On Being Poor and Feeling Poor: Low Socioeconomic ... - Springer Link

ERIKA BLACKSHER

ON BEING POOR AND FEELING POOR: LOW SOCIOECONOMIC STATUS AND THE MORAL SELF

ABSTRACT. Persons of low socioeconomic status generally experience worse health and shorter lives than their better off counterparts. They also suffer a greater incidence of adverse psychosocial characteristics, such as low self-esteem, self-efficacy, and selfmastery and increased cynicism and hostility. These population data suggest another category of harm to persons: diminished moral agency. Chronic socioeconomic deprivation can create environments that undermine the development of self and capacities constitutive to moral agency – i.e., the capacity for self-determination and crafting a life of one’s own. The harm affects not only the choices a person makes, but the chooser herself. This moral harm is particularly salient in modern Western societies, especially in the United States, where success and failure is attributed to the individual, with little notice of the larger social and political realities that inform an individual’s circumstances and choices. KEY WORDS: agency, autonomy, class, health disparities, identity, justice, poverty, selfdetermination, social determinants, socioeconomic status

SALLY’S STORY Sally is a 68-year-old white woman who suffers from multiple chronic illnesses, has a tenth grade education, and lives on about $750 a month from social security.1 She makes and sells crafts on the side, though she worries she will be “caught by the government” for doing so. She receives two of her four daily medications free-of-charge through a charitable drug company program. Sally’s physician suspects she is depressed, which may help explain the fact that she is about 60 pounds overweight, a condition that aggravates her 5 1 frame and rheumatoid arthritis. Sally says she does not know whether she is depressed or not; she knows only that she has felt “powerless” to change things all of her life. Sally’s 68 years have been filled with the stresses of poverty, abuse, and instability. She grew up on the margins of poverty alongside four siblings and in the shadow of alcoholic, abusive parents. Her father beat her mother; her mother beat the children. A divorce and new marriage was no improvement. Sally’s step-father, an alcoholic who had difficulty securing work, insisted she quit school when she was 16 to begin supporting herself.

Theoretical Medicine 23: 455–470, 2002. © 2002 Kluwer Academic Publishers. Printed in the Netherlands.

456

ERIKA BLACKSHER

A year later, she married her first husband, a man who also did not complete high school and worked as a construction worker. He was an alcoholic, antisocial, and mentally and physically abusive. After 20 years of marriage he left Sally and their three children. They never heard from him again. She soon married his brother, who although not physically abusive, was also an alcoholic, manipulative, and a brittle diabetic. Over the next six years Sally, her youngest daughter, and second husband moved nine times, each time after he had lost or quit a job. Twice they moved in with Sally’s oldest daughter to avoid homelessness. Eventually, Sally and her husband moved into low income housing and went on welfare. He lived for another nine years and grew increasingly debilitated. Sally was his fulltime caretaker. In addition to the physical demands of his care (he was 6 2 and well over 200 pounds), coordinating his care was psychologically crushing. She would, for example, spend hours on the phone each week to make his medical care appointments and arrange for payment; she would be transferred four or five times to the “right” person, waiting “on hold” for a half an hour or more, sometimes forgotten. Sally’s health and well-being, already fragile, spiraled downward. She experienced periods of suicidal ideation. Her husband had Medicaid and then Medicare, but she had no health insurance until age 65, six years after his death. When asked about the course of her life and the choices she has made, she often replies, “I made this bed, now I have to lie in it.” Sally’s story of origin is riddled with characters and plot lines that make her vulnerable to physical and mental health problems. Her vulnerability relates to both poor health and inadequate health care, but this paper’s focus is health vulnerability. Although health care is an important contributor to health, its contribution is minor when compared to social factors commonly referred to as the “social determinants of health”2 [1]. Family environments like Sally’s (characterized by parental abuse, domestic conflict, financial instability and insecurity, and educational deprivation) spell poor health and well-being for those born into such circumstances [2, 3]. Sally’s health-care needs pale in comparison to her need for safe, stable, and nurturing psychosocial environments. For background, I will briefly review the well-documented and widely accepted relationship between socioeconomic status (SES) and health status. The primary aim of the paper is to show that chronic socioeconomic deprivation injures not only the biological and psychological self, but the moral self. I will argue that chronic socioeconomic deprivation can undermine the development of capacities constitutive to moral agency – i.e., the capacity for self-determination and crafting a life worth living. I will draw on empirical and theoretical studies of social class and identity

