The police
have a standardprocedureof takingdrunksto that room,and the clerks
place themthereif theycome in on theirown and are definedas drunk
on the basis, not onlyof theirbreathodor (and occasionallythereis no
breathodor in someonedefinedas drunk),but in termsof theirdress,
manner,and absenceof protectors. The physicians,havingmorepressing
matters,tend to leave the drunksuntil last. Of course,they may miss
some pathologywhichcould cause unconsciousness or confusionbecause
theybelievethe standardprocedureprovescorrectin the greatmajority
of cases. They reallydo not know how oftenit does not prove correct
since they do not check up closely enoughto uncoverother formsof
pathologyin mostcases, and thelow social statusof thepatientsand the
factthat theyare seldomaccompaniedby anyonewho will protectthem
meansthatcomplaintsabout inadequateexaminationwill be rare.There
are occasionalchallengesby doctors-"How do you knowhe's drunk?"-
but in mostcases the busyscheduleof the house officer leaves littletime
forsuch luxuriesas a carefulexaminationof patientswho have already
beendefinedas drunksby others.Once thedrunklabel has been accepted
by the emergency-room staff,a morecarefulexaminationis not likelyto
be made unlesssomeparticularly arrestingnew information appears (for
example,thepatienthas convulsions, a relativeappearsto tell themthat
he has diabetes,an examinationof his wallet shows him to be a solid
citizen),and themoresubtlepathologiesare not likelyto be discovered.
Thus, it is just as trueto say that the label of "drunk"is acceptedby
hospitalpersonnelbecauseof theway thepatientis treatedas it is to say
thathe is treatedin a certainway because he is drunk.Occasionalcases
show how personswith alcohol on theirbreathwill not be treatedas
drunks.When an obviouslymiddle-classman (obvious in termsof his
dress,speech,and demandsforservice)was broughtin afteran automobile
accident,he was not put in the drunkroom,althoughhe had a definite
alcoholodor,but was givenrelativelyquick treatment in one of the other
examining roomsand addressedthroughout in a politemanner.
Most drunksare men. A commonnegativeevaluationfor womenis
PID (pelvic inflammatory disease). This is not just a medicaldiagnostic
category,but,by implication, a moraljudgment.There are manywomen
withdifficult-to-diagnose abdominalpains and fever.If theyare Negro,
young,unmarried, lowerclass in appearanceand speech,and have no one
along to championtheircause, doctorsfrequently make the assumption
thattheyhave beforethemtheend resultsof a dissolutesex life,unwanted

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 The Hospital EmergencyService
pregnancyand perhapsvenerealdisease,illegal abortion,and consequent
infectionof the reproductive organs.The label PID is thenattachedand
thepatientrelegatedto a groupless deservingof promptand considerate
treatment. This is not the same thingas sayinga diagnosisof PID leads
to rejectionby medicalpersonnel.
We observedone patientwho had been definedas a troublemaker be-
cause of his abusivelanguageand his insistencethathe be releasedimme-
diately.Whenhe beganto behavein a strangemanner(randomthrashing
about), thepolicewerepromptly calledto controlhimand theythreatened
him witharrest.A patientwho was not definedas a troublemaker and
exhibitedlike behaviorpromptedan effort on thepart of the staffto pro-
vide a medicalexplanationforhis actions.Here again, we see that the
categoryintowhichthepatienthas beenplaced may have moreeffecton
determining the decisionsof medicalpersonnelthan does his immediate
behavior.
Thus,it is notsimplya matterof finding which"objective"pathological
statesmedicalpersonnellike or dislikedealingwith.The verydefinition
of thesepathologicalstates dependsin part on how the patientis cate-
gorizedin moraltermsby the screeningand treatment personnel.

