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

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.