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Commentary

Exploring the concept of vulnerability in health care

Beth Clark and Nina Preto
CMAJ March 19, 2018 190 (11) E308-E309; DOI: https://doi.org/10.1503/cmaj.180242
Beth Clark
Provincial Health Services Authority (Clark, Preto); The University of British Columbia (Clark), Vancouver, BC
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Nina Preto
Provincial Health Services Authority (Clark, Preto); The University of British Columbia (Clark), Vancouver, BC
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  • Not all advantages are unearned
    Jon Royce
    Posted on: 18 October 2018
  • RE: Exploring the concept of vulnerability in health care
    Samantha Green and Stephanie Nixon
    Posted on: 04 April 2018
  • Posted on: (18 October 2018)
    Page navigation anchor for Not all advantages are unearned
    Not all advantages are unearned
    • Jon Royce, B.Comm, Toronto, Ontario

    In response to Drs Samantha Green and Stephanie Nixon's (Ph. D) letter about 'unearned advantages' perpetuating systemic failures for those who have an 'unearned disadvantage', I respond that they have replied to a perhaps legitimate problem by perpetuating an existing one.

    While I find it merely amusing that their letter highlights a concept of 'unearned advantage' that implies that experts have been nothing but lucky in gaining what appears to be an expertise and ironically thus calls into the validity their own position on the matter (noting that they may well have lucked into their MD and Ph D. credentials - which I highly doubt), but more dangerously, in an age when many patients do not trust doctors or scientific evidence, to their own detriment (anti-vaxxers, not completing medication prescriptions, etc.), it is almost dangerous to undermine the advice and learnings that doctors and scientists have earned through years of hard work and study by implying that we should not listen to experts as their knowledge has not been 'earned' and their advice is thus no better than what someone random told you on the internet. Skepticism is always warranted, but to argue that expert opinion is in some way unearned and by logical extension not valuable is to threaten the health of the broader population.

    Competing Interests: None declared.
  • Posted on: (4 April 2018)
    Page navigation anchor for RE: Exploring the concept of vulnerability in health care
    RE: Exploring the concept of vulnerability in health care
    • Samantha Green, Family Physician; Lecturer, St. Michael's Hospital; University of Toronto
    • Other Contributors:
      • Stephanie Nixon, Physiotherapist; Associate Professor

    We thank Beth Clark and Nina Preto for their recent article “Exploring the Concept of Vulnerability in Healthcare”. We appreciate their analysis of the term “vulnerable” and other terms used to describe groups at increased risk for poor health, particularly in the context of the CMAJ’s recent focus on “vulnerable populations.”

    We appreciate that the authors offer caution regarding the ways that words like “vulnerable” can perpetuate paternalism, oppression, social control, stigma, and disempowerment; we agree that the term “underserved” can highlight that the root of the problem is the system rather than the individuals with worse health.

    Yet, the authors could have gone further in their analysis.

    The problem is not only that some people are more “vulnerable” to illness, or that systems of inequality--including colonialism, racism, ableism, and sexism--give some groups unearned disadvantage, which can lead to being underserved. The direct corollary of unearned disadvantage is the unearned advantage that other groups receive from these same systems of inequality. Missing from Clark and Petro’s article is recognition that systems of inequality that cause harm to “vulnerable groups” also directly benefit others, leading to better health, increased wealth, and increased political capital.

    Leaving unearned advantage out of conceptualizations of inequity or vulnerability is harmful insofar as it reinforces the patterns that produce vulnerability....

    Show More

    We thank Beth Clark and Nina Preto for their recent article “Exploring the Concept of Vulnerability in Healthcare”. We appreciate their analysis of the term “vulnerable” and other terms used to describe groups at increased risk for poor health, particularly in the context of the CMAJ’s recent focus on “vulnerable populations.”

    We appreciate that the authors offer caution regarding the ways that words like “vulnerable” can perpetuate paternalism, oppression, social control, stigma, and disempowerment; we agree that the term “underserved” can highlight that the root of the problem is the system rather than the individuals with worse health.

    Yet, the authors could have gone further in their analysis.

    The problem is not only that some people are more “vulnerable” to illness, or that systems of inequality--including colonialism, racism, ableism, and sexism--give some groups unearned disadvantage, which can lead to being underserved. The direct corollary of unearned disadvantage is the unearned advantage that other groups receive from these same systems of inequality. Missing from Clark and Petro’s article is recognition that systems of inequality that cause harm to “vulnerable groups” also directly benefit others, leading to better health, increased wealth, and increased political capital.

    Leaving unearned advantage out of conceptualizations of inequity or vulnerability is harmful insofar as it reinforces the patterns that produce vulnerability. First, omitting unearned advantage reproduces and thereby reinforces inequity by positioning those who are “vulnerable” or “underserved” as helpless and those who are recipients of unearned advantage as experts whose role it is to help. We then create solutions to address “the problem” of those who are vulnerable or underserved without also framing those with unearned advantage as part of the problem.

    Worse still, neglecting unearned advantage allows and indeed encourages those who work with marginalized populations to be positioned as neutral and unconnected to the systems of inequality that produce vulnerability--and therefore worthy of praise for their altruism, courage, and selflessness for doing this work--instead of complicit in, and indeed a central part of, systems of inequity. In order to dismantle systems of oppression and inequality, and the negative health effects of unearned disadvantage, we must attend to the ways in which we are all part of systems of inequality. We can either remain blind to our complicity in these systems, and thereby reinforce them, knowingly and unknowingly by our everyday actions, or come to understand our positions of unearned advantage so that we can resist these patterns.

    Good intentions are not enough. The focus needs to be on impact. And the impact of neglecting unearned advantage in discussions of vulnerability is deeply harmful.

    Show Less
    Competing Interests: None declared.
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Canadian Medical Association Journal: 190 (11)
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Exploring the concept of vulnerability in health care
Beth Clark, Nina Preto
CMAJ Mar 2018, 190 (11) E308-E309; DOI: 10.1503/cmaj.180242

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Exploring the concept of vulnerability in health care
Beth Clark, Nina Preto
CMAJ Mar 2018, 190 (11) E308-E309; DOI: 10.1503/cmaj.180242
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