Moral disengagement and tolerance for health care inequality in Texas
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- McAlister, A.L. Mind Soc (2010) 9: 25. doi:10.1007/s11299-009-0065-2
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Societies vary in their levels of social inequality and in the degree of popular support for policies that reduce disparities within them. Survey research in Texas, where levels of disparity in health and medical care are relatively high, studied how psychological mechanisms of moral disengagement relate to public support for expanding access to government-subsidized health care. Telephone interviews (N = 1,063) measured agreement with statements expressing tendencies to minimize the effects of inequality, blame its victims and morally justify limits on government help. The interviews also assessed support for general and specific policies to reduce inequality, e.g., through state-subsidized health care for lower income groups, as well as political party affiliation, ideological orientation, gender, age, education and income. Agreement with beliefs expressing moral disengagement was associated with opposition to governmental policies to reduce inequality in children’s health care. Beliefs that justify the withholding of government assistance, blame the victims of societal inequality, and minimize perceptions of their suffering were strongly related to variation between and within groups in support for governmental action to reduce inequality.
KeywordsMoral disengagementHealth disparitySocial inequalitySymbolic racismHealth policyTexas
There is copious evidence that socioeconomic stratification and unequal distribution of social advantage has a powerful, perhaps predominant, influence on a population’s health (Tarlov and St Peter 2000). Some societies appear to tolerate these disparities more than others. Differences between societies in their tolerance for the suffering caused by economic and health care inequality may be ascribed to cultural differences in political ideology (Tarlov and St Peter 2000), but their specific elements have not been elucidated.
The concept of moral disengagement (Bandura 1999) was developed to help explain how people excuse themselves for inflicting suffering upon others. According to this concept, people use self-deceptive psychological maneuvers that make harmful actions (or inaction) acceptable by disengaging the social norms and personal standards that restrain aggression through civility. Mechanisms of moral disengagement include justificatory beliefs that make harmful actions appear to be necessary or even beneficial, attributing blame to victims and minimizing the degree to which harm and suffering are perceived and acknowledged. In addition to making it easier to inflict suffering overtly, these psychological mechanisms may increase tolerance for the suffering caused by disparities in access to health care.
Beliefs supporting arguments against state-subsidized health care or other government services might be expected to employ these mechanisms by providing moral justification with the assertion that government assistance does more harm than good, attributing blame for inequalities to perceived characteristics of disadvantaged groups and minimizing the acknowledged consequences of reductions in government services by claiming that adequate help is available from the private sector. The pilot research reported here was designed to study how these beliefs relate to political affiliation and ideology, and to support for policies to reduce disparity. The study was conducted in Texas, where state policy is highly influenced by conservative political ideology (Micklethwait and Wooldridge 2004) and a very high proportion of children lack health insurance (Mitka 2008).
2 Research methods
A statewide survey was conducted by telephone with standard polling methodology using randomly selected working home telephone numbers. Trained interviewers randomly selected one member of each household for the survey. A total of 1,063 complete surveys were obtained. The American Association for Public Opinion Research standard response rates were RR1 = 0.26, RR6 = 0.36. Survey participants were asked about their age, gender, education, income and their political affiliation (Republican, Independent or Democrat) and their political ideology (conservative vs. moderate or liberal).
To measure their general support for government actions to reduce economic inequality respondents were asked to express their agreement with this statement: The government should work to reduce the gaps between rich and poor people in our state. Support for specific programs to reduce disparity in access to health care was measured by asking participants to express their agreement with this question: The legislature should make it easier for poor families to qualify for free health care. The use of moral justification was measured by asking participants to express their agreement with this statement: Too much government help makes people less willing to help themselves. Willingness to blame the victims of social inequality was measured by asking about agreement with this statement: Some groups have values that limit their economic ambition. The tendency to minimize perceived suffering was assessed by gauging agreement with this statement: Poor people can get access to health services if they really need them. Response options for expressing agreement to the questions about support for government programs and mechanisms of moral disengagement were “agree” (strongly or somewhat), “not sure” or “disagree” (strongly or somewhat).