ON BEING POOR AND FEELING POOR

457

formation to support this claim. The analysis will reveal a moral harm of particular salience in modern Western societies, especially in the United States, and raises the question of whether health disparities are unjust. I offer no detailed response to the question, but my analysis supports a particular account of justice. In this paper, I use the terms class and SES interchangeably and focus not on the injuries of class per se, but on the injuries of chronic socioeconomic deprivation, with special concern for deprivation at the beginning of life. I intentionally frame the case in terms of class, not color. Both matter [4, 5]. My focus on class is not intended to minimize the profound impact race and ethnicity has on health status and health care. Fortunately, the impact of race and ethnicity on health status and health care are now the subject of much needed research [6], and the mechanisms of racial and ethnic disparities – segregation, discrimination, stereotyping and other conscious and unconscious practices and policies – are increasingly the subject of study and intervention. In a similar vein, this paper sets out to explore one mechanism of SES in an attempt to give shape to why class matters in matters of health. SOCIAL CLASS AND HEALTH VULNERABILITY We are all vulnerable to poor health and well-being, but we are unequally vulnerable. Vulnerability to poor health and well-being is experienced disproportionately by the worst off [7–9]. Persons with the fewest material and social resources suffer a “double injustice” of worse health and shorter lives than their better off counterparts [10]. “[T]thousands of studies” [11] confirm an inverse relationship between health status and socioeconomic status (measured by education, income, and occupation). So delicate is the balance between SES and health that the distribution of health is “not bipolar (advantaged vs. the rest) but graded, so that each advantage or disadvantage is in general associated with a change in health” [12:903]. This “social gradient” in health does not plateau once a certain level of advantage is attained, but persists into the highest reaches of the socioeconomic ladder and remains after controlling for risk factors [11]. As such, the relation of SES to health and mortality involves much more than inadequate financial resources or the substandard and risky living conditions associated with poverty. The social gradient in health has been well established since the beginning of the twentieth century [2]. More recently, the hotly contested “income inequality” hypothesis proposes that societies with significant income differences suffer the greatest incidence of adverse health

458

ERIKA BLACKSHER

consequences. “[W]hat the evidence shows is that the distribution of income among members of a society matters as much for their health and well-being as does their absolute standard of living” [9:xi]. One of the early proponents of this hypothesis, Richard Wilkinson, explains the impact of relative deprivation this way: Absolute income may affect health through exposure to toxic materials, through poor diet, damp housing, and inadequate heating. The powerful influence which relative income seems to have suggests that it is not so much a matter of what your circumstances are in themselves, but of their standing in relation to others: of where they place you in the overall scale of things, and of the impact this has on your psychological, emotional, and social life [8:110].

More recent and better data throw into question the relevance of income inequality to population health, although some research suggests that income inequality still matters within the United States [13]. Both lines of argument claim an association between class position and health. Numerous explanations for the relationship have been suggested. Causal factors at multiple levels of analysis – from individual variations to proximate environments to broader societal structures – appear to be implicated. “[I]ndividual characteristics are nested within social environments, with each level of analysis revealing information about the causes of health and illness that consideration of one level alone cannot provide” [14:413]. Possible causal factors include fundamental features of society, such as the degree of cohesion and trust (i.e., “social capital”); familial and workplace stability and security; access to life opportunities, especially education; and individual psychosocial characteristics, such as self-esteem and self-efficacy. A dearth of any of these goods is thought to be causally related to poor health, although clarity and consensus around causal pathways do not exist [15].