THE LEGITIMATE AND THE ILLEGITIMATE

The secondtypeof evaluationis thatrelatedto thestaffmembers'concept

of theirappropriateworkroles (Strauss et al. 1964, chap. 13). Every
workerhas a notionofwhatdemandsare appropriate to hisposition.When
demandsfalloutsidethatboundary,he feelsthattheclaimis illegitimate.
What he does about it dependson a numberof factors,includinghis
alternatives,his powerto controlthebehaviorof others,and his powerto
selecthis clientele(moreon thislater).
The internsand residentswho usuallyman the largerurbanemergency
serviceslike to thinkof thisassignment as a part of theirtrainingwhich
will give thema kindof experiencedifferent fromthe outpatientdepart-
mentor inpatientwards.Here theyhope to get somepracticein resusci-
tation,in treatingtraumaticinjuries,in diagnosingand treatingmedical
emergencies. Whenpatientswhoare no different fromthosetheyhaveseen
ad nauseamin the outpatientdepartment presentthemselves at the emer-
gencyward,thedoctorsin training believethattheirservicesare beingmis-
used.Also,onceon theemergency ward,thepatientis expectedto be "coop-
erative"so thatthedoctoris notblockedin his effort to carryouthistasks.
Nurses,clerks,and othersplay "littledoctor" and to this extentshare
theconceptsof theboundariesof legitimacy of the doctors.But, in addi-
tion to the broadlysharedperspective, each workspecialtyhas its own
notionsof appropriatepatient attributesand behaviorbased on their

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AmericanJournalof Sociology

own workdemands.Thus, clerksexpectpatientsto cooperatein getting

formsfilledout. Patientswitha "good reason,"unconsciousness, forex-
ample,are excusedfromcooperatingwithclericalprocedures,but other
patientswho are unable to give requestedinformation or who protest
against certainquestionsbring upon themselvescondemnationby the
clerkswho believethat a personwho subvertstheirefforts to complete
theirtaskshas no businesson theemergency ward.
A universalcomplaintamongthosewho operateemergency servicesis
thathospitalemergency roomsare "abused" by the public-or ratherby
a portionof thepublic.This is particularlythecase in thecityand county
hospitalsand voluntaryhospitalswith trainingprogramssubsidizedby
public fundswhichhandle the bulk of emergency cases in urban areas.
The great majorityof cases are thought of as too minoror lackingin
urgencyto warranta visitto the emergency room.They are "outpatient
cases" (OPD cases), thatis, patientswho could wait untilthe outpatient
department is open, or if theycan affordprivatecare, theycould wait
untila physicianis holdinghis regularofficehours.Patientsshouldnot
use theemergency roomjust becauseit givesquickerservicethantheout-
patientdepartment or because the hoursare moreconvenient(since it is
openall thetime).Pediatricians complainabout theirday filledwith"sore
throatsand snottynoses." Medical internsand residentscomplainabout
all the people presenting long-standingor chronicdiseaseswhich,though
sometimes serious,do notbelongin theemergency room.In everyhospital
-both public and private-wherewe made observationsor conducted
interviews, we repeatedlyheard the same kindsof "atrocitystories": a
patientwitha sorethroatof two-weeks' durationcomesin at 3:00 A.M. on
Sunday and expectsimmediatetreatmentfroman internwhomhe has
got out of bed (or such variationsas an itchof 75-days'duration,a con-
genitaldefectin a one-year-old child-always comingin at an extremely
inconvenient hour).
Directorsof emergency servicesrecognizethatsomeof theirpreoccupa-
tionwithcases whichare not "trueemergencies" is not simplya matterof
"abuse" by patients,but the resultof tasksimposedupon themby other
agencies-forexample,givingroutineantibioticinjectionson weekends,
caringforabandonedchildren,givingroutineblood transfusions, receiv-
ing inpatientadmissions,givinggammaglobulin,providingvenerealdis-
ease follow-up, examiningjail prisoners,arrangingnursing-home disposi-
tionsfortheaged. But theblameformostof theirdifficulty is placedupon
theself-referred patientwho,accordingto the emergency-room staff,does
not make appropriateuse of theirservice.
The OPD case typicallygets hurried,routineprocessingwith little
effortat a carefuldiagnosticwork-upor sophisticatedtreatmentunless
he happensto strikethe doctoras an interesting case (in whichcase he

