Is not behaving badly? Self-inflicted illness | Psychology Today Canada
“The Hangover” by the French artist Toulouse-Lautrec, 1887-89. Fogg Museum of Art, Harvard.
Source: Wikimedia Commons, Public Domain. Author: Daderot (Creative Commons CC0 1.0.)
Should a patient with severe liver disease due to years of chronic alcoholism be given a new liver? How about a lung transplant for a triple a day who continues to smoke? Or should a morbidly obese person qualify for bariatric surgery without adhering to diet and exercise?
Most importantly, how about caring for those who have refused to be vaccinated against COVID-19, potentially endangering their fellow human beings, and now needing a ventilator and months of intensive care to stay alive?
“The Vaccination” by French artist Victor Francois Tardieu, c. 1923. The hesitation and controversy over vaccines first appeared in the 19th century.
Source: ArtNet / Wikimedia Commons / Public Domain.
These are tough moral questions that arise when we consider how much responsibility we have for our own health, especially when our behavior affects the community and health care resources are limited.
“Teutonic to civil liberties and human rights is a right to be free from harm by others” (Terry, 2022). However, not everyone agrees on what is harmful.
The internet, for example, is full of pseudoscientific data accepted by anti-vaccination users. Anti-Vaxxers see themselves as “health advocates and crusaders” and, even more dangerous, as “informed experts” (DiRusso and Stansberry, 2021).
However, some who challenge the anti-Vaxxers believe that “certain failures of self-care”, such as refusal to be vaccinated, fall under the “crimes against society” category described by Fitzgerald in the 1990s. After all, “society” has to pay for its consequences, “wrote Fitzgerald, and” people owe it to society to stop misbehaving. “Illness then becomes evidence of this wrongdoing, especially when it comes to conditions of the “Self-abuse” goes (e.g. obesity, alcoholism, smoking, IV substance abuse, AIDS or now even COVID-19). those affected have taken it upon themselves and deserve our condemnation.
The face of a man with smallpox and a request for a vaccination. around 1940. There has always been controversy about vaccination, but social media has taken the controversy to a new level.
Source: Wellcome Trust Collection. Attribution: 4.0 International.
“One’s health freedom is another’s fetter on taxes and insurance premiums,” wrote physician John Knowles, then head of the Rockefeller Foundation (1977), who stated that health insurance is really “sickness insurance.” Knowles believed that people have a “public duty” to maintain their own health as the cost of “individual health irresponsibility” has become “prohibitive”.
“An old woman in rags who moves with crutches.” Gouache painting possibly after J. Callot. Early 17th century.
Source: Wellcome Trust Collection, Public Domain.
Personal responsibility for rationing health care is clearly controversial. Blaming the victim can place “unfair burdens” on the most vulnerable (Buyx, 2008), including the elderly, poor, disabled, mentally ill or addicts, and it does not take into account that there are multiple factors including political, economic and environmental influences that can contribute to health in addition to personal behavior (Allegrante and Green, 1981).
The concept of personal responsibility for health has a long history and even appears in Hippocrates’ Regime, and has surfaced regularly over the centuries (Reiser, 1985). Health care as a “social right” became popular in the 1970s with the Medicare and Medicaid Acts (Reiser).
Some researchers believe that more recently a focus on personal responsibility has emerged in response to “growing disillusionment with the limits of medicine” as well as cost pressures and growing self-help movements (Minkler, 1999). “Medical services as a means of maintaining health have been massively oversold” (Crawford, 1977).
Nowhere is this more evident than during our COVID-19 pandemic: “Medicine is steeped in ignorance” (Whooley and Barker, 2021). In addition, with the relocation of the “experience of illness” to the Internet, the Internet has become an “information machine”; Illness, which was once “largely private and lonely”, is “increasingly a public and collective experience” (Whooley and Barker).
“There was an old Man from Calcutta …” by the English artist Edward Lear, 1846. Private collection. Causal language permeates research on diet and obesity.
Source: Copyright Look and Learn / Bridgeman Images. Used with permission.
However, our understanding of disease is fraught with uncertainty; its scientific basis changes over time (Fitzgerald). Obesity is a case in point: the concept of obesity as a disease also remains controversial. Over the years obesity has been viewed as a sin of gluttony and indolence, an aesthetic crime, an energy failure, adequate or inappropriate adaptation to an obese environment, a genetic disorder, a behavioral psychological disorder with self-regulation or addiction, and even an example for body diversity (Karasu, 2014).
In a fascinating study, Allison and colleagues found that ideas Obese people are significantly influenced by the extent to which obesity is perceived as being controlled by a person: Obesity stigmatization is greater when people believe that obesity is due to a person’s behavior (Allison et al., 1991) .
More recently, Ringel and Ditto have reviewed the results of Allison et al. replicates: The more people attributed obesity to behavior, the more indignant they became and the more likely they were to discriminate against obese people. They also viewed bariatric surgery as more likely to be unnecessary or even a “lazy way” to achieve weight loss, even if the researchers stated that the surgery still requires significant patient effort (2019).
A skeleton serving alcohol, circa 1880-1910 by Mexican artist Jose Guadalupe Posada. Some diseases, such as alcoholism, suffer from a low level of “disease prestige” and are stigmatized.
Source: Metropolitan Museum of Art, NYC. Public domain. Gift of Jean Charlot, 1930.
Friesen (2018) found that discussions about personal responsibility actually reflect prejudices against highly stigmatized behaviors. “Self-inflicted” diseases suffer from a low “disease prestige” (Traina and Feiring, 2020). If responsibility were really taken into account, every dangerous job, hobby or sport would have to be put to the test (Frisians).
Furthermore, our entire concept of cause and effect, including the concept of causal responsibility, is extremely difficult to justify (buyx). However, Allison and colleagues found (Cofield et al., 2010; Ejima et al., 2016) that “inappropriate” use of causal language permeates research studies, particularly in the areas of diet and obesity.
Police “Wanted” notice, after Keith Monk, mid 20th century. Public health poster.
Source: Wellcome Trust Collection. Department of Health, London. Public domain.
Despite difficulties in attributing causality or even determining accountability (Friesian), the UK has proposed measures to limit elective surgery for smoking or obese patients until they undergo a “health optimization process”, a term straight out of Orwell who calls for a period in which patients can change their behavior (Pillutla et al., 2018).
It is evident that behavior changes are difficult to sustain over time (Minkler). While self-inflicted illness creates stigma and blame, the limitations of medicine force society to demand at least some personal responsibility from us for our health.