SOCIAL CLASS AND THE PSYCHOSOCIAL SELF The social determinants of health data point not only to disparities in biological health but to psychosocial health. Persons of lower SES more commonly have low self-esteem, self-mastery and self-efficacy; increased levels of hostility and anger; and are more likely to commit suicide [8, 9, 16, 17]. These clinical-sounding phrases mask sufferers’ harsher selfdescriptions: “foolish, stupid, ridiculous, inadequate, defective, incompetent, awkward, exposed, vulnerable, insecure, helpless” [18:181]. Of course, anyone anywhere along the social continuum may experience feelings of inadequacy, vulnerability, or shame; indeed, some social theorists


459

argue that such adverse feelings are built into the processes of human development [19, 20]. What these data suggest, however, is that for those on the lower end of the socioeconomic scale these adverse feelings are chronic. Like barnacles, these feelings “attach,” becoming a permanent part of their host. It is not difficult to imagine how this might be so. Socioeconomic status shapes daily routines, human interactions, and the physical settings and communities within which they take place. These tangibles and intangibles surround us like water, invisibly shaping our self-understanding, our world, and our expectations of it. Socioeconomically deprived waters too often are characterized by apathy, hopelessness, and ignorance; instability, insecurity, and chaos; mistrust, conflict, and fear; abuse and violence. Children born into these circumstances, not unlike those born into more advantaged circumstances, learn how and what to be, what to expect of themselves and others, what to hope for and aspire to. The disadvantage and deprivation may vary in content, intensity, and duration, but these variables congeal to form a life story. Commentators have suggested that social class may not be stable, self-conscious, or inherited [21]. But for some it is all of those things. Critical aspects of low SES – poor health and health outcomes, parenting behavior, low educational attainment – have been shown to follow families through generations3 [2, 22, 23]. “[T]he status of one’s parents helps to determine the community where one grows up, which, by the early school years, starts to influence the child’s life chances through the social networks, community values, and opportunities which present themselves” [2:149]. The cumulative impact of these adverse psychosocial features of lower SES appear to affect health and well-being in a variety of ways. Some researchers believe the exposure to and chronic stresses of unhealthy environments become, over time, embedded in human biology. “Because the central nervous system, which is the center of human consciousness, ‘talks to’ the immune, hormone, and clotting systems, systematic differences in the experience of life will increase or decrease levels of resistance to disease” [2:145]. Growing up in such environments not only often fails to provide models of healthy, positive behaviors and living, but exposes one to the frustrations and assaults associated with segregation and discrimination [24]. The individual’s emotional experience of isolation and lack of social connection may also contribute to poor health. Studies suggest that a lack of trust, connectedness, and reciprocity among citizens in communities and nations (i.e., “social capital”) adversely affects population health [25, 26]. Populations are healthier where social capital exists; less healthy where it is fragile or absent.

460

ERIKA BLACKSHER

SOCIAL CLASS AND THE MORAL SELF Chronic socioeconomic deprivation can injure not only the physical and psychosocial self, but the moral self. “Moral self” here refers to a person’s “moral agency” – one’s capacity to act autonomously, to be selfdetermining, to make a life plan that reflects one’s values, interests, and hopes for a future. As this list of descriptors suggests, accounts of agency can range in their level of stringency. The most demanding accounts describe an agent who not only acts in accordance with her values and life plan, but has reflectively adopted them. The agent becomes the source of her values and life plan and demonstrates “real autonomy” or “authenticity” [27, 28]. This high-bar standard requires the agent to “discover [her] own original way of being” in the world [28:47]. Acknowledging such a standard as an aspirational ideal but improbable for the majority of “normal choosers,” other accounts of agency suggest less demanding criteria [27]. For purposes of this analysis there is no need to adopt a particular account. The aim is to show only that chronic socioeconomic deprivation puts agents at risk of diminished agency, however defined. The “injuries” to the moral self refer not only to the diminished autonomy of choices and choosers, but to the source of both: one’s identity or “sense of self.” The harm of diminished autonomy characterizes a range of agency considerations, from a person’s capacity to choose to a person’s choices. In the former, the harm describes one’s capacity for the exercise of autonomy; in the latter, instances of the exercise of autonomy. Criteria for autonomous persons and autonomous decisions are distinct, though importantly related in that the latter are intended to protect and enable the former [27]. Both categories will prove useful for this analysis. Before undertaking the analysis, a caution is in order. Analyses of autonomy have implications for the principle of respect for autonomy. An argument that makes the case that chronic socioeconomic deprivation can thwart the autonomous agency of low SES selves may seem to suggest that their decisions and actions ought not to be respected as autonomous. No such implication is intended. This analysis does raise questions about when and under which circumstances individuals and their decisions can be considered autonomous. But the overarching goal of the analysis is to illuminate the degree to which “we” – as individuals, families, communities, and the larger society – are responsible for fostering and enabling the agency of others. Choices and choosers The first moral harm under examination is the impact socioeconomically deprived environments can have on important life decisions. Decisions and