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 The Hospital EmergencyService
is no longerclassifiedas an OPD case). Thus, pediatricresidentsmove
rapidlythroughtheirmass of sore throatsand snottynoses witha quick
look in ears and throatwith the otolaryngoscope, a swab wiped in the
throatto be sentto thelaboratory, and if the childdoes not have a high
fever(the nursehas alreadytaken his temperature), the parentis told
to checkon thelaboratoryresultsthenextday, the emergency-ward form
is marked"URI" (upperrespiratory infection),and the nextchildmoves
up on thetreadmill. If a patientor a visitorhas givenanyonetrouble,his
care is likelyto deteriorate below the routinelevel. Often,doctorsdefine
theirtaskin OPD cases as simplya stopgapuntilthepatientgetsto OPD
on a subsequentday, and therefore a carefulwork-upis not considered
necessary.
Medical cases are moreoftenconsideredillegitimate thansurgicalcases.
In our publichospitaltabulations,the diagnosticcategorieshighestin the
illegitimate categoryweregynecology, genito-urinary,dental,and "other
medical."The lowestin proportionof illegitimatecases were pediatrics
(anotherbit of evidencethat childrenare moreacceptablepatientsthan
adults), beatingsand stabbings,industrialinjuries,auto accidents,other
accidents,and "othersurgical."Much of the surgicalwork is suturing
lacerationsand makingotherrepairs.Althoughtheseare not necessarily
seriousin termsof dangerto life (veryfewwere),such injurieswereseen
by the staffas needingpromptattention(certainlywithin24 hours) to
reducethe riskof infectionand to avoid scarringor otherdeformity.
It is not surprisingthatin surgicalcases the attributesand behaviorof
thepatientsare of lesserconsequencethanin medicalcases. The ease with
whichtheconditioncan be definedand theroutinenatureof thetreatment
(treatingminorlacerationsbecomesso routinethatanyonethinkshe can
do it-medical students,aides, volunteers)means that the characteristics
and behaviorof the patientcan be largelyignoredunlesshe becomesex-
tremelydisruptive.(Even violencecan be restrainedand the treatment
continuedwithoutmuchtrouble.)Certainotherthingsare handledwith
routineefficiency-high feversin children,asthma,overdose,maternity
cases. It is significant
thatstandardrulescan be and have been laid down
in suchcases so thateveryone-clerks, nurses,doctors(and patientsonce
theyhave gone throughthe experience)-knowsjust how to proceed.In
suchcases,theissueof legitimacy seldomarises.
We findno similarroutineswithset rulesin the case of complaintsof
abdominalpains,delusions,musclespasms,depression, or digestiveupset.
Here theprocessof diagnosisis muchmoresubtleand complex,the ques-
tionof urgencymuchmoredebatableand uncertain.The way is leftopen
forall emergency-ward staffmembersinvolvedto makea judgmentabout
whetherthe case is appropriateto and deservingof theirservice.Unless
thepatientis a "regular,"no one on theemergency serviceis likelyto have

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AmericanJournalof Sociology
backgroundinformation on the patient,and the staffwill have to rely
entirelyon clues garneredfromhis mode of arrival,his appearance,his
behavior,thekindof peoplewhoaccompanyhim,and so on. The interpre-
tationof theseclues thenbecomescrucialto further treatment and, to the
casual observer, mayappearto be thecause of suchtreatment.
It is also not surprising that "psychiatriccases" are usuallyconsidered
illegitimate. Internsand residentsdo not (unless theyare planningto go
intopsychiatry)findsuch cases usefulforpracticingtheirdiagnosticand
treatmentskills,2and thereforeregardsuch patientsas an unwelcome
intrusion. But whatconstitutes a psychiatric case is not based on unvary-
ingcriteria.An effort is usuallymade to place a patientin a moreexplicit
medicalcategory.For example,a wristslashingis a surgicalcase requiring
suturing. An adultwhotakesan overdoseof sleepingpillsis a medicalcase
requiringlavage and perhapsantidotes.Only whena patientis trouble-
some-violent, threateningsuicide, disturbingother patients-is the
doctorforcedto definehim as a psychiatriccase about whoma further
decisionmustbe made. (In some clinics,psychiatrists are attempting to
broadenthe definition by makinginternsand residentsaware of more
subtlecues forjustifying a psychiatricreferral and providingthemwitha
consultingserviceto deal withsuch cases. However,theymust provide
a promptresponsewhencalled upon,or theirservicewillsoongo unused.)
It is no accidenteitherthat in the privatehospitals(especiallythose
withoutmedicalschool or public clinic affiliation)the legitimacyof a
patientdependslargelyon his relationship to the privatemedicalsystem.
A standardopeningquestionto the incomingpatientin such hospitalsis,
"Who is yourdoctor?"A patientis automatically legitimateif referred by
a physicianon thehospitalstaff(or thephysician'snurse,receptionist, or
answeringservice).If he has not been referred, but gives the name of a
staffdoctorwhomthenursecan reachand who agreesto handlethe case,
thepatientis also legitimate. However,if he does not give a staffdoctor's
name, he falls under suspicion.The hospital services,includingthe
emergency room,are designedprimarily to servetheprivatephysicianson
the staff.A patientwho does not fitinto this schemethreatensto upset
theworks.It is thereceptionist's or receivingnurse'sjob to tryto establish
the properrelationshipby determining whetherthe case warrantsthe
serviceof thecontractphysicianor thedoctoron emergency call, and if so,
to see to it thatthepatientgetsintothehandsof an attendingstaffdoctor
for follow-uptreatmentif necessary.Any patient whose circumstances
makethisprocessdifficuft or impossiblebecomesillegitimate. This accounts

