Communication & Medicine
Volume 8(3) (2011), 211–221
Copyright © Equinox Publishing Ltd
Sheffield
http://equinoxpub.com
DOI: 10.1558/cam.v8i3.211
Moral accounts and membership categorization in primary care medical interviews
P k J. D
University of South Florida, USA
Abstract
Although the link between health and morality has
been well established, few studies have examined
how issues of morality emerge and are addressed in
primary care medical encounters. This paper ad-
dresses the need to examine morality as it is (re)
constructed in everyday health care interactions. A
Membership Categorization Analysis of 96 medical
interviews reveals how patients orient to particu-
lar membership categories and distance themselves
from others as a means of accounting (Buttny 1993;
Scott and Lyman 1968) for morally questionable
health behaviours. More specifically, this paper ex-
amines how patients use membership categoriza-
tions in order to achieve specific social identity(ies)
(Schubert et al. 2009) through two primary strate-
gies: defensive detailing and prioritizing alternative
membership categories. Thus, this analysis tracks
the emergence of cultural and moral knowledge
about social life as it takes place in primary care
medical encounters.
Keywords: medical interviews; accounting; morality;
Membership Categorization Analysis
1. Introduction
Americans’ visits to primary care physicians’ offices
total more than 910 million each year (United
States National Center for Health Statistics 2006).
These primary care interviews serve an impor-
tant function in the provision of health services.
A primary care practice is often a patient’s first
point of entry into the health care system and is,
ideally, the continuing focal point for all needed
health care services (American Academy of Family
Physicians 2009). By serving these important
functions, primary care medical interviews play
an important role in the overall health of patients.
Thus, patient–physician interaction in primary
care is established as an important area of inquiry
across a variety of academic disciplines (Heritage
and Maynard 2006).
Although medical interviews are often associ-
ated with the exchange of objective facts related
to the physical nature of medical problems (Linell
and Bredmar 1996; Tracy and Robles 2009), talk in
medical encounters (as in other types of conversa-
tion) is also ‘drenched with implicit moral judgments,
claims, and obligations’ (Heritage and Lindström
1998: 398). The idea of a link between health and
morality is nothing new in Western scholarship.
Scholars have long posited that health behaviours
constitute an important role in constructing defini-
tions of moral character, such that, to be healthy is
to be a ‘good’ person (Stephens and Breheny 2008).
However, if we are to truly understand the relation-
ship between health and morality we must heed
Bergmann’s (1998) call to examine morality as it is
constructed in and through everyday social interac-
tion in health institutions.
This paper addresses this need by building on
previous research to examine morality as it is (re)
constructed in everyday health care interactions.
Drawing upon Membership Categorization Analysis
(MCA, Sacks 1992; Baker 1997a; Hester and Eglin
1997), the analysis presented here focuses on how
patients orient to particular membership catego-
rizations and distance themselves from others as a
means of accounting (Scott and Lyman 1968; Buttny
1993) for morally questionable health behaviours.
More specifically, this paper examines how patients
use categorization in order to achieve specific social
212 Patrick J. Dillon
identity(ies) (Schubert et al. 2009) and tracks the
emergence of cultural and moral knowledge about
social life as it takes place in primary care medical
encounters. Before proceeding with a detailed
analysis of how issues of morality are managed in
these encounters, I will first review previous research
relevant to the present study and describe my meth-
odological approach.
2. The problem presentation phase
Physician–patient interaction in primary care
medical interviews has been a popular area of
inquiry across a variety of disciplines (Heritage
and Maynard 2006; Cegala and Street 2010). Of
particular interest to many scholars has been the
problem presentation phase of medical interviews
(Stoeckle et al. 1963; Mechanic 1972; Zola 1973;
Brody 1987; Heritage and Robinson 2006). Though it
is often short in duration, the problem presentation
phase is an important component of the medical
interview (Beckman and Frankel 1984; Marvel et al.
1999). Heritage and Robinson (2006) describe the
problem presentation phase as ‘one of the few (and
often the only) opportunities available for patients
to present their concerns in their own way and
in accordance with their own agendas’ (2006: 49,
emphasis in original).