461

choices are, of course, always shaped by a person’s circumstances. And, a person’s circumstances will shape what kind of choices and decisions a person faces. Some contexts enable human freedom; others impede it. But at what point do circumstances and conditions so reduce human freedom that the choices and decisions made can be considered to lack autonomy – to be unfree? To address this question, one could turn to measures of autonomous decisionmaking commonly used in biomedical ethics. The criteria used to assess an individual’s exercise of autonomy include: competence, disclosure, understanding, and voluntariness [29]. Competence refers to a person’s ability to perform a task; disclosure, to the adequacy and completeness of information provided; understanding, to comprehension of the information; and voluntariness, to independence from others’ deception, coercion, or manipulation. The utility of these criteria is limited for purposes of this analysis. First, it is not clear how these criteria apply to life decisions that are not defined decisionmaking moments for which consent is sought. These criteria are intended to enable and protect autonomy when particular kinds of decisions need to be made, such as decisions to participate in research or undergo a medical procedure. Second and related, these criteria do not account for broader social policies and political forces that inform the circumstances in which people find themselves and that exert influence over their decisions. The criteria account only for a small sphere of potentially coercive and manipulating “others.” Despite these limitations, they provide a useful beginning framework for examining the exercise of autonomy and focus the analysis at the level of “individual choice,” an important cultural notion in the United States. Let’s begin by examining a number of Sally’s decisions that had major consequences for her health and well-being and raise serious questions as to her capacity as an autonomous agent. Did she exercise autonomy when she left high school after the 10th grade? Was her decision to marry and stay with her first physically abusive husband autonomous? How about her decision to marry his brother one year later? According to the criteria for autonomy described above, one could argue that Sally was not “competent” to make the decisions she did. Competence is a measure of one’s ability to perform a task. The criteria for competence vary relative to specific tasks and contexts [29]. A person’s competence for any particular task may also vary from time to time, depending on a person’s situation and state of mind. Consider the following example provided by Beauchamp and Childress: A female patient, who suffers from chronic back pain decides to control the pain

462

ERIKA BLACKSHER

through non-surgical measures, against the strong recommendation of her specialist to undergo surgery. When this “eminent surgeon” asks her to sign the surgical permit, she yields to his request. Her belief that she can control her back pain through the use of a brace, an approach she has used successfully in the past, buckles under this surgeon’s forceful and authoritative personality. Was this woman competent to make this decision? According to Beauchamp and Childress, no. Commenting on this woman’s capacity for autonomous decisionmaking, they say, “[I]t is psychologically too risky for her to act as she desires. She is competent to choose in general, but she is not competent to choose on this occasion because she lacks the needed capacity” [29:135]. If demonstrating psychological fragility in the face of an authoritative or forceful person disqualifies one from being considered competent, and as such from being able to make an autonomous decision, one could argue that Sally failed to exercise autonomy in a number of instances. Sally was unable in many instances to chart a path that diverged from the will of the authoritative and abusive fathers and husbands that dominated her life. But which instances and decisions constitute failures of autonomy? Her departure from high school was not a “decision” she made. The decision was thrust upon her by an uncaring, abusive parent. She did not act voluntarily; she was coerced and without options. But what about her decision to marry and remain with a physically threatening husband? Were these decisionmaking moments? It is not clear that they were. In one sense, Sally surely did “decide” to marry her first husband. But at age 16, living in a boarding house for women, training to become a telephone operator, and learning to live on her own, Sally might have felt that marrying a man was surest way to succeed at this task. She was uneducated, lacking a supportive family or community, and had few options. But what about when her first husband started exhibiting signs of physically abusive behavior, especially when he attempted to kill her? Surely, with her life at risk, she could have mustered the will to pack up her children and leave? Again, her preparedness for life and options are critical to any answer. She had no high school degree, little work experience, three children to support, and no extended family who could help. When his brother came along and offered to take care of her, could she resist the offer of shelter and food for herself and one remaining child? Did her deprived circumstances eclipse her freedom to choose? Was Sally free? What is important to notice about this analysis of autonomy is that the locus of study has shifted from Sally’s decisions to Sally herself. By the time Sally was “free” to begin making decisions for herself, much had been decided for her. “We may believe that a human being is free, if ever, when