2 The authorsof Boys in White (Becker et al. 1961, pp. 327-38) make the same point.
A "crock" is a patient fromwhom the studentscannot learn anythingbecause there
is no definablephysicalpathologywhich can be tracked down and treated.

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 The Hospital EmergencyService
forthebitterdenunciation of the "welfarecases"3 and the effort to deny
admissionto people withoutmedicalinsuranceor otherreadilytappable
funds.(Most physicianson the hospitalstaffdo not wantsuch people as
patients,and feel theyhave been trickedif a colleaguetalks theminto
acceptingthemas patients;neitherdoes the hospitaladministration want
themas inpatients.)Also, such hospitalshave no routinemechanismfor
dealingwithwelfarecases, as have the public hospitalswhichcan either
givefreetreatment or referthepatientto a social workeron thepremises.
Such patientsare commonlydealt withby transferring themto a public
clinicor hospitalif theirconditionpermits.
The negativeevaluationof patientsis strongest whentheycombinean
undeserving characterwithillegitimate demands.Thus, a patientpresent-
inga minormedicalcomplaintat an inconvenient houris morevigorously
condemned if he is a welfarecase thanif he is a "respectablecitizen."On
theotherhand,a "real emergency" can overcomemoralrepugnance. Thus,
whena presumedcriminalsuffering a severeabdominalbulletwoundin-
flictedby police was broughtinto one emergency ward,the staffquickly
mobilizedin a vigorouseffort to preventdeathbecause thisis thekindof
case thestaffsees as justifying theexistenceof theirunit.The samepatient
broughtin witha minorinjurywouldalmostcertainlyhave been treated
as a moraloutcast.Even in thecase of "real emergencies," however,moral
evaluationis not absent. Althoughthe police prisonerwith the bullet
woundreceivedprompt,expertattention, the effort
was treatedsimplyas
a technicalmatter--anopportunity to display one's skill in keepinga
severelytraumatizedpersonalive. When the same emergencyward re-
ceiveda prominent local citizenwho had been stabbedby thugswhilehe
was tryingto protecthis wife,the staffagain provideda crasheffortto
save his life,but in thiscase theywereobviouslygreatlyupset by their
failure,not simplya failureof technicalskillsbut the loss of a worthy
personwho was the victimof a viciousact. One may speculatewhether
thisdifference in staffevaluationsof the twovictimsmayhave resultedin
an extraeffort in the case of the respectedcitizendespitethe appearance
of a similareffort in thetwocases.

STAFF ESTIMATES OF "LEGITIMATE" DEMANDS

As is commonin relationshipsbetweena workgroupand its clientele,the

membersof the workgrouptend to exaggeratetheirdifficulties withthe
clientswhen they generalizeabout them. In conversations, we would
typicallyhear estimatesof 70?o-90% as the proportionof patientswho
wereusingthe emergency serviceinappropriately.
Yet, whenwe actually
t,"Welfarecases" include not only those who presentwelfare cards, but all who are
suspectedof tryingto work the systemto get freeor low-pricedcare.

