Illness as Failure: Blaming Patients

Abstract

At fifty, everyone has the face he deserves. --George Orwell Thy rebuke hath broken my heart; I am full of heaviness: I looked for some to have pity on me, but there was no man, neither found I any to comfort me. They gave me gall to eat: and when I was thirsty they gave me vinegar to drink. --Prayer Book Washington, a fifty-eight-year-old man with a long history of heavy cigarette smoking and alcohol consumption, presented to the emergency room with weight loss and severe difficulty swallowing. A battery of diagnostic tests quickly disclosed that he was suffering from advanced cancer of the esophagus. Once this conclusion had been reached, more than one member of the health care team could not help remarking that Washington had brought it on himself, through decades of abusing his health. When one physician heard other members of the team express this attitude, she became indignant and accused the others of the victim. Mr. Washington has suffered enough already, and what little remains of his life will be even worse, she said. don't you stop worrying about who is to blame, and instead focus your energies on taking good care of your patient? Should we roundly condemn victim blaming in all cases, and devote our full attention to every patient, without regard to the role their own choices may have played in generating their afflictions? Or might there come a point at which the link between patients' choices and their afflictions appears so strong that it diminishes the strength of their claims on our resources, our ministrations, and perhaps even our sympathy? Why and How We Blame Patients The phenomenon of assigning moral blame for illness is far from new. The Bible often describes illness as the wages of sin, and the Book of Leviticus repeatedly links bodily affliction with ritual impurity. In recent times, epidemiological research has transformed venerable moral vices such as sloth, gluttony, intemperance, and fornication into medical risk factors--sedentary lifestyle, obesity, alcoholism, and unsafe sex. Implicit throughout is a causal association between habit and health, according to which the afflicted may be regarded as the instigators of their own bodily misfortune. As our biological and epidemiological understanding continues to advance, more and more illness becomes explainable in terms of risk factors. The progressive elucidation of avoidable risk factors, in turn, strengthens the case for treating patients themselves as the cause of their diseases.[1] Once we admit that patients bear some degree of responsibility for their afflictions, the circle of blame is limited only by our understanding of pathology and epidemiology. To the obvious example of cigarette smoking one could add a host of other hazardous conditions and behaviors for which patients might be blamed: alcohol and drug abuse (increasing the risk of cirrhosis, heart disease, and AIDS), failure to wear seat belts (injury or fatality in a motor vehicle accident), obesity (diabetes and cardiovascular disease), sedentary lifestyle (cardiovascular disease), and multiple sex partners and unprotected sex (AIDS, other venereal diseases, and cervical cancer). The list of hazardous choices extends even further, to include avoidance of marriage (singles of both sexes tend not to be as healthy as their married counterparts), nulliparity (women who have never had children suffer an increased risk of breast and endometrial cancer), and even failure to find satisfying work (people who like their jobs tend to be healthier than people who don't). To blame people for the health habits they adopt, two factors in addition to the link between habit and health must be taken into account. First, individuals must genuinely choose to adopt those habits, and their failure to relinquish them must also be a matter of personal choice. Second, individuals must understand that what they are doing is hazardous. …