463

she not only has a range of options but an education that enables her to recognize those options as such and the self-respect that makes her choice among them a real one. Ignorance, lack of imagination, and lack of selfrespect are not just external constraints on the range of your options: they can cripple the power of choice itself” [30:60–61]. What matters most morally in Sally’s case is not her inability to exercise autonomy at critical junctures in her life course, but the utter lack of opportunity and resources she needed to fully develop her capacity for it in the first place. The criteria for autonomous agency are similar to the criteria for informed consent. One such account describes autonomous persons as those who act with intention, with understanding, and without controlling influences [27]. Acting with intention, on this account, means acting in accordance with a plan. The condition of understanding requires that the person apprehend both the nature of the action and the foreseeable consequences and possible outcomes of performing or not performing the act. The third condition requires that the person be free from controlling influences. Influences vary in form and degree of impact. “Threats of physical harm, promises of love and affection, economic incentives, reasoned argument, lies, and appeals to emotional weaknesses are all influences” [27]. Successful coercion eliminates the autonomy of the person; manipulation substantially reduces it. Pressed against such a framework, how does Sally fair? Many of Sally’s actions that ramified across her life course – leaving high school, marrying both the first and second husband – could be viewed as compromised in terms of autonomous agency. As a teenager with little formal or informal preparation for life, many of her actions were taken with little understanding of the consequences. More crippling still were the coercive and manipulative influences of others The threats of abandonment and violence were coercing influences; the promises of love and security, manipulative. Other actions or failures to act, especially those commonly thought of as health-related “lifestyle” behaviors, can also be scrutinized. For example, why didn’t Sally quit smoking when the risks became widely known? Why did she not begin to exercise, eat better, lose weight? All of these actions could have improved her chances of health and well-being, even if she had started relatively late in life. Assessing Sally’s agency in these instances cannot be isolated from the broader context of her life. Smoking and eating food that gave her instant gratification were small pleasures in a life with few. Exercising was not easy, especially in a neighborhood that was not only ugly by day but unsafe at night. To ask these

464

ERIKA BLACKSHER

sorts of questions of Sally is fair only if pressed against her life story and an understanding of how she came to be who she is. Sense of self Empirical and theoretical studies illuminate how socioeconomic deprivation and adversity can undermine one’s sense of self and with it, one’s capacity for agency. For example, a 1971 study of U.S. blue collar workers, found that the workers felt powerless and inadequate, despite having made strides up the socioeconomic ladder [31]. Their educational deficits and occupational status were interpreted by them as a lack of freedom, which in turn symbolized for them a lack of dignity. They described the causal connection between their self-worth and social status as the lack of opportunity to develop “powers inside themselves,” powers that would enable them to express themselves in rational and controlled ways, powers that would enable them to win the respect of others. One of these men, for example, expressed shame about his impoverished childhood, “not because there was a lack of things, but rather because the people who had nothing acted like animals” (emphasis mine) [31:22]. When talking about the people he grew up with, Frank would “fuse material deprivation with chaotic, arbitrary, and unpredictable behavior” [31:22]. This selfperceived lack of agency and ability extended equally to achievements, from surviving a violent childhood home to supporting a family. Rather than taking credit for clearing these life hurdles, they viewed themselves as passive agents, “on the receiving end of events rather than their cause” [31:20]. And yet, paradoxically, they felt fully responsible for those aspects of their lives that caused them shame. Whereas this study of blue collar workers explores how a person’s place in society can inform his identity, a phenomenon called “stereotype threat” demonstrates how others’ identification of a person can influence her place in society. Stereotype threat is “the threat of being viewed through the lens of a negative stereotype, or the fear of doing something that would inadvertently confirm that stereotype” [32:46]. For example, researchers have found that black students perform “dramatically less well” than their white counterparts, when they know they are being tested for cognitive ability. Black students know they are viewed as having inferior cognitive abilities. Despite the untruth of such ugly stereotypes, the intimidation of the stereotype undermines their performance, making it all the more difficult to prove the stereotype wrong. Much of the research has focused on race consciousness, but it has been shown that anyone subject to the invocation of a disparaging stereotype may experience it. Stereotype threat