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AmericanJournalof Sociology

followedcases throughthe clinic, we found the majoritywere being

treatedas if theywerelegitimate. In one voluntary hospitalwithan intern
and residency trainingprogram,we classifiedall cases we followedduring
our timeon theemergency roomas legitimate or illegitimatewheneverwe
had any evidenceof subjectivedefinition by staffmembers, eitherby what
theysaid aboutthepatientor themannerin whichtheytreatedthepatient.
Amongthosecases suitable forclassification, 42 were treatedas legiti-
mate,15 as illegitimate, and in 24 cases therewas insufficient evidenceto
make a classification. Thus, the illegitimate proportion was about 20%-
25% dependingon whetherone used as a base the totalof definitelegiti-
mateand illegitimate cases or also includedtheunknowns. In a veryactive
publichospitalemergency roomwe did not use directobservation of each
case, but ratherdevelopeda conceptionof what kind of diagnosticcate-
gorieswereusuallyconsideredlegitimateor illegitimate by the clinicstaff
and thenclassifiedthe total censusfortwo days accordingto diagnostic
categories.By thismethod,23% of 938 patientswereclassifiedas illegiti-
mate.This constitutes a minimum figurebecause diagnosticcategorywas
not theonlybasis foran evaluation,and someotherpatientswerealmost
certainlyregardedas illegitimate by thestaff.But it does suggestthatonly
a minority wereregardedas illegitimate.
The numbersof specificundesirableor inappropriate categoriesof pa-
tientswerealso consistently exaggerated. Thus,whilein thepublichospital
the internscomplainedabout all the drunksamongthe men and all the
reproductive organ infectionsamong women ("The choice betweenthe
male and the femaleserviceis really a choice betweenalcoholicsand
PIDs," accordingto one intern),drunksmade up only 6% of the total
emergency-room populationand the gynecologypatients2%'o. Venereal
diseasewas also considereda commontypeof case by clerks,nurses,and
doctors,but in fact made up only about 1% of the total E.R. census.
Psychiatric cases werereferred to as a constanttrouble,but,in fact,made
up onlya littleover2% of thetotal.Somedoctorsbelievedinfections and
long-standing illnesseswerecommonamongthe E.R. populationand used
this as evidenceof neglectof health by the lower classes. Here again,
however,the actual numberswerelow-these two categoriesmade up a
littlemorethan3% of thetotalcensus.In twosmallprivatehospitals,the
staffswereparticularly bittertoward"welfarecases" whomtheyregarded
as a constantnuisance.However,we oftenspent an entireshift (eight
hours) in the emergency roomsof thesehospitalswithoutseeinga single
patientso classified.
Workersjustifythe rewardsreceivedfor theirlabors in part by the
burdenswhichtheymustendureon thejob. One of theburdensof service
occupationsis a clientelewhichmakeslifehard fortheworkers. Thus, the

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 The Hospital EmergencyService
workerstendto selectforpublicpresentation thoseaspectsof theclientele
whichcause themdifficulty. Teachers' talk deals disproportionately
with
disruptiveand incompetentstudents,policemen'stalk with dangerous
criminalsand difficult
civilians,janitors'talk withinconsideratetenants.
A case-by-caseanalysisof clientcontactsis likelyto demonstrate in each
instancethattheexamplesdiscussedby thestaffare not representative of
theirtotalclientele.

