Combatting Stigma: Inclusion And Other Options
03/25/2014 - 07:41
Alfred Tauber
Patient Responsibility by Alfred Tauber
Patient Responsibility by Alfred Tauber

The stigma associated with all kinds of human difference pervades social awareness. Whether prejudice is based on race, ethnicity, religion, nationality, physical characteristics or disabilities, few possess the neutrality towards the other we espouse as a liberal ideal. Western democracies combat the inequalities stemming from such differences. By statute and judicial judgment, access to housing, jobs, education, transportation, and the right to vote have been mandated, but despite significant legislative advances over the past 30 years, few are satisfied that the goals of such laws have achieved their intended effects.

A broad notion of inclusion has guided activists’ efforts to improve the separations imposed by stigma. In the case of persons with mental or emotional disabilities, my main concern here, programs and policies directed at employment, education and social interactions all fit under the general rubric of inclusion. When the politics and moral merits coincide, we can all agree on advocacy for inclusion.

However, politics can intrude even with the best of intentions. I have witnessed how some advocates of inclusive policies attempt to thwart other approaches. They believe that by pursuing a spectrum of options a dilution effect occurs: Only one approach can be advocated and success seems to require single-minded determination. A stalwart position is taken because they regard other solutions as competing and thus diminishing the impact of the inclusion message.

Unfortunately, the ethics under-pinning the inclusion position are not so simple. Inclusion is good sometimes, but not always. Other ethical principles are at play in combating stigma and discrimination. These must be acknowledged.  The most obvious is autonomy, the right to choose from a variety of options. One such option is deciding not to be included.

Let’s look at a dramatic example, persons with psychiatric disabilities living on the street. They might be ‘included’ but for lack of facilities or poor treatment outcomes. While some tragically slip through the health care net, others choose not to receive care. Of the latter group, we more often than not honor their decisions and make little or no attempt to coerce them into therapeutic programs or designated housing. Now the ethical question looms before us: Do we insist they be ‘included’
or do we respect their right to live as they choose? I see little argument against exercising choice. Inclusion is good sometimes, but not always. The courts agree.

Now let’s take a less extreme example, but one falling within the same moral logic. The principle of autonomy also covers those who select residences especially designed for their care. Whether living in halfway houses or larger facilities, people often pick a segregated domicile where they feel protected and thus function more successfully. They represent another class of the dis-included as they choose to live a life separated from ‘the normal.’ I also respect that choice. 

Simply put, some wish to be included in a heterogeneous community and others do not. And both groups have legitimate claims and justifications, but based on different moral principles. Inclusion stems from rights of equality, while separatists exercise autonomous choice. Two principles are at work, and they do not conflict if one accepts plurality of values.

With the inevitable mixture of ethical principles at work, we must find the proper balances of individual rights as determined by the needs and desires of citizens. And if we have a single moral principle that grounds the others, I suggest it is freedom of choice. So, to strike out against so-called segregationist policies solely on the basis of political utility and gamesmanship strikes me as both a wrongful imposition of values and harmful to the welfare of those who choose to live apart.

Let different voices sing in the choir and may we find harmony among them. The advocacy of a single position narrowly conceived can only restrict options of the entire population at risk. No one should deny the full range of options to anyone, especially those who would assert their freedom of choice. Let us not confuse political expediency for ethics.  Inclusion for some, separation for others. Let choice reign supreme.

Dr. Alfred Tauber is a physician and advocate for the rehabilitation of the mentally ill, where he has sponsored programs in Boston and Israel.  The thesis presented here is more fully developed in his Patient Autonomy and the Ethics of Responsibility (MIT Press, 2005).
 

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