465

has been shown to affect many categories of persons: advanced female math students competing against their male counterparts, white male math students competing against their Asian counterparts, lower class French students competing against their upper class counterparts. These sociological studies suggest that the “self’s perception of the evaluation of self by others” is a powerful psychosocial dynamic [19]. Its reach is deep, informing the development of self-respect and the behavior that flows from it. Human capacity to perform a variety of functions – from taking a test to possessing hope for a future – can be compromised. The longer one is exposed to adversity and deprivation, the more disabling its impact. The deprivation stealthily settles in, coming to characterize not only one’s circumstances but one’s sense of self, possibility, and aspirations. “In situations of persistent adversity and deprivation, the victims do not go on grieving and grumbling all the time, and may even lack the motivation to desire a radical change of circumstances” [33:6]. The moral harm in situations such as these has been described as nothing less than an impaired capacity for “formulating and pursuing a conception of the good” [30:58]. These sociological studies resonate with what some theorists have described as a “dialogical” and “sociological” self [34, 35]. On this view selves do not form in monologue, but in an ever-present dialogue with significant others, culture, and history. And much of that dialogue is given. One’s story of origin – told through salient factors such as race, class, language, family, and neighborhood, history and culture – sets in motion the development of a self, habits of mind and behavior, values and views. Throughout the life course there are opportunities for self-invention, resistance, defiance, and originality. One can redefine oneself, but the process always takes place against a familial, historical, cultural backdrop that was unchosen and over which one has little control until early adulthood. In the end, identity is a composite of chosen and unchosen fragments. “[N]one of us have individual identities except by reference to collective social experiences, and yet all of us retain some degrees of freedom for self-invention out of the found materials of biographical and social life” [35:23]. When those “found materials” are the stuff socioeconomic deprivation, negotiating a hopeful, healthy self becomes a high stakes enterprise. The combination of factors that make it possible is unknown, if not truly mysterious. What confluence of personal traits and social encounters, relationships and experiences enabled and disabled Sally’s will to choose for herself? Perhaps resilience, native intelligence, creativity were at work. No doubt, plain luck was responsible, too.

466

ERIKA BLACKSHER

CONCLUDING REMARKS: A JUST AND LIBERAL PROMISE I have traced an anatomy of harms to human health, dignity, and agency that attend chronic socioeconomic deprivation. What makes these harms morally important is not that our nation suffers poor health, as much as that matters. What makes these harms morally important is that the burden of poor health and well-being falls disproportionately on the shoulders of those who are poor and disadvantaged. They shoulder this burden not because they engage in unhealthy behaviors or embody bad genes, but because they have had the bad luck of being born the wrong color or class. The worse off deserve not only a fair opportunity to live a healthy life, but to lead a life they can call their own, and in this sense, to fulfill the Enlightenment (and very American) dream. The analysis above is not intended to criticize the ideal that fuels the dream. Rather, it is intended to show that not everyone has an equal opportunity to reach for it. Persons are not born into the world as equal, independent, rational choice makers; they do not start out life similarly situated. They are born into circumstances, families, and communities, which in turn are informed by social policies and political forces of the larger society, all of which work together – for better or worse – to frame an individual’s life chances and choices. Liberal societies ought not to be in the business of specifying individuals’ conceptions of the good, but they ought to be in the business of enabling their citizens to live a good life. This assertion raises the question of whether the disparities described above are unjust. There is no consensus on the question. And among those who believe health disparities are unjust, different understandings of and approaches to the problem are proposed [36]. Some justice proposals focus on outcomes; justice is achieved when human welfare (states of health and well-being) are fairly distributed. Others proposals focus on resources or the means to achieve states of welfare. On such accounts, justice is achieved when resources (e.g., income, fair opportunity for education and offices) are fairly distributed. “[W]hatever pattern of welfare or health is produced in society by a particular distribution of resources is just, so long as resources are distributed justly” [36:453]. Among other proposals, notably Amartya Sen’s, focus on capabilities or “human functionings” to achieve freedom and with it states of well-being [33]. The locus of concern in Sen’s proposal is neither an equitable distribution of the resources thought to enable health and well-being, nor the health and well-being achieved, but on the positive freedom (range of choices) achieved. The genetic and social lottery creates differences in persons’ and classes of persons abilities to convert goods into outcomes