CONTROL OF INAPPROPRIATE DEMANDS FOR SERVICE

When membersof a serviceoccupationor serviceorganizationare faced

withundesirableor illegitimate clients,what can theydo? One possible
procedureis to selectclientstheylike and avoid thosetheydo not like.
The selectingmaybe donein categoricalterms,as whenuniversities admit
undergraduate studentswho meetgivengrade and test standards.Or it
maybe doneon thebasis of detailedinformation aboutspecificindividuals,
as whena graduatedepartment selectsparticularstudentson the basis of
academicrecord,recommendations fromcolleagues,and personalinforma-
tionaboutthestudent.Of course,suchselectionis notmadeon a unidimen-
sionalbasis and theselectingagentmustoftendecidewhatweightto give
conflictingfactors.(Thus, a medicalspecialistmay be willingto take on
a patientwho is morallyrepugnantbecause the patienthas a medical
conditionthe specialistis anxiousto observe,study,or experiment with.)
But thereis an assumption thatthemorehighlyindividualized theselection
and the moredetailed the information on whichit is based, the more
likelyone is to obtaina desirableclientele.Alongwiththisprocessgoes
thenotionof "selectionerrors."Thus, whena patientis classedas a good
risk for a physicalrehabilitation program,he may later be classed as
a selectionerrorif doctorsuncoversomepathologywhichcontraindicates
exercise,or if thepatientprovesso uncooperative thatphysicaltherapists
are unableto conductany training, or if he requiresso muchnursingcare
thatwardpersonnelclaimthathe "doesn'tbelong"on a rehabilitation unit
(Roth and Eddy 1967,pp. 57-61).
Selectivity is a relativematter.A well-known law firmspecializingin a
givenfieldcan accept only those clientswhosedemandsfitreadilyinto
the firm'sdesiredschemeof workorganizationand who are able to pay
well fortheservicegiven.The solo criminallawyerin a marginalpractice
may, forfinancialreasons,take on almosteverycase he can get, even
thoughhe may despisethe majorityof his clientsand wish he did not
have to deal withthem (Smigel 1964; Wood 1967). A commonoccupa-
tionalor organizational aspirationis to reacha positionwhereone can be
highlyselectiveof one's clientele.In fact,such powerof selectionis a

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AmericanJournalof Sociology

commonbasis forratingschools,law firms, hospitals,and practitionersof

all sorts.4
If one cannotbe selectivein a positivesense,one may stillbe selective
in a negativesenseby avoidingsomepotentially undesirableclients.Hotels,
restaurants, and places of entertainment may specificallyexcludecertain
categories ofpersonsas guests,or moregenerallyreservetherightto refuse
serviceto anyonetheychoose. Cab driverswill sometimesavoid a pre-
sumed"bad fare" by pretendinganotherengagement or just not seeing
him.Cab driving,incidentally, is a good exampleof a line of workwhere
judgmentsabout clientsmust oftenbe made in a split second on the
basis of immediatesuperficial clues-clues based not onlyon thebehavior
and appearanceof theclienthimself, but also on such surrounding factors
as the area, destination,and timeof day (Davis 1959; Henslin1968,pp.
138-58). Ambulancecrewmensometimesmanageto avoid a "bad load,"
perhapsmakinga decisionbeforegoingto the scene on the basis of the
call sourceor neighborhood, or perhapsrefusingto carryan undesirable
patientif theycan finda "goodexcuse" (Douglas 1969,pp. 234-78).
Medical personneland organizations vary greatlyin theircapacityto
selectclients.Specialunitsin teachinghospitalsand specializedoutpatient
clinicsoftenare able to restricttheirpatientsto thosetheyhave individ-
ually screenedand selected.The more run-of-the-mill hospitalward or
clinic less selective,but stillhas a screeningprocessto keep out certain
is
categoriesof patients.Of all medicalcare units,publichospitalemergency
wardsprobablyexercisetheleast selectivity of all. Not onlyare theyopen
to the publicat all timeswithsignspointingthe way, but the rule that
everyonedemanding care mustbe seenprovidesno legal "out" forthestaff
whenfaced withinappropriate or repugnantpatients (althoughpersons
accompanying patientscan be, and oftenare,preventedfromenteringthe
treatment areas and are isolatedor ejected if troublesome).In addition,
the emergency wardservesa residualfunctionforthe restof the hospital
and oftenforotherpartsof themedical-care system.Anycase whichdoes
notfitintosomeotherprogramis sentto theemergency ward.Whenother
clinicsand officesclose for the day or the weekend,theirpatientswho
cannotwaitforthenextopenhoursare directedto theemergency service.
It is preciselythis unselectiveinfluxof anyoneand everyonebringinga

4 I am glossingover some of the intraorganizational complexitiesof the process.Often

differentcategoriesof organizationalpersonnelvary greatlyin their participationin
the selectionof the clientele.Thus, on a hospital rehabilitationunit, the doctors may
select the patients,but the nursesmust take care of patientsthey have no directpart
in selecting.Nurses can influencefutureselectiononly by complainingto the doctors
that they have "too many" of certainkinds of difficultpatientsor by tryingto con-
vince doctors to transferinappropriatepatients.These attemptsat influencingchoice
oftenfail because doctors and nurseshave somewhat different criteriaabout what an
appropriatepatient is (Roth and Eddy 1967, pp. 57-61).

