Being Healthy Is Not the Same as Being Virtuous

‘Illness and disability are not ways to measure the value of a human life’

Close-up of a reflected pill on a reflective surface. Colorful lights background.
Photo: Aitor Diago/Getty Images

There is a common, problematic way that many of us conceive of “health.” Too often we equate the absence of illness with morality. This leads down many troublesome paths both on a personal and a policy level. It seems we need to be reminded periodically that health is not a moral virtue.

Diet and lifestyle are probably the most commonly moralized aspects of health. How many times have you heard disparaging comments about “lazy” people who “pop pills”? Or the notion that medication is an easy substitute for the hard work of eating “clean” and exercising?

As a family physician, I see patients frequently who internalize these ideas and feel like medication is a personal failing, a sign that they are somehow morally weak. This sets up a dichotomy: Either you are virtuous and take no medication, or you are sick with vice and medication is the punishment you deserve.

This is — of course — ridiculous.

Many medical conditions have nothing to do with lifestyle or even if they are improved by lifestyle change, medication is still necessary. Do I celebrate with patients when we are able to de-prescribe one of their medications? Absolutely! But not because they have found some new moral strength. I’m simply happy when patients feel better. Full stop.

There’s a huge difference between lifestyle counseling and selling a cure-all based on lifestyle change. The former makes you a health care provider, the latter makes you a grifter.

Moralizing ideas are nothing new — they are some of the historical roots of medical grifting and snake oil selling. Over 100 years ago, a guy you might have heard of by the name of John Kellogg led a pseudoscientific health movement that was utterly fixated on virtuous eating. He quite literally believed that flavorful food would lead to a whole host of sins, chief among them masturbation. Really.

The modern wellness industry inherited Kellogg’s moralizing attitude toward diet, but now the aesthetic of the messaging and the ever-changing fad “superfoods” are different.

Lifestyle can indeed cause illness, there is no doubt about that. I counsel patients on how lifestyle changes can make them feel better all the time. But there’s a huge difference between lifestyle counseling and selling a cure-all based on lifestyle change. The former makes you a health care provider, the latter makes you a grifter.

Remember that whenever we overemphasize individual behavior as causative of health issues, we lose sight of the larger systemic factors that promote illness. Poverty is a major contributor to illness and only persists because we don’t have robust policies to eliminate it. It’s unconscionable to blame people who can’t access high-quality food or afford a gym membership as though it was a simple individual choice and not a result of systemic inequity.

Fixation on diet also promotes fat shaming and fatphobia, neither of which improve the health and well-being of fat people and in many cases cause substantial harm — including within health care, where bias and discrimination based on patient weight is a very real problem.

Mental health is no stranger to moralizing stigma, of course. Similar to how lifestyle is judged, we see the idea that avoiding medication makes you a stronger and better person. The view that mental illness is not real is part of the issue. Taking medication for a fake disease seems immoral and gets spun as the “easy way out.” But ask someone who has struggled with mental illness how easy it felt to treat their condition and you will get a vastly different perspective.

I can’t tell you how often my patients struggle because of these judgments. No one agonizes over whether treating their psoriasis or cataracts makes them weak, but people will suffer because “I just want to fix this on my own” or “my family says I shouldn’t need happy pills.” We are doing active harm to people with mental illness by perpetuating these toxic ideas.

On a policy level, moralizing attitudes on health are also harmful. Substance use is highly stigmatized, to the point that widely supported, evidence-based therapies for opioid addiction are continually rejected by policymakers. This stigma has caused untold suffering and death over the years and continues to threaten lives during the pandemic.

The reasons for not using therapies like supervised consumption are often thinly veiled hand-wringing over funding the indulgence of vice. After all, if vice is connected to poor health, how can it be possible to improve health through vice? It must be wasted money, and immoral to boot!

There’s an even more sinister type of moralizing happening here too, one that devalues the lives of people deemed “addicts” and therefore makes life-saving treatment not really worth time and effort. Often, comparisons to a more legitimate (that is, less immoral) illness are made. This forces another type of false dichotomy — either we fund diabetes treatment OR opioid addiction, there’s no room for both.

Let’s also remember that these illnesses are not mutually exclusive. You can certainly have diabetes and a substance use disorder, and indeed there are lots of people who do.

I got into a painful debate on a friend’s Facebook page about these sorts of either/or memes a while back. Even after I explained the clear public interest in reducing spread of HIV and hepatitis C, the rebuttals still focused on people who inject drugs not “deserving” to have clean needles. In other words, not only should we dismiss the health and safety of people we judge to be immoral, we must overlook everyone’s risk from public health concerns like infectious disease. That’s cutting off your nose to make your face feel more virtuous.

Substance use is highly stigmatized, to the point that widely supported, evidence-based therapies for opioid addiction are continually rejected by policy makers.

This may sound familiar to Erin O’Toole. The leader of the federal opposition in Canada took issue with vaccinating incarcerated people against Covid-19. Never mind the risk to prison workers and their families from a virus that thrives in congregate settings, the important thing is apparently to signal the utter lack of value of the lives behind bars. That this is a compelling message even when it harms the community at large demonstrates how powerful moralizing can be — it literally trumps life and death in the midst of a pandemic.

I still remember Princess Diana making headlines for the simple act of touching HIV+ people. This was one of many turning points in the AIDS crisis, based on the changing public perception of HIV+ people as actual human beings and not ciphers representing sin. Think how many lives we could have saved if we had reached this rather obvious conclusion sooner.

Ultimately, moralizing ideas on health run deep and are hard to root out. We should be open to re-examining our instinctive reactions to illness and ready to interrogate our own ideas of virtue and vice where health is concerned.

The bottom line is that health is not a moral virtue. Likewise, illness and disability are not ways to measure the value of a human life. That value is inherent and not connected to a person’s medical history. Whether or not someone needs to take medication is not an indication of moral weakness and being able to live medication-free is not a demonstration of moral strength.

We also need to remember that individual behavior can impact health, but policies and systemic issues like poverty and discrimination are much more significant. All illness is worthy of treatment, all suffering deserves support, and all the ways in which we as a society can reduce the burden of disease are worth exploring.

This piece originated from my Feb. 11 Twitter thread.

Dr. Michelle Cohen (@DocMCohen) is a family physician in rural Ontario and an assistant professor in the Dept of Family Medicine at Queen's University.

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