Rheuminations: Why I Don’t Use the Term ‘Stakeholder’

Modern healthcare is, for better or for worse, the hybrid of many different fields—some that are expected, such as biomedical science, and others that are less well appreciated, such as astrology and palmistry. One modern contributor to healthcare is management. Nowadays, we’re inundated with all sorts of jargon from the business and policy worlds: turnover, wait times, downstream effects and more. These all irritate me, but I do occasionally use these terms to express my thoughts. That’s not so with the word stakeholder. You will never hear me use the word stakeholder unironically, even as it is becoming more and more popular. And I’m not alone in this.

The term stakeholder is rife with connotations that don’t necessarily align with our current values and has a history that is muddled, to say the least. Perhaps after reading this, you’ll agree. Let’s rheuminate on stakeholders.

Stakeholders in Rheumatology

First, let’s consider who would be considered a stakeholder in rheumatology. Certainly, rheumatology clinicians are stakeholders, as are patients. So too are other members of the healthcare environment, such as funders, clinics, pharmaceutical companies, advocacy organizations and more.

This list would be fairly standard for most specialties. But rheumatology differs slightly in that we don’t own an organ. Therefore, our stakeholders, whatever the term may imply, are more broadly distributed and involve more than people who look at, think about or have a rheumatic disease. Our effects are diffuse and, sometimes, intangible and immeasurable. As we continue to think about the term, let’s keep this in mind.

Staking a Claim to History

Nowadays, we frequently use terms that have the word stake in them: stake a claim, stake out and burned at the stake are examples.¹ They are all derived from literal stakes—or poles driven into the ground. The word stakeholders comes from the world of gambling—where the wagers would literally be placed on stakes. The pot would be guaranteed by an independent person, who came to be called the stakeholder.² Slowly, the term moved from the world of gambling and evolved to become less and less literal, until a stakeholder simply became someone with an interest in an issue.³

In parallel, stakeholder also came to mean “a person holding property or owing an obligation that is claimed by two or more adverse claimants and who has no claim to or interest in the property or obligation.”⁴ This is particularly relevant with respect to the word’s sensitivity and appropriateness when it comes to people who have historically been dispossessed of these stakes.

Herein lies the problem: Issues are neither property, nor are they wagers. Stakeholder carries an inherent assumption and value proposition that only those stakes that have monetary worth are legitimate. In the world of healthcare, we hear about stakeholder engagement and delineate the people who we see as affected by certain clinical or research initiatives.⁵ But I contend this is a projection of who we see as having stakes.

In short, a lot of our beliefs about who should be included get mixed with who needs to be included. Even well-meaning steps toward inclusion may exclude people who don’t seem to be directly invested. In using the term stakeholder engagement, we inadvertently open the door that allows the justification of exclusion.

Stakeholders or Shareholders?

Stakeholder is also remarkably similar to shareholder, and I have witnessed how people sometimes slip between the words with ease. Both words emphasize the commodification of a certain good or service. Shareholder may have a connotation more overtly related to business and the stock market, but stakeholder still has much of the same punch.

Making things worse is that a shareholder is a type of stakeholder, and one that is often prioritized among others.⁶ Just as modern businesses see themselves as vehicles to keep shareholders happy, we may be lulled into thinking that our primary job is to keep our stakeholders happy. Of course, keeping people happy is a major part of what rheumatologists endeavor to do, but it is not the driving factor.

Similarly, stakeholder puts us in a framework that unintentionally de-emphasizes the power asymmetries and disparities among relevant parties. In the American healthcare system, we know that powerful forces determine agenda and outcomes. It has been a long struggle to make sure that those without adequate representation have a chance to sit at the table, but it is still far from an equitable arrangement.

Whenever I read the phrase “relevant stakeholders were consulted,” I rarely read any follow-up regarding how power disparities were addressed. It raises my suspicion that perhaps this aspect of sharing the stakes was not addressed.

This framework also makes us far too anthropocentric. The generally accepted paradigm is that stakeholders are people, after all, but the general public is an amalgam of all sorts of people and non-people.⁷ Principles and values, such as environmental conservation, commitment to social equity and preventive health, may get lost, unless there is a particular champion for them as stakeholders. Indeed, even those that are far removed from a clinical or a research initiative are often affected through various indirect effects. By stating that stakeholders were consulted, we may be undercutting these considerations.

Finally, the term stakeholder may inadvertently feed into a colonialist mentality. Those who work with Native Americans and Indigenous groups tend not to use the word because it is laden with connotations of claiming land.⁸ In these contexts, a proverbial stake can be more than just a stick or a pole, but rather a potent symbol of something that can be possessed or hoarded.⁹ At the very least, it can engender a strong sense of suspicion regarding equitable treatment given the historical use of the term.¹⁰ If we are committing to the principles of diversity, equity and inclusion, it would make sense to avoid this problematic term in other contexts, too.