467

[33]. These functionings range from being adequately nourished to having self-respect and they are, according to Sen, nothing less than constitutive to our well-being. On Sen’s view, freedom and the choices therein have not only instrumental value, but intrinsic value. “Choosing may itself be a valuable part of living, and a life of genuine choice with serious options may be seen to be for that reason richer” [33:41]. Sally’s story illustrates a seamless reciprocity between resources and capabilities. Sally was born into a resource-poor family. She had shelter and adequate nutrition, but she lacked familial support, stability, security, love and attention and was subject to parental conflict, neglect, and abuse. These early experiences and environments shaped, or more accurately misshaped, Sally’s capabilities to avail herself of future opportunities and resources – the means that could have helped to make her free, healthy and well. Sally could have, for example, studied for and obtained her GED, left a bad husband, and found a place in the workforce that would have welcomed her work ethic and creativity and helped her achieve economic independence. But she didn’t. She did not know she was capable; she did not think she deserved a better life. Although she possessed the skills to survive (to avoid malnutrition and escapable morbidity and mortality), she lacked the more complex human functionings (self-esteem, imagination, and hope) that would have enabled her to see and stretch for opportunities. The relevance of Sally’s story (and the millions of stories like hers) for the justice discussion is twofold. First, as just described, the case illustrates the reciprocity between resources and capabilities when considering their impact on health and well-being. Resources are necessary for the development of agency; agency is necessary for the conversion of resources into well-being. Resources help persons develop the capacities they need to see, access, and avail themselves of future and unfolding opportunities (such as education and jobs). Second, and related, the case illustrates the critical importance of making resources available early in life and in adequate supply to children and the families and communities that raise and shape them. A society’s human capital – healthy, hopeful, resourceful, imaginative selves – ought not to be left entirely to the luck of the social and genetic draw.

ACKNOWLEDGEMENTS I am indebted to many reviewers for their insights and encouragement. They include Annette Dula, Anthony Kessel, Robert Martensen, Erik Parens, Don Reynolds, John Stone, and Jennifer Stuber. My deepest grat-

468

ERIKA BLACKSHER

itude extends to Sally, my mother, for giving me permission to tell her story and teaching me how to make lemonade out of lemons.

NOTES 1 The Federal Poverty Level for a person 65 or older is $8,259 per year. U.S. Census

Bureau. Poverty in the United States: 2000. U.S. Departement of Commerce, 2000. 2 Al Tarlov, Texas Institute for Society and Health, presentation for Kansas Institute of Health, Kansas Health Researchers Meeting, Topeka, Kansas, September 25, 2001. 3 See New York Times, August 21, 2002, “Father Steals Best: Crime in an American Family,” for a discussion of criminality and its tendency to “run in families.”

REFERENCES 1. Adler NE, Boyce WT, Chesney MA et al. Socioeconomic inequalities in health: no easy solution. Journal of American Medical Association 1993; 269: 3140–3145. 2. Hertzman C. Early child development in the context of population health. In: Tarlov A, St. Peter RF, eds. The Society and Population Health Reader: A State and Community Perspective. New York: The New Press, 2000. 3. Pincus T, Esther R, DeWalt DA et al. Social conditions and self-management are more powerful determinants of health than access to care. Annals of Internal Medicine 1998; 129(5): 406–411. 4. Navarro V. Race or class versus race and class: mortality differentials in the US. Lancet 1990; 336: 1238–1240. 5. Williams D. Race, socioeconomic status, and health. The added effects of racism and discrimination. In: Annals of the New York Academy of Sciences. New York: NY: The New Academy of Sciences, 1999; 896: 173–188. 6. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. In: Smedley BD, Stith AY, Nelson AR, eds. Washington DC: National Academy Press, 2002. 7. Sorlie P, Backlund E, Keller J. US mortality by economic, demographic, and social characteristics: the national longitudinal morality study. American Journal of Public Health 1995; 85: 949–956. 8. Wilkinson RG. Unhealthy Societies: The Afflictions of Inequality. London: Routledge, 1996. 9. Kawachi I, Wilkinson RG, Kennedy BP. Introduction. In: Kawachi I, Kennedy BP, Wilkinson RG, eds. The Society and Population Health Reader: Income Inequality and Health. New York: The New York Press, 1999. 10. Wilkinson RG. Socio-economic differences in mortality: interpreting the data on their size and trends. In: Wilkinson RG, ed. Class and Health. New York, NY: Tavistock Publications, 1986. 11. Mechanic D. Rediscovering the social determinants of health. Health Affairs 2000; 19: 267–276. 12. Blane D. Editorial: Social determinants of health – socioeconomic status, social class, and ethnicity. American Journal of Public Health 1995; 85: 903–904.