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 The Hospital EmergencyService

wide spectrumof medicaland social defectsthat elicitsthe bittercom-

plaintsof emergency-service personnel.Of course,theyare not completely
withoutselectivepower.They occasionallyviolatethe rulesand refuseto
accept a patient.And even afterregistration, some patientscan be so
discouragedin the earlystagesof processingthat theyleave. Proprietary
hospitalstransfersome patientsto public hospitals.But comparedwith
otherpartsof the medical-caresystem,the emergency-service personnel,
especiallyin public hospitals,have verylimitedpower of selectionand
must resignthemselvesto dealing with many people that they believe
shouldnotbe thereand thatin manycases theyhave a strongaversionto.
What recoursedoes a serviceoccupationor organization have whenits
membershave littleor no controlover the selectionof its clients?If you
cannotpick the clientsyou like,perhapsyou can transform thoseyou do
getsomewhatcloserto theimageof a desirableclient.This is particularly
likelyto occur if it is a long-term or repeatedrelationshipso that the
workercan reapthebenefitof the"training"he givestheclient.We tenta-
tivelyput forththisproposition:Tke amountof troubleone is willingto
go to to trainhis clienteledependson howmuchpowerof selectionhe has.
The easierit is forone to avoid or get rid of poor clients(that is, those
clientswhosebehavioror attributesconflictwithone's conceptionof his
properworkrole), the less interestedone is in puttingtimeand energy
intotraining clientsto conform morecloselyto one's ideal. And,of course,
theconverse.
Janitorshave to endurea clientele(that is, tenants)theyhave no hand
in selecting.Nor can a janitorget rid of bad tenants(unlesshe buys the
buildingand evictsthem,as happenson rareoccasions). Ray Gold (1964,
pp. 1-50) describeshow janitorstry to turn "bad tenants"into more
tolerableones by teachingthem not to make inappropriatedemands.
Tenants mustbe taughtnot to call at certainhours,not to expectthe
janitorto makecertainrepairs,not to expecthimto removecertainkinds
of garbage,to expectcleaningservicesonly on givendays and in given
areas, to expectheat onlyat certaintimes,and so on. Each occasionon
whichthejanitoris able to makehis pointthat a givendemandis inap-
propriatecontributes to makingthosedemandsfromthe same tenantless
likelyin the futureand increasesthe janitor'scontrolover his workload
and workpacing.One findsmuchthe same long-term efforton the part
of mentalhospitalstaffswho indoctrinate inmateson the behaviorand
demandsassociated with "good patients"-who will be rewardedwith
privilegesand discharge-and behaviorassociatedwith"bad patients"-
who willbe deniedtheserewards(Stantonand Schwartz1954, pp. 280-
89; Belknap1956,chaps.9 and 10). Prisonsand schoolsare otherexamples
of suchlong-term teachingof clients.5
O
of course, my brief presentationgreatly oversimplifiesthe process. For example,