Past studies have often focused on the content
and form of patients’ presentations of their medical
problems, including patients’ descriptions of the
nature of their symptoms, how the symptoms were
discovered (Halkowski 2006), and how patients
account for seeking medical attention (Heritage and
Robinson 2006). These studies have provided valu-
able insights into the problem presentation phase
of medical interviews, but have largely ignored the
moral component of medical encounters (Bergmann
1992; Heritage and Lindström 1998). In contrast, the
present study examines how patients attend to the
moral components of their medical condition in the
problem presentation phase.
3. Health behaviours, morality and accountability
Scholars have long recognized a connection between
the local moral world and individual health (Stephens
and Breheny 2008). Work in this area has focused
attention on a Western societal emphasis on personal
responsibility for illness (Crawford 1977; Petersen
and Lupton 1996). Within the Western bio-medical
model of medicine, individuals are expected to
engage in behaviours that will promote health and
prevent illness (Parsons 1951; Brown 1999). Thus,
individual’s health behaviours become a matter of
personal responsibility and are rife with potential
moral implications (Baruch 1981).
A deeper understanding of the connection
between health and morality requires scholarly
examination of how morality is constructed in and
through social interaction through the analysis of
the intricacies of everyday medical interactions
(Bergmann 1998). Far from focusing on biological
and physiological facts, Tracy and Robles (2009)
note that talk in medical interviews often involves
the discussion of ‘sensitive’ behavioural and life-
style choices. Building on this notion, a growing
body of research has focused on moral discourse
in a variety of healthcare institutions. Examples of
this work include Arronson and Cederborg’s (1989;
1997) descriptions of how physicians avoided overtly
challenging parents regarding problematic family
life issues (e.g. food, pets) by jokingly addressing
children during paediatric consultations and how
competing narratives about a 14-year-old patient’s
relationship with her boyfriend revealed a discon-
nect between adult and adolescent conceptions of
moral order in a family therapy session. Further
examples include: Peräkylä’s (1998) empirical obser-
vation that physicians do not present patient diag-
noses from an unaccountable position of externally
or institutionally granted authority; Silverman and
Peräkylä’s (1990) examination of how practition-
ers and patients interactionally negotiate ‘delicate’
issues in HIV/AIDS counselling sessions; and Sil-
verman’s (1987) discussion of how charge-rebuttal
sequences operate in morally inflected discussions
of parenthood in diabetic clinics.
This study contributes to this body of research
by examining how issues of morality emerge and
are addressed in talk between patients and physi-
cians in the problem presentation phase of medical
interviews. Heritage and Robinson (2006) state that
any patient’s presentation of medical information is
simultaneously a presentation of self. According to
Goffman (1961) participants in any social encounter
are motivated to position themselves as moral agents,
but the existence (or potential existence) of particular
health conditions can pose threats to individuals’
moral standing (Brown 1999). When individuals per-
ceive that their status as moral agents is threatened,
they are motivated to attend to these threats through
talk (Stokoe 2003).

The focus of this study is to examine how patients
offer accounts for their health-related actions (Herit-
age and Robinson 2006). The practice of accounting
can be described in several ways (Evaldsson 2007). For
the purposes of this study, the definition of account-
ing is derived from the work of Scott and Lyman
(1968) that was further developed by Buttny (1993).
Based on this work, accounts are designated as ‘talk
designed to recast the pejorative significance of action
and an individual’s responsibility for it, and thereby
transform other’s negative evaluations’ (Buttny 1993:
1).
The relationship among health, morality and mem-
bership categorization is very complex. Although the
problem presentation phase of medical interviews
has been a widely researched setting and the link
between health behaviours and morality has been
well-established, further scholarship is needed to
explore how morality is constructed in and through
social interaction between patients and physicians
in medical interviews. Thus, the aim of this paper
is to provide insight into the ways in which patients
use categorization as a means of accounting for their
health-related behaviours in primary care medical
encounters.
4. Methodological approach
The following analysis draws upon the ethnometh-
odological (EM) approach of Membership Catego-
rization Analysis (MCA, Sacks 1992; Hester and
Eglin 1997; Baker 1997a, 2000, 2004). The aim of
EM inquiry is to analyse the situated conduct of
societal members in order to understand how they
make sense of their social world (Garfinkel 2002).