Avoid Mistakes

One reason that stakeholder has gained so much currency is because it’s an easy, almost throwaway, term. It’s elastic enough to cover any person or group that has an interest or concern in a project. That ambiguity is, in many ways, its greatest strength, as well as its greatest weakness. One can always sidestep the issue, speak on behalf of many people and then get little resistance by saying that it is the mandate of the stakeholders. Thinking of alternative terms or phrases is much tougher and sometimes ends up with even more problematic language.¹¹

Personally, I tend to use the word participant when I have to generically substitute for stakeholder. It is certainly not synonymous, but it probably conveys the more nuanced reality of stakeholder engagement or participation in the research that I do.¹² I like this term because it reverses the logic of stakeholding: Instead of stakeholders being invited and identified because they have stakes, participants derive their own investment by virtue of their participation.

Use of the word participant also helps undo the value proposition that may be engendered by the term stakeholder. Participant is, after all, a low bar—it describes the people who have been directly involved, rather than a high bar of holding a stake and speaking on behalf of others. It also doesn’t necessarily shut out those who did not or could not participate because they didn’t have stakes. But, as mentioned, it doesn’t capture in its fullness what is meant by being a stakeholder.

Other terms that I’ve encountered include interested parties and partners.¹³ These are probably better than stakeholders and retain a sense of ambiguity, but like participant, are still inadequate. After all, partner implies a sense of equality or equity, but power differentials can be hidden even with such plain language. Interested parties also sends a signal that only those with direct interest should be parties in the outcome of a project. Think of uninterested parties, and the distinction becomes clearer. These terms also may have legal definitions that can complicate issues. In any case, such positives and negatives of each term may be why no clear alternative to stakeholder has arisen.

Pull Up the Stakes

Perhaps because of their intensive involvement into Native American health projects, the Centers for Disease Control and Prevention (CDC) discourages the use of the term stakeholder and considers it potentially stigmatizing language.¹⁴ Instead of substituting one word for another, the CDC recommends a more nuanced approach, one that I agree with. Working partners, community collaborators and others can be named specifically as is. That dignifies who they are and characterizes their roles in much clearer language. Consultants, contributors, coalition members, advocacy groups, sponsors and funders are all terms that bring greater clarity to the issue.

Inherent in this stance is that the stakeholder is a mythical concept. We construct it based on our collective history, which is steeped in many negative facets including dispossession and intolerance. But we can undo this, too, by judicious use of language. We can demythologize stakeholder and recognize there are deeper things that need to be changed for us to have more equitable and inclusive approaches to healthcare and, in particular, rheumatology.

Rheumatology, and medicine as a whole, inherits a lot from different fields. It is, in many ways, the product of what we choose it to be. We aspire to be inclusive, equitable and diverse. Toward that end, we employ language to demonstrate this commitment. But when we adopt terminology rooted in the opposite, we end up in a situation that is not necessarily much better.

I hope I’ve convinced you to avoid using the word stakeholder as much as you can. No matter who you are, you are a key stakeholder in contributor to the world of rheumatology.

Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the associate program director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on Twitter @BharatKumarMD.

References

1. Stake. The Free Dictionary. Farlex Inc.
2. Townley B. Stakeholders. In Reconfiguring Knowledge Production: Changing Authority Relationships in the Sciences and their Consequences for Intellectual Innovation. Whitley R, Gläser J, Engwall L (eds). New York: Oxford Academic Press; 1 Sep 2010; 45–69. doi:10.1057/9781137355850_2.
3. What are stakeholders. American Society for Quality.
4. Townley B. Conceptions of the ‘stakeholder.’ In Stakeholder Theory and Organizational Ethics. Phillips R. Oakland, Calif.: Berrett-Koehler Publishers; 2003; 45–67. doi:10.1057/9781403982292_11.
5. Sharfstein JM. Banishing ‘stakeholders.’ Milbank Q. 2016 Sep;94(3):476–479.
6. Smith HJ. The shareholders vs. stakeholders debate. MIT Sloan Management Review. 2003 Jul 15.
7. Bowen KJ, Alexander D. The stakeholder concept in public health: Stakeholder concept analysis. Landscape and Urban Planning. 2014;129:55–64. doi:10.1016/j.landurbplan.2014.05.005.
8. Reed MS. Why we shouldn’t banish the word ‘stakeholder’ [blog]. Fast Track Impact. 2022 Aug 2.
9. Indigenous Corporate Training Inc. Nine terms to avoid in communications with Indigenous peoples. 2018 May 11.
10. McGlinchey C. Stakeholders and its conflicting meanings: A problem for cultural heritage studies? [blog] Medium. 2022 Jul 6.
11. Reed MS. Alternatives to the word ‘stakeholder’ [blog]. Fast Track Impact. 2022 Nov 22.
12. Williams C, Fang L. A value-focused multiple participant-multiple criteria (MPMC) decision support approach for public policy formulation. Group Decis Negot. 2019 Feb;28:99–126.
13. Lye I. What are the stakeholders or interested parties? [blog] BCM Institute. 2019 Jul 15.
14. Gateway to health communication. Inclusive communication principles. Preferred terms for select population groups & communities. Centers for Disease Control and Prevention. 2022 Nov 3.