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.
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References
1.
E.Goffman, Stigma: Note on the Management of Spoiled Identity (Englewood Cliffs, N.J.: Prentice-Hall, 1963).
2.
Id. at 19.
3.
J.Stuberet al., “Smoking and the Emergence of a Stigmatized Social Status,”Social Science & Medicine67, no. 3 (2008): 420-430, at 422.
4.
See, e.g., V.Earnshaw and D.Quinn, “The Impact of Stigma in Healthcare on People Living with Chronic Illnesses,”Journal of Health Psychology17, no. 2, (2011): 157-168; J.Schabertet al., “Social Stigma in Diabetes: A Framework to Understand a Growing Problem for an Increasing Epidemic,”Patient6, no. 1 (2013): 1-10.
5.
J.Roberts and E.Leonard, Healthism: Health-Status Discrimination & The Law (forthcoming Cambridge University Press, 2018).
6.
See Earnshaw, supra note 4.
7.
See Schabert, supra note 4, at 5 (discussing feelings that contribute to stigma with respect to diabetes).
8.
R.Puhl and C.Heuer, “Obesity Stigma: Important Considerations for Public Health,”American Journal of Public Health100, no.6 (2010): 1019-1028.
9.
Id. at 1019-1020.
10.
Earnshaw, supra note 4, at 158.
11.
Stuber et al., supra 3, at 424.
12.
J.Stuberet al., “Stigma and Smoking: The Consequences of Our Good Intentions,”Social Service Review83, no. 4 (2009): 585-609, 598.
13.
Id.
14.
S.Kim and J.Shanahan, “Stigmatizing Smokers: Public Sentiment Toward Cigarette Smoking and Its Relationship to Smoking Behaviors,”Journal of Health Communication8, no. 4(2003): 343-367, 349.
15.
R.Puhlet al., “Legislating for Weight-Based Equality: National Trends in Public Support for Laws to Prohibit Weight Discrimination,”International Journal of Obesity40, no. 8 (2016): 1320-1324; R.Puhl and K.Brownell, “Confronting and Coping with Weight Stigma: An Investigation of Overweight and Obese Adults,”Obesity14, no. 14 (2006):1802-1815; Puhl and Heuer, supra note 8, at 1019.
16.
Puhl and Brownell, supra note 15, at 1802; Puhl and Heuer, supra note 8, at 1019; R.Puhl and C.Heuer, “The Stigma of Obesity: A Review and Update,”Obesity (2009).
17.
Puhl and Brownell, supra note 15, at 1805, 1809, 1812.
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).
21.
K.Bellet al., “Smoking, Stigma, and Tobacco ‘Denormalization’: Further Reflections on the Use of Stigma as a Public Health Tool,”Social Science & Medicine70, no.6 (2010): 795-799, 795.
22.
Id. at 795-796.
23.
Puhl and Heuer, supra note 8, at 1019.
24.
R.Bayer, “Stigma and the Ethics of Public Health: Not Can We But Should We,”Social Science & Medicine67, no. 3 (2008): 463-472, 466; see alsoS.Burris, “Disease Stigma in U.S. Public Health Law,”Journal Law, Medicine & Ethics30, 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).
25.
Stuber et al., supra note 12, at 586-87.
26.
Stuber et al., supra 3, at 422.
27.
Bell et al., supra note 21, at 796-97.
28.
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).
29.
Id.
30.
Id.
31.
Puhl and Heuer, supra note 8, at 1020.
32.
E.Emens, “The Sympathetic Discriminator: Mental Illness, Hedonic Costs, and the ADA,”Georgetown Law Journal94, no. 2 (2006): 399, 409.
33.
J.Roberts, “‘Healthism’: A Critique of the Antidiscrimination Approach to Health Insurance & Health-Care Reform,”University of Illinois Law Review2012, no. 4 (2012): 1159, 1187.
A.Friedmanet al., “Evidence Suggests that the ACA’s Tobacco Surcharges Reduced Insurance Take-Up and Did Not Increase Smoking Cessation,”Health Affairs35, no. 7 (2016): 1176.
40.
SeeL.Wiley, “Shame, Blame, and the Emerging Law of Obesity Control,”U.C. Davis Law Review47, no. 1(2013): 121, 121.
41.
Id. at 159-160.
42.
See 42 U.S.C. § 300gg-4(j).
43.
Puhl and Heuer, supra note 8, at 1020.
44.
Id.; Wiley, supra note 40, at 145-146.
45.
Puhl and Heuer, supra note 8, at 1021.
46.
Roberts and Weeks, supra note 5.
47.
Id.
48.
Id. (discussing unconscious bias in healthism)
49.
B.Link and J.Phelan, “Conceptualizing Stigma,”Annual Review of Sociology27 (2001):. 363, 367-375.
50.
Id. at 375-376.
51.
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).
52.
Bayer, supra note 24; Stuber et al., supra note 12 (discussing harnessing stigma to reduce smoking rates).
53.
J.Roberts, “Healthism & The Law of Employment Discrimination,”Iowa Law Review99, no. 2 (2014): 571, 577-579; see also Stuber et al., supra 3, at 421.
54.
Stuber et al., supra 3, at 421.
55.
Id. at 421-422.
56.
Stuber et al., supra note 12, at 587 (applying Link and Phelan’s five-step process of stigma formation to smokers).
57.
Wiley, supra note 40, at 150.
58.
Id. at 163.
59.
Schabert, supra note 4, at 5 (discussing efforts to conceal diabetes with potentially negative results).
60.
Id. at 6 (discussing in the context of diabetes).
61.
Stuber et al., supra note 12.
62.
Stuber et al., supra note 12, at 589.
63.
Bell et al., supra note 21, at 797.
64.
Puhl and Heuer, supra note 16, at 15-16; Puhl and Heuer, supra note 8, at 1022-1023.
65.
Puhl and Heuer, supra note 8, at 1022.
66.
Id.
67.
Earnshaw, supra note 4, at 157 (discussing being perceived as unhealthy in relation to chronic disease).
68.
Schabert, supra note 4, at 6 (discussing in the context of diabetes).
69.
Bell et al., supra note 21, at 797.
70.
Earnshaw, supra note 4, at 159, 163.
71.
Id. at 159, 164.
72.
Id. at 159.
73.
Id. (citing M.A.Chesney and A.W.Smith, “Critical Delays in HIV Testing and Care: The Potential Role of Stigma,”American Journal of Behavioral Scientist42, no. 7(1999): 1158-1162.
74.
Puhl and Heuer, supra note 8, at 1024.
75.
Bell et al., supra note 21, at 797.
76.
Id. at 797-98; Puhl and Heuer, supra note 8, at 1025.
77.
D.Fagundes and J.Roberts, “Distributive Justice, Libertarian Paternalism, and the HUD Smoke-Free Policy” (in progress).