The EM approach provides an understanding of how
humans ‘do’ social life (Stokoe 2003) and how ‘the
properties of social life which seem objective, factual
and transsituational, are actually managed accom-
plishments or achievements of local processes’
(Zimmerman 1978: 11). Two methods of analysing
interactional data are rooted in EM: conversation
analysis (CA) and MCA. Although both approaches
are derived from the work of Harvey Sacks (see Sacks
1992, and specifically lecture 6 in part I, lectures 7,
8 in part II and lectures 1, 2 in part III) and aim to
examine how individuals ‘produce and recognize
courses of social activity’ as they are used in context
(Clayman and Maynard 1995: 2), MCA and CA
have developed largely independently of each other
(Hester and Eglin 1997). While CA has emerged as
a ‘well-established method for explicating the order
Moral accounts in primary care interviews 213
of social life via the sequential analysis of everyday
interaction’ (Stokoe 2003: 320), MCA has ‘largely
taken off beyond CA’s program of tracking sequen-
tial features’ by focusing on how members use
categories by drawing on cultural knowledge (Bar-
tesaghi and Bowen 2009: 231). Following Evaldsson
(2007), I retain some features of CA’s attention to
the sequential organization of talk but am primarily
interested in MCA’s focus on examining members’
understanding and use of social categories (Antaki
and Widdicombe 1998; Baker 2000; Hester and
Eglin 1997; Sacks 1992).
Sacks (1992) initially developed MCA ‘in order to
explicate the rules people draw upon in the course
of talking together and going about their daily lives’,
with a particular focus on speaker’s situated categori-
zations of themselves and others (Stokoe 2003: 321).
MCA is based around the notion of the Membership
Categorization Device (MCD), which Sacks (1972:
218) defined as:
any collection of membership categories, containing
at least as a category, which may be applied to some
population containing at least a member, so as to
provide, by the use of some rules of application, for
the pairing of at least a population and a categori-
zation device member. A device is then a collection
plus rules for application.
These rules of application are not external mandates
but encompass how members will ordinarily hear
second and even third and fourth pair parts. For
example, the MCD of family can imply the indi-
vidual categories of mother, father and child (Baker
2000). These categories connect to particular actions
(category-bound activities) or characteristics (natural
predicates) such that there are conventional expecta-
tions about what constitutes normative behaviour for
members of particular categories (Hester and Eglin
1997). This is not to say that the categories always
index the same meaning or behaviours (Stokoe
2003). Rather, the orderliness of categories and their
predicates ‘is achieved and is to be found in the local
specifics of categorisation as an activity’ (Hester and
Eglin 1997: 46).
One central feature of MCA is that ‘a strip of
text may tell you which membership category is to
be heard, or it may require you to make an infer-
ence about what membership category is relevant’
(Lepper 2000: 15; see also Evaldsson 2007). This
means that the MCA analyst ‘necessarily draws on
extracontextual interpretative resources to explicate
the sense-making orientations of the participants’
(Evaldsson 2007: 383; see also Stokoe and Smithson
2001). Borrowing from Schubert et al. (2009), I view
214 Patrick J. Dillon
social memberships ‘not to be static demographic
characteristics of persons, but rather to be situ-
ated accomplishments, developed and maintained
through the medium of everyday talk’ (2009: 501).
Holding to this belief I use the framework of MCA to
identify how patients perform moral work (Schubert
et al. 2009) in the problem presentation phase of
primary care interactions by examining how patients
employ discursive devices to achieve desired social
identities (Edwards and Potter 2001) and, in turn,
reflect or create a situated moral reality (Jayyusi
1984; Stokoe 2003).
5. Data
The present study consists of a secondary analysis
of data drawn from a database of 96 recordings of
physician–patient interactions1 (see Dillon 2012).
The recorded interactions took place at two primary
care medical clinics in Michigan, United States. The
first clinic was a small family practice located in rural
northern Michigan. The second was a larger primary
care clinic located in an urban area of south-east
Michigan.
