Hostname: page-component-78c5997874-m6dg7 Total loading time: 0 Render date: 2024-11-10T07:23:12.921Z Has data issue: false hasContentIssue false

Stigmatizing the Unhealthy

Published online by Cambridge University Press:  01 January 2021

Abstract

Stigma can lead to poor health outcomes. At the same time, people who are perceived as unhealthy may experience stigma as the result of that perception. As part of a larger project examining discrimination on the basis of health status or “healthism,” we explore the role of stigma in producing disadvantage based on health status. Specifically, we look to the principles of health equality and health justice. An intervention violates health equality when it is driven by animus, which can be the result of stigma. Additionally, laws and policies offend health justice when they worsen health outcomes or they create or deepen health disparities. An intervention that produces stigma — whether intentionally or unintentionally — may offend health justice by making people worse off, in absolute or in comparative terms. Stigma-related health laws and policies can therefore be healthist in at least two ways. We therefore conclude that stigma should neither be the basis, nor the product, of efforts to improve health.

Type
Symposium Articles
Copyright
Copyright © American Society of Law, Medicine and Ethics 2017

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Goffman, E., Stigma: Note on the Management of Spoiled Identity (Englewood Cliffs, N.J.: Prentice-Hall, 1963).Google Scholar
Id. at 19.Google Scholar
Stuber, J. et al., “Smoking and the Emergence of a Stigmatized Social Status,” Social Science & Medicine 67, no. 3 (2008): 420-430, at 422.CrossRefGoogle Scholar
See, e.g., Earnshaw, V. and Quinn, D., “The Impact of Stigma in Healthcare on People Living with Chronic Illnesses,” Journal of Health Psychology 17, no. 2, (2011): 157-168; Schabert, J. et al., “Social Stigma in Diabetes: A Framework to Understand a Growing Problem for an Increasing Epidemic,” Patient 6, no. 1 (2013): 1–10.Google Scholar
Roberts, J. and Leonard, E., Healthism: Health-Status Discrimination & The Law (forthcoming Cambridge University Press, 2018).CrossRefGoogle Scholar
See Earnshaw, , supra note 4.Google Scholar
See Schabert, supra note 4, at 5 (discussing feelings that contribute to stigma with respect to diabetes).Google Scholar
Puhl, R. and Heuer, C., “Obesity Stigma: Important Considerations for Public Health,” American Journal of Public Health 100, no.6 (2010): 1019-1028.CrossRefGoogle Scholar
Id. at 1019-1020.Google Scholar
Earnshaw, , supra note 4, at 158.Google Scholar
Stuber, et al., supra 3, at 424.Google Scholar
Stuber, J. et al., “Stigma and Smoking: The Consequences of Our Good Intentions,” Social Service Review 83, no. 4 (2009): 585-609, 598.Google Scholar
Kim, S. and Shanahan, J., “Stigmatizing Smokers: Public Sentiment Toward Cigarette Smoking and Its Relationship to Smoking Behaviors,” Journal of Health Communication 8, no. 4(2003): 343-367, 349.Google Scholar
Puhl, R. et al., “Legislating for Weight-Based Equality: National Trends in Public Support for Laws to Prohibit Weight Discrimination,” International Journal of Obesity 40, no. 8 (2016): 1320-1324; Puhl, R. and Brownell, K., “Confronting and Coping with Weight Stigma: An Investigation of Overweight and Obese Adults,” Obesity 14, no. 14 (2006):1802-1815; Puhl and Heuer, supra note 8, at 1019.Google Scholar
Puhl, and Brownell, , supra note 15, at 1802; Puhl and Heuer, supra note 8, at 1019; Puhl, R. and Heuer, C., “The Stigma of Obesity: A Review and Update,” Obesity (2009).Google Scholar
Puhl, and Brownell, , supra note 15, at 1805, 1809, 1812.Google Scholar
Saad, L., “One in Four Americans Have Less Respect for Smokers,” GALLUP (Aug. 5, 2011), available at <http://www.gallup.com/poll/148850/one-four-americans-less-respect-smokers.aspx> (last visited December 8, 2017).+(last+visited+December+8,+2017).>Google Scholar
Puhl, and Heuer, , supra note 8, at 1023.Google Scholar
Kim and Shanahan, supra note 14, at 348 (discussing how “individual responsibility has led public health policies to focus exclusively on the change of individuals unhealthy behaviors, ignoring the question of social environmental, economic, and cultural culpability”); Puhl et al. 1, supra note 15, (explaining how society blames people for obesity and attributes obesity to personal factors); Puhl and Heuer, supra note 8, at 1019 (noting that it is socially acceptable to discriminate against obese people because of the common perception they are at fault for their weight).Google Scholar
Bell, K. et al., “Smoking, Stigma, and Tobacco ‘Denormalization’: Further Reflections on the Use of Stigma as a Public Health Tool,” Social Science & Medicine 70, no.6 (2010): 795-799, 795.CrossRefGoogle Scholar
