The roots of many healthcare concerns and ethical issues lie in poverty, especially in resource-scarce countries. The inextricable link between poverty and health manifests in the wide acknowledgement of poverty as a social determinant of health. Recent research continues to support Amartya Sen’s argument that shame lies at the core of poverty. While less access to health, sanitation, and nutrition disproportionately affects people of lower socioeconomic status, they also experience worse treatment outcomes and increased risks of illness and death. Research shows that disparities in health outcomes usually result from financial barriers to accessing treatment and care. However, studies suggest an association between socioeconomic disadvantage and worse health outcomes, despite equal access to healthcare or universal free access. Thus, the relation between one’s health and socioeconomic disadvantages goes beyond access to care and treatment.
While improving access to healthcare is important, we must also look at the other mechanisms at work that reduce health outcomes. Stigma, shame, humiliation and other negative self-conscious emotions may be such mechanisms linking socioeconomic disadvantage to poorer health outcomes. Noting the actions, behaviours and attitudes that stigmatisation, shaming or disrespect cause among low-income individuals across societies is nothing new. Many studies suggest that experiencing poverty-related stigma negatively impacts health and health outcomes.
Increased interest in the role of self-conscious emotions in health encounters has led to recent healthcare debates that consider the importance of understanding shame and stigma within medical encounters and the doctor-patient relationship. Dolezal and Lyons suggests that shame is an affective determinant of health. While some studies report that patients experience stigma, shame and other self-conscious emotions relating to race, caste or specific health conditions, much of the discussion focuses on medical illness alone. Noting and understanding these self-conscious emotions from the perspective of medical illness through an intersectional lens is significant. However, we should also see these self-conscious emotions as moral emotions; they influence the moral standards and behaviours that individuals navigate in everyday experiences. Thus, these self-conscious emotions play a significant role in healthcare interactions, relationships and patients’ sense of self.
Poverty-induced stigma, shame and humiliation do not just negatively affect the health outcomes of individuals; they also serve an important moral function, particularly in healthcare interactions. These moral emotions lead to self-imposed affective consequences as the individual evaluates the ethics of behaviour or actions, assessing and reflecting on herself. Similar to other scholars, my earlier work illustrates the moral significance of micro-inequities and the social construction of incompetence, investigating how subtle acts and behaviours in the background of social inequalities raise concerns for patient and family members’ dignity and respect. For instance, evidence shows that some doctors use patient socioeconomic status to decide what information to discuss, regarding treatment and alternative options. Furthermore, some nurses and doctors treat patients differently during these interactions on the basis of how they perceive those patients. For example, they may consider poor patients as ‘incapable’, ‘incompetent’ or ‘passive’ and withhold from them information relevant to their treatment. Patients and family members internalise and normalise their sense of belonging (or not) by reflecting on their socioeconomic status during these interactions. This has huge consequences for how they act, behave and engage with healthcare decision-making and in healthcare encounters. For instance, a fish vendor taking care of her son in a government hospital said, ‘There is no one to take care of us. He was admitted five days ago. I cannot stay inside the ward for more than the briefest of periods. The senior staff nurse scolds me if she sees me when I visit him. I walk out immediately when she stares at me. It is my fate that I can’t take him to a private hospital. Well, this is how we are treated everywhere.’
When we critically reflect on the narratives of patients and family members, we can identify processes of moral evaluation of acts and behaviours, and we can understand how people experience negative self-conscious emotions, such as poverty-induced stigma, shame and humiliation, and the pernicious effects these experiences have. Having lived most of my life in poverty, experienced poverty in different shades, I have been reminded of my caste and class identity during my personal and professional interactions. These experiences haunt me and serve as a constant reminder of the large impact that poverty-induced stigma, shame and humiliation have on people’s lives and their moral significance for healthcare interactions and one’s moral self.
Supriya Subramani, Postdoctoral Fellow, Institute of Biomedical Ethics and History of Medicine, University of Zurich and organizer of the Respect and Shame in Healthcare and Bioethics Seminar Series.