Participation in the original project was volun-
tary for both patients and physicians. The inclusion
criteria for participants were: being over the age of
18, speaking fluent English as identified by the par-
ticipants, and being a patient of one of the clinical
sites. The interviews were recorded on audiocas-
settes and transcribed using transcription notation
adapted from Jefferson (1984; see Appendix A). All
identifying information (including personal and place
names) was omitted from the transcripts to ensure
the anonymity of participants.
The transcripts were analysed according to the
principles of MCA, as described by Baker (1997a)
and Stokoe (2003). I began by identifying the central
categories of people, places or things that underpin
talk that were named explicitly or implied by the
‘activities’ associated with them. I continued by
examining the activities associated with each of the
categories in order to understand the attributions
that were made to each of the categories. The final
step was to examine the connections among cat-
egories and attributions that were produced by the
participants in the interaction in order to discover
courses of social action that were implied (how
could or should members of categories behave).
Ultimately, I directed attention to the discursive and
rhetorical aspects of the participants’ talk by focus-
ing on the mechanisms in which the membership
categories were invoked, ascribed, avowed or disa-
vowed by participants and the particular social or
moral actions accomplished by these devices (Stokoe
2003; Schubert et al. 2008).
6. Analysis
The analysis presented here draws attention to ways
that patients engage in membership categorization
work as a means of moral accounting in primary care
medical interviews. More specifically, the analysis
draws attention to two primary ways that patients
utilize membership categorization in order to account
for past behaviours: (a) defensive detailing and (b)
prioritizing alternative membership categories. These
categorization strategies are not mutually exclusive
and may be used in combination (as demonstrated
in Extract 3).
6.1. Accounting for past behaviours through
defensive detailing
The notion of defensive detailing refers to instances
when individuals build a case for an episode or
behaviour being problematic or immoral but not a
transgression on their part (Drew 1998). The idea of
defensive detailing is originally derived from Jeffer-
son’s (1985) analysis of the often extensive detailing
that speakers use to describe their behaviours as
outside their control or as the fault of some external
force (e.g. another person’s decision).2
In order to illustrate defensive detailing, Drew
(1998) offers the example of a man who had arranged
to give a friend a ride out of town on the following
weekend but then calls the friend to explain that he
will be unable to do so. During the phone call, the
man explains that he can no longer provide the ride
because the friend with whom he was intending to
stay with had decided at the last minute to go out of
town. Thus, the use of defensive detailing is meant to
displace accountability for an action that is potentially
morally sanctionable. In the context of a medical
interview, the following example makes it clear that
accounting by way of defensive detailing is used by
patients as a means of membership categorization
work.
In the following example, k (a high school senior)
discusses her pregnancy with Dr M. Near the begin-
ning of the medical interview, Dr M and k discuss
her status as a high school student before Dr M shifts
the topic of conversation to k’s pregnancy:
 Moral accounts in primary care interviews 215

(1) Extract 1 that there is something problematic about associating

1 Dr M: So uh you’re a senior this year, right? pregnancy with this category.
2 : Yeah hhh fin:ally Starting in line 14, k describes using condoms as
Six lines omitted (‘small talk’ about classes is taking ‘doing everything’ she and her boyfriend were sup-
and the time of high school graduation) posed to do in order to prevent pregnancy (line 14-15)
and as ‘responsible’ sexual behaviour (line 20-21). k
9 Dr M: Well let’s uh why don’t we talk about
10 you preg[nancy= continues by contrasting her ‘responsible’ behaviour
11 you preg[okay with her friends’ failure to use condoms (line 22-23),
12 Dr M: Was it expected? indirectly labelling such behaviour as ‘irresponsible’.
13 : No hhh I was pretty surprised These utterances serve to create a morally organ-
14 We were doing everything we were ized contrast pair (Housley and Fitzgerald 2009) of
15 supposed to do ‘responsible’ and ‘irresponsible’ sex by high school
16 Dr M: (.5) Mhmhm students.
17 : Yeah we were using condoms every time By invoking these categorizations to account for
