Absolving the powerful at the expense of the poor

“The future is both/and, not either/or.”

A colleague said that to me recently — I’ll explain what it means in a moment — and I thought it very fitting, given what I’ve been reading in the paper lately.

I’ve been struggling with where to start in addressing the flurry of arguments and characterizations of some of the most vulnerable — and resilient — members of our community.

For what I hope is the last time, I would like to set the record straight.

I read Dr. Julie Curwin’s Nov. 27 opinion piece, “Why Dr. Milburn’s salvo against ‘victimhood culture’ went viral,” and could not help but shake my head. Rather than people having “learned helplessness,” there is abundant data that shows that forces beyond our control have a lot to do with how we get through life.

Literal economic treatises have been written about how wealth begets wealth (Capital, by Thomas Picketty), how deprivation changes our ability to make decisions (Scarcity, by Sendhil Mullainathan and Eldar Shafir) and how childhood adversity shapes our health in adulthood (the ACES study).

On the other hand, some of the foundational experiments of “learned helplessness” involved giving electrical shocks to dogs until the poor animals just gave up. All that to say our decisions might not always be good, but they are coming from somewhere.

Given all this research, it’s all the more disappointing to read arguments as an either/ or, as if people can only have free will over their actions or be the product of circumstances beyond their control. As my colleague said, the future is both/ and — meaning people experience victimhood and responsibility simultaneously .

The justice system and the Criminal Code don’t give people a pass if they’ve had a tough life. In fact, the very opposite is true. Poor, racialized or otherwise marginalized people are also criminalized at higher rates than their counterparts. Unless we accept that being poor or racialized or LGBTQI2S+ or otherwise disadvantaged makes a person inherently more criminal (it doesn’t) then it is obvious that there is more going on.

But the real danger of framing issues of social justice as a case of people not taking personal responsibility for their actions is actually not some risk of labelling people victims and “teaching” them to become “helpless” or giving “criminals” a free pass. Rather, it is that those of us in positions of power, privilege and authority are absolved from critically examining the inequitable ways in which our system operates. By labelling people “criminals,” we can ignore the conditions that lead to crime, which are much more difficult to address. Even more terrifying, if we unravel who benefits and who is harmed by policies, we may find that we are benefiting at someone else’s expense.

Statistics may show more crime in poor communities, but unless we fix the poverty, we won’t fix the crime. When we put all the blame on individuals, we ask those who are most vulnerable to fill and correct the gaps in our system all by themselves. After all, they are ultimately responsible for their own outcomes, so the rest of us don’t have to worry about it.

Physicians may complain about arrested or incarcerated folks being brought to us for “non-medical” reasons, but the fact of the matter is they are coming because there is nowhere else they can safely go for care. If they are “medically cleared” after assessment in the emergency room, then we should be glad, because there was no life-threatening medical condition to treat. Patients are — at least in terms of their physical health — safe.

No one who works with folks at the margins would ever argue that they are not agents of change, fully responsible for their lives. They have compelling stories and they know exactly what is wrong with the system. Many of them are understandably very angry about it, and they’re equally angry about the circumstances they experience. Which brings me back to perhaps the most important “both/and” of them all. As physicians, we must do the best we can with what we’ve got and be proud of the work we do. At the same time, we must work hard to dismantle injustice in our health-care institutions. Our patients deserve no less.