Health with Humanity
By Joanna Burke-Bajaj
Moving from Health-Related Deservingness to Rights-Based Approaches to Health
The concept of deservingness is a social idea related to the moral judgements and biased assumptions that we make about whether or not, or to what degree, others are deserving of what they receive. In a sense, the idea of deservingness can be understood as the opposite of rights, in that the judgement is entirely subjective, relational, and situationally contextual rather than expected to be delivered in an equal manner (Willen & Cook, 2016). Within the study of health equity, judgements focused on deservingness can often be at the root of systemic disparities in the types of care offered to populations that are made structurally vulnerable by race, class, gender, sexuality, or even by citizenship and previous health concerns (Holmes et al., 2021). As Paul Farmer famously stated, “The idea that some lives matter less is the root of all that is wrong with the world.” This concept that some individuals are ‘deserving’ of a high standard of healthcare, and others may not be deserving of care at all, is a key human bias underlying the services offered to marginalized populations. Every interaction between patients and providers has the potential to be shaped by the unspoken judgements made about who deserves the investment of time, resources, and quality in care (Holmes et al., 2021).
In the case of those needing access to healthcare without citizenship, there are numerous examples of healthcare providers and even the wider public insisting that individuals who are not citizens or legal residents should not be provided access to healthcare based on the idea that they are not deserving of a right to health unless they hold citizenship. In many cases, these judgement-based limitations on access to care exist even in nations where legislation protects the right to health and universal access to care is intended to be protected, such as Costa Rica where Nicaraguan migrant women in particular find major disparities when attempting to receive healthcare, with some who are denied care being told that they create national declines in health system resources (Goldade, 2009). Again, migrant populations face the dichotomy between rights and deservingness when health providers engage in judgements on who they believe deserves healthcare resources, as if the lives in need of their care are not of equal value.
“At the local and national levels, questions of ‘who deserves what’ are pivotal, if implicit, throughout the political process… At an international level, such questions challenge us to confront the profound health implications of contemporary patterns of global inequality,” (Willen & Cook 2016).
Another key form of health-related deservingness that is used to deny care to those in need is the idea that those who have previous health concerns are ‘undeserving’ of future care, and this notion is especially prevalent in public attitudes about those who engage in substance use. The most clear example of this form of denial based on moral deservingness can be found in the restrictions on organ transplants faced by those with a history of substance use and addiction. Despite the fact that many individuals with a past history of substance use are at higher risk for requiring some types of organ transplants, they face significant barriers to accessing transplant organs, and many are simply never admitted to the waiting lists for transplant centres (Caplan, 2014). In denying transplant services to those with a history of certain illnesses or activities, the moral judgement being projected on that individual now becomes more than a judgement and turns into an inequitable and tangible barrier to their right to life.
While the global COVID19 pandemic has illuminated many of the large disparities and gaps in healthcare that are still growing worldwide, it has also ignited a spark in the healthcare field with a surge of new research and programs dedicated to addressing health inequalities. In this push for more equitable care, we must not only consider how to ensure that healthcare is a human right accessible to all, but also how to curb the biases of the health system that have catered to the conditions of ‘deservingness‘ for too long, while leaving out structurally marginalized communities.
Health-related deservingness is a part of the social structures of discrimination that shape and yet also are shaped by the other social identities by which individuals are judged, from immigration status to occupations to overall health status. In this way, the central question to ask in beginning the journey towards a rights-based approach to healthcare is: What would our healthcare system do differently if we felt that every individual deserved the same level of care for their life? What would healthcare look like for marginalized communities if high quality healthcare was administered truly as a basic human right and not as a subjective function of identities, judgements of morality, and social conditions? A rights-based approach to healthcare does not only involve ensuring that everyone has an equal legal right to health or legal eligibility for care, but also should go further to ensuring that in practice there is equal access to care with a high quality standard for all. Understanding how the approach of health-related deservingness can find its way into even the strongest of rights-based universal healthcare legislation can help public health practitioners, healthcare providers, and policymakers, change the micro- and macro-level health system politics that allow disparate healthcare access and quality to continue.
Caplan A. (2014). Bioethics of organ transplantation. Cold Spring Harbor perspectives in medicine, 4(3), a015685. https://doi.org/10.1101/cshperspect.a015685
Goldade K. (2009). “Health Is Hard Here” or “Health for All”?: The politics of blame, gender, and health care for undocumented Nicaraguan migrants in Costa Rica. Medical Anthropology Quarterly, 23(4):483-503. Accessed at www.jstor.org/stable/40541934.
Holmes S.M., Castañeda E, Geeraert J, et al. (2021). Deservingness: migration and health in social context. BMJ Global Health 6:e005107.
Willen S., and Cook J. (2016). Health-related deservingness. In Thomas, F. (Ed.), Handbook of migration and health. Edward Elgar Publishing. pp.95-118.