18 It must have um broke or something her sexual (medically relevant) behaviour, k engages
19 Dr M: Uh huh
in defensive detailing. While answering Dr M’s ques-
20 : Yeah we did what we could to be
21 responsible
tion, k makes it clear that she had met the standard
22 You know so many of our friends use uh of ‘responsible’ sexually activity by using a condom.
23 (.3) nothing but haven’t had it happen k describes becoming pregnant as the result of
24 Dr M: I see. condom failure (see Sznitman et al. 2009). In offer-
25 Well uh I want to ask a few more ing this account, k attempts to reduce her personal
26 (.5) questions about how you are uh feeling responsibility by shifting the causal attributions from
27 : Oh (.3) sure= herself to external elements (Higgins et al. 1991)
28 =I feel great yo`u know very excited! and claim membership in the desirable category of
29 [We bo]th are ‘responsible’ high school student, a categorization
30 Dr M: [Ok um[
that she indicates is undermined by her status as an
31 : [Ok um[Yeah,
expectant mother.
32 (name) and me are going to raise the
33 uh baby together= k then further attends to her moral standing by
34 =as like a uh real family indicating that she and her boyfriend intended to
35 Dr M: That’s uh good raise their baby together ‘like a uh real family’ (line
36 but I uh me:ant how you are 16). In MCA terms, the category ‘mother’ forms part
37 were feeling ↑physically of the standardized relational pair (SRP) ‘mother–
38 : HHHhhh oh ok father’. An SRP is a ‘pairing of members such that the
relation between them constitutes a locus for rights
Although there is no clear indication that Dr M’s and obligations’ (Lepper 2000: 196). By labelling
question about whether ’s pregnancy was expected them as a ‘real family’, k draws upon her cultural
serves an evaluative function, responds by offering knowledge to define the normative make-up of the
an account. Further, ’s response indicates a view of Membership Categorization Device (CMD) of family
unexpected pregnancies as undesirable. Given the as including both a mother and a father and reinforces
conversational context in which ’s status as member heteronormative family relations (Stokoe 2003). As
of the category high school senior (lines 1-2, omitted Sacks (1992: 585) notes, ‘the fact that activities are
lines) prior to the abrupt shift to a question about category-bound also allows us to praise or complain
her pregnancy, it seems reasonable to suggest that about “absent” activities’. By labelling a family consist-
is indicating that an unexpected pregnancy may be ing of a mother, father and child as ‘real’ (line 32-34),
particularly problematic for a high school student. k suggests that something less than this (i.e. a family
This makes high school student relevant in the inter- without a father) is morally questionable.
action. As she accounts for her actions, assigns the In this example, k demonstrates that one way of
engagement in sexual activity as typical behaviour accounting for morally problematic health behav-
for members of this category by indicating she (lines iours is to draw upon cultural knowledge in order to
14-15) and ‘so many’ of her friends (line 22) were (re)construct desirable membership categories and
engaging in sex. Although these utterances position align oneself to these desirable categories through
her engagement in sexual activity as a typical predi- talk. Of interest in this example is the patient’s use
cate of the category high school student, and thus of defensive detailing as a means of orienting to the
not accountable, the utterances that follow suggest desirable membership categories (i.e. responsible high
216 Patrick J. Dillon
school student, part of a ‘real’ family) that could be
undermined by her current health status. Consistent
with Jefferson’s (1985) notion of defensive detailing,
this extract provides an example of how patients use
details to describe their behaviours as outside their
control or as the fault of some external force. By miti-
gating personal responsibility, the patient attends to
the potential moral implications of her health-related
behaviours.
6.2. Accounting by prioritizing alternative
membership categorizations
As Parsons (1951) pointed out, there is an expectation
on the part of the person who is ill that he or she must
want to get better and exert every effort to do so; he
or she must work to overcome the illness by deferring
to the professional judgment of medical authority.
Thus, good health has become conceptualized as a
commodity that one can gain and as a project for the
self to work on by following the instructions offered
by medical authorities (Brown 1999). Within the data
analysed here, there were several examples of patients
attending to their moral standing in relation to failing
to engage in or choosing to discontinue behaviours
recommended by their physician. In these cases, the
patients frequently attended to the moral implications
of their choices by strategically prioritizing their own
potential membership categorizations.
