Stigmatizing the Unhealthy

Abstract

Stigma can lead to worse relative health and worse health outcomes. However, the perception of ill health itself can be stigmatizing. As part of a larger project comprehensively examining the increasing incidence of “healthism,” we examine a host of examples of normatively wrong discrimination based on health status. One of our criteria for designating a particular form of health-status discrimination normatively wrong is whether it is stigmatizing. Related criteria include whether the classification is animus-driven and whether it has the tendency to punish individuals for private conduct. Although our criteria operate in conjunction, the presence of stigma may turn what otherwise would be a socially desirable, rational reason to treat an individual differently based on health status, including health-related conduct, into an instance of healthism.

In this paper, we would apply our healthism paradigm to two examples, in which stigma is particularly salient. In the United States, two particular groups perceived as being unhealthy — smokers and the obese — face well-documented stigma. One potential source of this stigma is the belief that those individuals are at fault for their smoking or their weight and therefore should bear the risks and the costs of those unhealthy decisions. Not surprisingly then, health policymakers have singled out smokers and the obese as acceptable targets of regulation. Consider the tobacco surcharge in health insurance or the dramatic public service announcements targeting childhood obesity. Yet while smokers and the obese face heightened stigma, whether these policies that result from that stigma actually improve health is uncertain. Given that certain historically disadvantaged individuals — mainly people of color, people with disabilities, and the poor — are more likely to use to tobacco and be overweight, health policies that target smoking and obesity may pose a disproportionate burden on those populations and in so doing exacerbate existing health disparities. Through discussion of these two examples, our paper would explore stigma against individuals perceived as unhealthy and the laws and policies that are enacted on the basis of such stigma. Viewing these examples through our healthism lens reveals that such enactments may worsen health disparities, rather than improving individual or population health.

Keywords: health law, healthism, health care, stigma, status, insurance, discrimination, illness, sickness, unhealthy, smoking, tobacco use, overweight, obesity, health equality, health justice

JEL Classification: K19, K23, K29, K32, I11, I13, I14, I18