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AmericanJournalof Sociology
The formthat"client-training" takes dependsin part on the timeper-
spectiveof the trainers.Emergency-ward personneldo not have the long-
timeperspective of thementalhospitalstaff,teachers,or janitors.Despite
the fact that the majorityof patientshave been to the same emergency
wardpreviously and willprobablybe back again at some futuretime,the
staff,withrare exceptions,treatseach case as an episodewhichwill be
completedwhenthepatientis discharged.Therefore, theyseldommake a
directeffort to affectthe patient'sfutureuse of theirservices.They are,
however,interested in directingthe immediatebehaviorof clientsso that
it willfitintotheirconceptofproperpriorities(in termsof theirevaluation
of the clients)and theproperconductof an emergency service,including
theworkdemandsmade upon them.Since theydo not conceiveof having
timeforgradualsocializationof theclients,theyrelyheavilyon demands
for immediatecompliance.Thus, patientsdemandingattention,if not
deemedby staffto be urgentcases or particularly deserving,will be told
to wait theirturnand may even be threatenedwithrefusalof treatment
if theyare persistent.Visitorsare promptly orderedto a waitingroomand
are remindedof wheretheybelongif theywanderinto a restricted area.
Patientsare expectedto respondpromptlywhencalled,answerquestions
put to themby the staff,prepareforexaminationwhenasked,and coop-
erate withthe examinationas directedwithoutwastingthe staff'stime.
Failure to complypromptlymay bringa warningthat theywill be left
waitingor evenrefusedfurther care if theydo notcooperate,and themore
negativethe staffevaluationof the patient,the morelikelyhe is to be
threatened.6
Nursingstaffin proprietary hospitalsdealingwiththe privatepatients
of attendingphysiciansdo not have as authoritative a positionvis-'a-vis
theirclientsas public hospital staffhave; therefore, the demands for
promptcompliancewithstaffdirectionsmustbe used sparingly.In such
a case moresurreptitious formsof controlare used. The most common
deviceis keepingthepatientwaitingat somestepor stepsin his processing
or treatment. Sincethepatientusuallyhas no way of checkingthevalidity
of the reasongivenforthe wait,thisis a relativelysafe way that a nurse
can controlthedemandsmadeon herand also servesas a way of "getting

much of the teachingis done by the clientsratherthan directlyby the staff.But, ulti-
mately,the sanctions are derived fromstaffeffortsto control work demands and to
expresstheirmoral evaluation of the clients.
6 Readers who are mainly interestedin what happens on an emergencyward should
not be misled into thinkingthat it is a scene of continuousorders and threatsbeing
shouted at patients and visitors.Most directivesare matter-of-fact,and most clients
complypromptlywith directionsmost of the time.But when the staff'sdirectivepower
is challenged,even inadvertently,the common response is a demand for immediate
compliance.This situationarises frequentlyenough so that on a busy unit an observer
can see instancesalmost everyhour.

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 The Hospital EmergencyService
even" withthosewho make inappropriate demandsor whomshe regards
as undeserving forsomeotherreason.
In general,we mightexpectthat: The longerthetimeperspective of the
trainers,themorethetrainingwilltake theformof efforts towardprogres-
sive socializationin the desireddirection;theshorterthe timeperspective
of the trainers,themorethe trainingwill take the formof overtcoercion
(tgivingorders")if thetrainershavesufficient poweroverthe clients,and
effortsat surreptitiousbut immediate controlif theylack suchpower.

CONCLUSION

Whena personpresentshimselfat an emergency department (or is brought

thereby others),he inevitablysets offa processby whichhis worthiness
and legitimacyare weighedand becomea factorin his treatment. It is
doubtfulthatone can obtainany serviceof consequenceanywherewithout
going throughthis process.The evidencefromwidelyvaryingservices
indicatesthattheserversdo notdispensetheirservicein a uniform manner
to everyonewhopresentshimself, but makejudgmentsabout the worthi-
nessof thepersonand the appropriateness of his demandsand take these
judgments intoaccountwhenperforming theservice.In largeand complex
serviceorganizations,thejudgmentsmade at one pointin thesystemoften
shapethejudgments at another.
The structureof a serviceorganizationwill affectthe mannerand
degreeto whichthe serverscan varytheirservicein termsof theirmoral
evaluationof the client.This studyhas not exploredthisissue in detail.
A usefulfutureresearchdirectionwould be the investigation of how a
systemof servicemaybe structured to controlthediscretion of theservers
as to whomtheymustserveand how theymustserve them.This paper
offeredsomesuggestions concerningthe meansof controlling the inappro-
priatedemandsofa clientele.The examplesI used to illustratetherelation-
shipsofpowerof selectionand thenatureof training of clientsare fewand
limitedin scope. An effortshould be made to determinewhetherthese
formulations (or modifications
thereof)applyin a widervarietyof occupa-
tionalsettings.

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