In the following extract, B has visited his primary
care physician (Dr M) because he was suffering from
flu-like symptoms (e.g. mild fever, runny nose), a
routine acute problem. After B describes the symp-
toms associated with his primary complaint, Dr M
inquires if there is anything else she should know. B
responds by disclosing that he has discontinued his
use of a prescribed antidepressant drug (presumably
prescribed by this same doctor). The extract begins
with Dr M’s question:
(2) Extract 2
1 Dr M: uhh okay uh (.) so is there anything else
2 I nee- you uh think I should know?
3 B: I um thought I should tell you that I
4 uh am not taking the [drug name]
5 anymore
6 Dr M: Oh (.5) well why did you decide to um
7 do that?
8 I thought it was helping
9 B: Yeah (.) uh it’s kind of sensi[tive
10 Dr M: Yeah (.) uh it’s kind of sensi[yeah=
11 B: =I was having some of those sex problems
12 Dr M: I see
13 (.) What about treating your uh
14 depression issues?
15 B: Well it’s uh not worth it if I can’t
16 per:form as a man
17 You know uh sexually
18 Dr M: I see
19 =Well that is your um choice
20 (.) But I want to be sure we are doing
21 something about that (depression)
22 as well
23 B: Yeah (.3) only if it doesn’t uh
24 affect me
Hester and Eglin (1997) note that, in addition to
intimates such as husband–wife, SRPs also include
occupational category pairings like doctor–patient.
Additionally, Sacks (1992) also introduced the
concept of ‘category-bound activities’, which include
activities that are expectably done by people who are
members of particular categories. Others (e.g. Jayyusi
1984; Watson 1978; Watson and Weinberg 1982) have
expanded Sacks’ thinking regarding the predicates,
including knowledge, obligations, and rights that
can be conventionally associated with particular
categories.
Following Baker’s (1997a) conception of interviews
as category elaboration, the medical interview high-
lights the SRP of doctor–patient and their associated
predicates. In Dr M’s question, she draws on her
(institutionally sanctioned) position as the physi-
cian by suggesting that there is information that she
‘should know’ (line 2). B tacitly acknowledges that
he is fulfilling this obligation by indicating that, as
a member of the category ‘patient’, he ‘should’ (line
3-5) tell his doctor when he chooses to stop using a
medication. Dr M responds by asking B to explain
the reasons for his decision by explicitly soliciting an
account with a why-type interrogative (line 6-7, see
Bolden and Robinson 2011). Robinson and Bolden
(2010) suggest that ‘account solicitations of this sort
convey a challenging stance toward the accountable
event (indexing a claim that the accountable event
does not accord with common sense and is, thus,
possibly inappropriate or unwarranted) and commu-
nicate a critical stance toward the agent(s) responsible
for its production’ (p.504). Interestingly, before B has
a chance to respond, Dr M seems to reinforce the
account solicitation (line 8). By stating ‘I thought
it was helping’, Dr M indirectly formulates a set of
expectations by drawing on normative knowledge (i.e.
one would continue a medication that is adequately
addressing a medical issue) combined with a set of
contrasting happenings that sets up a paradox which
requires an account (see Edwards and Potter 2005).
In their analysis of HIV/AIDS counselling ses-
sions, Silverman and Peräkylä (1990) noted that
patients and counsellors often delayed the delivery

of utterances about delicate subjects. This feature
seems consistent with B’s response to Dr M’s inquiry.
He begins by explicitly noting that the issue is ‘sensi-
tive’ (line 9). Dr M responds with a latched minimal
response that encourages B to continue (line 10). B
continues his accounting work by indicating that the
medication has been causing him to have what he
describes as ‘sex problems’ (line 11). Dr M offers an
acknowledgement token (line 12), and then pauses
before indirectly challenging B about his plan to treat
his ‘depression issues’ (line 13-14). Interestingly, this
utterance shifts the topic of conversation back to B’s
obligation to perform the ‘sick role’ by attempting
to ‘get better’ (Parsons 1951). B responds to Dr M’s
attempt to emphasize his obligation to address his
‘depression issue’ by rejecting the category of ‘patient’
as being most relevant to his behaviours. He begins
by noting that it (continuing the medication) is ‘not
worth it’ if he cannot perform as a ‘man’ (line 15-16).