Data were analyzed with SPSS for PC to produce frequency distributions describing the demographic features of the survey participants, political affiliation and ideology, support for general actions to reduce inequality and specific actions to broaden health care access and their tendency to use the three mechanisms of moral disengagement. Cross tabulations were used to examine the extent to which survey respondents with different affiliations and ideologies supported government actions and their use of mechanisms of moral disengagement. Cross tabulations were also used to assess the relationship between mechanisms or moral disengagement acting singly and together on support for government actions, both in the whole survey group and among those with different political affiliations and ideologies. Chi square calculations were used to test the significance of differences between proportions.
Conservative Republicans opposed general government programs to reduce inequality more than other groups. The proportion agreeing that the government should reduce gaps in society ranged from less than 30% among conservative Republicans to more than 60% among moderate or liberal Democrats. Independents occupied an intermediate position (P < 0.01). A majority of all groups expressed support for legislative action in Texas to increase access to subsidized health insurance (87% among moderate and liberal Democrats), but support was weakest among conservative Republicans (55%).
Agreement with statements expressing mechanisms of moral disengagement was consistently associated with general support for government policies to reduce inequality and support for specific policies to reduce health disparities. People who agreed with statements expressing mechanisms of moral disengagement were less likely to support increases in subsidized health insurance than those who disagreed with those statements (P < 0.05–0.01). The greatest difference was associated with agreement with the belief that too much government help reduces people’s willingness to help themselves, with 68% support for reducing health care disparity among those who hold that belief and 82% support among those who do not. Beliefs representing moral disengagement were highly associated with support for health care disparity reduction among conservatives. In that group only 49% expressed support among those agreeing with all three beliefs, whereas 82% expressed support among those who agreed with none of them (P < 0.01). Among Texans who agreed with no more than one of the statements measuring moral disengagement, there was no difference between conservatives and other political groups in their support (<80%) for increasing access to government-subsidized health care.
The concepts of moral disengagement have arisen within the distinct theoretical foundations of Albert Bandura’s social cognitive theory (Bandura 1999). But the statements with which they are measured, and our findings, resemble those in research with other theoretical perspectives. The statement expressing victim-blaming is similar to statements expressing subtle forms of racism (Pettigrew and Meertens 1995), and with measurements of the well-known construct of symbolic racism (Sears and Henry 2003). The statements expressing justifications for opposition to disparity reduction in this study are also similar to those employed in studies of system-justification theory (Jost et al. 2004). They can be easily linked to assertions that are commonly made in opposition to government programs intended to reduce economic inequality (Gans 1995). Some scholars claim that government assistance does more harm than good because it reduces individual initiative (e.g., Mead 1997). This provides moral justification for limiting government assistance in housing and health care. Related arguments against government assistance blame poverty on the groups that experience it. While decrying racism, some social analysts argue that income inequalities are explained mainly by cultural deficiencies in economic ambition (D’Souza 1995), stereotypical traits popularly ascribed to African-Americans and Hispanics (Smith 1990). Opponents of government-subsidized health and social services may also minimize the perceived harm caused by withdrawal of government assistance by asserting that private charities provide superior help for those who need it the most (Olasky 1992).
The conceptualization of beliefs justifying opposition to government actions to reduce disparity as a representation of Bandura’s (1999) mechanisms of moral disengagement, with victim-blaming expressed via symbolic racism (Sears and Henry 2003), may explain why health care inequalities are tolerated in Texas. Constructive debate about health policy will probably not be advanced by judging those justificatory beliefs to be “immoral” or “racist.” But advocacy for equity may benefit from appeals specifically designed to change opinions about the harmful effects of government assistance, reduce prejudice toward disadvantaged groups and compellingly display the consequences of inequality.
Texas lawmakers fail to save measure expanding kids’ health insurance (headline)
Houston Chronicle, May 29, 2009.
Research supported in part by the US National Institutes of Health (R21 HD40067).