Id. at 795-796.Google Scholar
Puhl, and Heuer, , supra note 8, at 1019.Google Scholar
Bayer, R., “Stigma and the Ethics of Public Health: Not Can We But Should We,” Social Science & Medicine 67, no. 3 (2008): 463-472, 466; see also Burris, S., “Disease Stigma in U.S. Public Health Law,” Journal Law, Medicine & Ethics 30, no. 2(2002): 179-190 (arguing that while tobacco denormalization may not be de facto stigmatizing, policy makers should monitor whether those strategies lead to stereotyping, status loss, or internalization of negative social attitudes).CrossRefGoogle Scholar
Stuber, et al., supra note 12, at 586-87.Google Scholar
Stuber, et al., supra 3, at 422.Google Scholar
Bell, et al., supra note 21, at 796-97.Google Scholar
Roberts and Weeks, supra note 5 (outlining the four governing principles of healthism: (1) health welfarism, (2) health egalitarianism, (3) health libertarianism, and (4) health justice).Google Scholar
Puhl, and Heuer, , supra note 8, at 1020.Google Scholar
Emens, E., “The Sympathetic Discriminator: Mental Illness, Hedonic Costs, and the ADA,” Georgetown Law Journal 94, no. 2 (2006): 399, 409.Google Scholar
Roberts, J., “‘Healthism’: A Critique of the Antidiscrimination Approach to Health Insurance & Health-Care Reform,” University of Illinois Law Review 2012, no. 4 (2012): 1159, 1187.Google Scholar
Id. at 1166-1170.Google Scholar
See 42 U.S.C. § 300gg.Google Scholar
78 Fed. Reg. 33158, 33180, June 3, 2013.Google Scholar
Bell, et al., supra note 21.Google Scholar
Newport, F., “Most U.S. Smokers Want to Quit, Have Tried Multiple Times,” Gallup, July 31, 2013, available at <http://www.gallup.com/poll/163763/smokers-quit-tried-multiple-times.aspx> (last visited Dec. 8, 2017)+(last+visited+Dec.+8,+2017)>Google Scholar
Friedman, A. et al., “Evidence Suggests that the ACA’s Tobacco Surcharges Reduced Insurance Take-Up and Did Not Increase Smoking Cessation,” Health Affairs 35, no. 7 (2016): 1176.Google Scholar
See Wiley, L., “Shame, Blame, and the Emerging Law of Obesity Control,” U.C. Davis Law Review 47, no. 1(2013): 121, 121.Google Scholar
Id. at 159-160.Google Scholar
See 42 U.S.C. § 300gg-4(j).Google Scholar
Puhl, and Heuer, , supra note 8, at 1020.Google Scholar
Id.; Wiley, supra note 40, at 145-146.Google Scholar
Puhl, and Heuer, , supra note 8, at 1021.Google Scholar
Roberts and Weeks, supra note 5.Google Scholar
Id. (discussing unconscious bias in healthism)Google Scholar
Link, B. and Phelan, J., “Conceptualizing Stigma,” Annual Review of Sociology 27 (2001):. 363, 367-375.Google Scholar
Id. at 375-376.Google Scholar
Burris, supra note 24; Stuber et al., supra note 12, at 588 (explaining the conflicting perception of the proper role of stigmatization in tobacco regulation).Google Scholar
Bayer, supra note 24; Stuber et al., supra note 12 (discussing harnessing stigma to reduce smoking rates).Google Scholar
Roberts, J., “Healthism & The Law of Employment Discrimination,” Iowa Law Review 99, no. 2 (2014): 571, 577-579; see also Stuber et al., supra 3, at 421.Google Scholar
Stuber et al., supra 3, at 421.Google Scholar
Id. at 421-422.Google Scholar
Stuber et al., supra note 12, at 587 (applying Link and Phelan’s five-step process of stigma formation to smokers).Google Scholar
Wiley, , supra note 40, at 150.Google Scholar
Id. at 163.Google Scholar
Schabert, , supra note 4, at 5 (discussing efforts to conceal diabetes with potentially negative results).Google Scholar
Id. at 6 (discussing in the context of diabetes).Google Scholar
Stuber, et al., supra note 12.Google Scholar
Stuber, et al., supra note 12, at 589.Google Scholar
Bell, et al., supra note 21, at 797.Google Scholar
Puhl, and Heuer, , supra note 16, at 15-16; Puhl and Heuer, supra note 8, at 1022-1023.Google Scholar
Puhl, and Heuer, , supra note 8, at 1022.Google Scholar
Earnshaw, , supra note 4, at 157 (discussing being perceived as unhealthy in relation to chronic disease).Google Scholar
Schabert, , supra note 4, at 6 (discussing in the context of diabetes).Google Scholar
Bell, et al., supra note 21, at 797.Google Scholar
Earnshaw, , supra note 4, at 159, 163.Google Scholar
Id. at 159, 164.Google Scholar
Id. at 159.Google Scholar
Id. (citing Chesney, M. A. and Smith, A. W., “Critical Delays in HIV Testing and Care: The Potential Role of Stigma,” American Journal of Behavioral Scientist 42, no. 7(1999): 1158-1162.Google Scholar
Puhl, and Heuer, , supra note 8, at 1024.Google Scholar
Bell, et al., supra note 21, at 797.Google Scholar
Id. at 797-98; Puhl, and Heuer, , supra note 8, at 1025.Google Scholar
Fagundes, D. and Roberts, J., “Distributive Justice, Libertarian Paternalism, and the HUD Smoke-Free Policy” (in progress).Google Scholar
Roberts and Weeks, supra note 5.Google Scholar