In this instance, ‘it’s not worth it’ appears to act as a
contrast, which suggests acceptance that addressing
his ‘depression issues’ is a normative expectation of
his role as patient. B makes it clear that he is more
interested in fulfilling the category-bound activities
of being a ‘man’, a category he makes relevant (line
15-16). In emphasizing this category, B focuses on
‘performing’ sexually as a necessary predicate of
fulfilling the category of man (line 17).
Dr M acknowledges (line 18) and seemingly
accepts B’s reasoning (line 19); however, her following
utterance once again highlights B’s obligations as a
‘patient’ by noting the category-bound obligation to
attend to his depression (line 20-22). B responds by
acknowledging this category-bound responsibility
but, once again, prioritizing the category of ‘man’.
Thus, B presents himself as choosing to fulfil his
obligations as a ‘man’ (as he describes it) as opposed
to a patient that is failing to fulfil the moral obligation
to attend to a health condition (Parsons 1951).
6.3. Accounting through defensive detailing
and prioritizing alternative membership
categories
As noted above, patients may also draw upon both
defensive detailing and category prioritization in
accounting for health behaviours. Although both
of the extracts above may include examples of both
defensive detailing and category prioritization, it is
most evident in the following extract. In this extract,
C (a patient suffering from a severely infected wound)
is discussing his failure to attend an appointment
with a specialist with Dr , as Dr examines the
wound:
Moral accounts in primary care interviews 217
(3) Extract 3
1 Dr : It doesn’t uh look good uh well
2 Why did you let it get to this point?
3 C: Yeah (.6) uh
4 Dr : You had the appointment with Dr L
5 But she says you never um went
6 I’m trying to understand [why
7 C: I’m trying to understand [well
8 I couldn’t go through there
9 You know I uh have um four kids who
10 have to eat
11 I uh couldn’t get the d:ays off
12 Dr : I see
13 C: I know uh I am uh supposed to go
14 (.3) I mean what was I supposed to uh
15 do as a dad?
After noting that his wound did not ‘look good’
(line 1), Dr k solicits an account from C using a
why-type interrogative (line 2, see Bolden and Rob-
inson 2011). Robinson and Bolden (2010) argued
that explicit account solicitations are deployed in
instances where the speaker attempts to enact aggra-
vated disaffiliation. Dr k’s explicit account solicitation
suggests that C’s failure to attend an appointment
with Dr L is strongly dispreferred. The fact that Dr
k pursues an answer to his initial account solicita-
tion (line 6) when C fails to provide a clear response
(line 3) offers further evidence that his initial why-
interrogative (at line 1) was an explicit attempt to
solicit an account (see Robinson and Bolden 2010).
Similar to the occurrence in Extract 2, Dr k indirectly
formulates a set of expectations for the contextu-
ally relevant categorization of ‘patient’, which then
is explicitly contrasted with C’s actions (lines 4-5).
These utterances suggest a paradox that requires an
explanation from C (see Edwards and Potter 2005).
Dr k’s solicitations suggest that C has failed to enact
his obligation as a ‘patient’ to follow the advice of his
physician and engage in behaviours that will improve
his health (Parsons 1951; Brown 1999).
C resists Dr k’s accusatory utterances by priori-
tizing his membership categories. In this extract, C
addresses his failure to attend the appointment with
Dr L by offering that he ‘couldn’t’ go (line 7). C resists
Dr k’s attempt to prioritize C’s categorization as a
patient as most salient. He begins by implying the
salience of an altenative category (i.e. father) in high-
lighting that he has ‘four kids who have to eat’ (line 9).
This stated category-bound obligation of providing
food for his children highlights ‘father’ as the more
relevant category.
Similar to B in the previous abstract, C implies
an understanding of the obligations associated with
being a ‘patient’ by noting that he ‘couldn’t go through
218 Patrick J. Dillon
there’ (line 8). This description suggests that C was
forced to act against his intentions or desires. He
then engages in defence detailing by suggesting that
external factors beyond his control (i.e. the inability
to secure time off, see Jefferson 1985) prevented him
from attending the appointment (line 10). By indicat-
ing that he knows he is ‘supposed’ to go to his appoint-
ment (line 12), C acknowledges that the category of
patient entails particular responsibilities, including
attending medical appointments. In his account,
however, C recasts his failure to attend the appoint-
ment as a result of external forces beyond his control
and emphasizes the alternative category of ‘father’
by highlighting the category-bound obligations of
this category. Thus, C’s accounting work utilizes a
combination of defensive detailing and prioritizing
alternative membership categories.