13. 14.

15. 16. 17.

18.

19. 20. 21. 22. 23.

24.

25. 26. 27. 28. 29. 30.

31. 32. 33. 34.

469

Mackenbach J. Income inequality and population health. British Medical Journal 2002; 324: 1–2. Taylor SE, Repetti RL, Seeman T. Health psychology: what is an unhealthy environment and how does it get under the skin? Annual Review of Psychology 1997; 48: 411–447. Lurie N. What the federal government can do about the nonmedical determinants of health. Health Affairs 2002; 21(2): 94–106. Lantz P, House JS, Lepkowski JM et al. Socioeconomic factors, health behaviors, and mortality. Journal of the American Medical Association 1998; 279: 1703–1708. Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Social Science Medicine 1997; 44: 809–819. Scheff TJ, Retzinger SM, Ryan MT. Crime, Violence and self-esteem: review and proposals. In: Mecca AM, Smelser NF, Vasconcellos J, ed. The Social Importance of Self-Esteem. Berkeley: University of California Press, 1989. Scheff TJ. Microsociology. Chicago/London: University of Chicago Press, 1990. Goffman E. The Presentation of Self in Everyday Life. New York: Doubleday, 1959. Levin BW, Schiller NG. Social class and medical decisionmaking: A neglected topic in bioethics. Cambridge Quarterly of Healthcare Ethics 1998; 7: 41–56. Case A, Paxson C. Parental behavior and child health. Health Affairs 2002; 21(2): 164–178. Fonagy P, Higgitt A. Early influences on development and social inequalities: an attachment theory perspective. In: Tarlov A, St. Peter RF, eds. The Society and Population Health Reader: A State and Community Perspective. New York: The New Press, 2000. Stuber J, Galea S, Ahern J et al. The association between multiple domains of discrimination and self-assessed health: a multilevel analysis of latinos and blacks in four low-income New York City neighborhoods. New York Academy of Medicine, unpublished manuscript. Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality, and mortality. American Journal of Public Health 1997; 87: 1491–1498. Kawachi I, Kennedy BP, Glass R. Social capital and self-rated health: A contextual analysis. American Journal of Public Health 1999; 80: 1187–1192. Faden RR, Beauchamp TL. A History and Theory of Informed Consent. New York/Oxford: Oxford University Press, 1986. Taylor C. Ethics of Authenticity. Cambridge, Mass: Harvard University Press, 1991. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 4th edn. New York/Oxford: Oxford University Press, 1994. Korsgaard CM, Cohen GA. Equality of what? on welfare, goods, and capabilities. In: Nussbaum MC, Sen A, eds. The Quality of Life. Oxford: Oxford University Press, 1993. Sennett R, Cobb J. The Hidden Injuries of Class. New York/London: W.W. Norton & Company, 1972. Steele CM. Thin ice: stereotype threat and black college students. Atlantic Monthly, August 1999: 44–54. Sen A. Inequality Reexamined. Cambridge: Harvard University Press, 1992. Taylor C. The Ethics of Authenticity. Cambridge: Harvard University Press, 1991.

470 35. 36.

ERIKA BLACKSHER

Minow M. Not Only for Myself: Identity, Politics, and the Law. New York: The New Press, 1997. Marchand S, Wikler D, Landesman B. Class, health, and justice. The Millbank Quarterly 1998; 76(3): 449–467.

Midwest Bioethics Center Kansas City, Missouri USA E-mail: [email protected]