7. Conclusion
The idea of a link between health and morality is
nothing new in Western scholarship. Scholars have
long posited that health behaviours constitute an
important role in constructing definitions of moral
character, such that, to be healthy is to be a ‘good’
person (Stephens and Breheny 2008). However, as
Mäkitalo (2003) notes, actions that are regarded
as morally sanctionable in face-to-face interaction
cannot be ‘determined in vacuo’ (p.496). Instead,
there is a continued need to examine accounts and
what these accounts reveal about morality in specific
contexts, particularly within institutions. Thus, if
we are to truly understand the relationship between
health and morality we must heed Bergmann’s
(1998) call to examine morality as it is constructed
in and through everyday social interaction in health
institutions.
This paper represents a further step in this direc-
tion. Based on the analysis, it is clear that primary
care medical interviews are more than an exchange
of biological/physiological facts and descriptions.
Talk in medical encounters frequently involve dis-
cussion of behavioural and lifestyle choices (Tracy
and Robles 2009) that may threaten patients’ stand-
ing as moral agents and motivate them to attend to
their social identities through accounting (Goffman
1961; Buttny 1993). Patients may attend to such
threats in a variety of ways. This paper draws atten-
tion to two primary ways that patients attend to their
moral standing by engaging in categorization work.
More specifically, it draws attention to the ways
that patients use talk in order to orient to particular
membership categorizations and distance themselves
from others as a means of accounting for morally
questionable health behaviours: defensive detailing
(Jefferson 1985) and prioritizing alternative member-
ship categories.
Roberts, Sarangi and Moss (2004) suggest that
‘patients come with a wide variety of expectations
about the role of the doctor and patient, about how
they should present themselves and how the con-
sultation should proceed’ (p. 167). Though physi-
cians may assume that inquiring about patients’
behaviours are part of the ‘business’ of the medical
interview, patients’ subsequent accounts suggest the
moral inflection of such inquiries. Being aware of
the moral nature of this aspect of patient–provider
interaction offers an opportunity to (re)evaluate
how social and behavioural inquiries can best be
integrated into medical consultations (Waitzkin
1991).
Acknowledgement
The author wishes to acknowledge Dr Mariaelena
Bartesaghi for her guidance in completing this
manuscript.
Notes
1. The study protocol was approved by the Institutional
Review Board at Central Michigan University as well
as the parent health systems of both clinics.
2. Maynard (2003) also notes the issue of defensive de-
tailing in medical encounters as it relates to delivering
good news and bad news in his book.
Appendix A: Transcription Conventions
CAPS Indicates louder than surrounding
talk
Underlining Indicates emphasis
(.) Micropause
(0.5) Timed pause to nearest halfsecond
= Latching – no pause between turns
yes[I agree
yes[ye:ah Indicates beginning of overlapping
talk
Ye:ah Colon indicates prolonged sound of
preceding part of utterance
? Rising intonation
! Excited intonation
↑↓ Shift to higher or lower pitch

Wh- Hyphen marks abruptly cut-off
sound
.hhh and hhh Intake of breath/exhalation
>he is< Talk in brackets is slower than sur-
rounding talk
<he is> Talk in brackets is faster than sur-
rounding talk
°Quiet° Softer tone within degree signs
HHHhhhh Laughter: louder represented by
capital letters
(?), ( ), Untranscribable word or words, or
transcriber’s guess at a word
[…] Lines omitted for the purpose of
brevity
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Patrick J. Dillon (M.A., Central Michigan University, 2009)
is a doctoral student in the Department of Communication
at the University of South Florida. His research interests
include patient–provider interaction, health disparities
and research methodology. Address for correspondence:
Department of Communication, 4202 E. Fowler Ave, CIS
1040, University of South Florida, Tampa, FL 33620-7800,
USA. Email: pdillon@mail.usf.edu
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