Single With COVID-19: Will You Get the Treatment You Need?

Will patients with partners get priority for coronavirus treatment?

Posted Mar 22, 2020

We are living in the age of the coronavirus pandemic. It can be a frightening time for anyone. It is possible that people who are not married face a risk that married people do notthat if they have symptoms of COVID-19, they will not receive the treatment they need.

The scholar who has done the most important work in demonstrating potential biases against single people in the health care system is Joan DelFattore. Her findings have appeared in the most prestigious medical journal and in other influential publications. We don’t know yet what is going to happen to single people as cases of COVID-19 increase and resources continue to be stretched to the limit. I am grateful to DelFattore for sharing her ideas with us, and offering some suggestions for how single people can improve their chances of being treated fairly.

Single with COVID-19: Will You Get the Treatment You Need?

By Joan DelFattore, Ph.D.

As coronavirus dominates the headlines, we don't yet know how, or whether, marital status will affect priority for treatment. There's reason to raise the question early on, though, because extensive research shows that medical decisions may be influenced by providers' personal attitudes toward marital status, as well as toward such characteristics as race, ethnicity, gender, age, and weight.

By no means is this an attack on the medical profession, whose members are addressing the present crisis under extreme pressure and at great personal risk. To the contrary, as psychiatrist Jonathan Metzl attests, open dialogue on this topic serves not only patients, but also medical professionals who genuinely seek to provide equitable care.

Metzl, an expert on medical bias who directs Vanderbilt University's Center for Medicine, Health, and Society, pointed out in an interview for a story in the Washington Post that unthinkingly acting on the basis of one's personal beliefs is “inherent in human interaction, and believe it or not, doctors are human too.” It is thus counterproductive to treat that aspect of human nature as a taboo subject, as if medical professionals should somehow be exempt from it, or feel shamed if they are not. As Metzl expressed it, the healthiest approach is this: “Get it out on the table, talk about what’s influencing a particular decision. It’s good to be self-aware of one’s own assumptions.”

Lessons from the Past: Grim Findings from Oncology

In that spirit, let's look at what we already know about associations between marital status and medical care. The best evidence to date comes from a massive database maintained by the National Cancer Institute, which tracks millions of cancer cases by, among other things, the patient's marital status. These data show that cancer patients listed as currently married are more likely to receive surgery and radiotherapy than those who are divorced, separated, widowed, or always single. In itself, that finding is not news, nor is it in dispute. As I pointed out in a New England Journal of Medicine article, dozens of studies published since 1987 document the systematic undertreatment of unmarried patients, even when researchers control for things like age and the stage of the cancer.

The authors of those studies—including those published as recently as 2019—speculate that unmarried adults are less likely to receive aggressive treatment because they couldn't handle it. Among the suggested reasons are depression, mental illness, alcoholism, drug use, nonadherence to instructions, lack of anything to live for, and social isolation. As regular readers of Living Single will recognize, these unsupported speculations conflict with a large body of sociological and psychological research. And yet, medical researchers continue to present them as credible explanations for a well-documented pattern of undertreatment, without considering the very real possibility that those same assumptions about unmarried adults might affect physicians' judgments about what treatments to offer.

Of course, not every unmarried cancer patient is undertreated. I received aggressive care myself—but only after I walked away from an oncologist who declined to provide it because of my single status. Similarly, although some unmarried adults do receive organ transplants, recent research suggests that singlism may be an obstacle in some cases. In a culture as uncompromisingly marriage-centered as ours has traditionally been, it's not surprising that some individuals who work in health care absorb and reflect singlist attitudes.

The Coronavirus Pandemic: What Might the Future Hold?

And now here we are, at the beginning of a pandemic that may stress our medical system to the point of rationed care. Although no guidelines have yet been written specifically for coronavirus, existing disaster guidelines discourage the use of factors such as race, sexual orientation, and perceived quality of life in allocating medical resources. Nevertheless, it's not inconceivable that some medical decision-makers might feel justified in giving preference to patients based on marital status and family relationships, without stopping to consider that single adults may be major contributors to the larger community and primary caregivers for friends and extended family, as well as having lives that matter. In that scenario, not only would some individuals be branded as relatively disposable, but they may even be blamed for daring to assert their right to equal treatment as fellow humans.  

What Can We Do About It?

What, then, should unmarried adults do if they fall seriously ill? The advice most commonly offered is to bring someone along to medical appointments, but that's problematic for some singles at any time, and during a pandemic we might hesitate to expose others to infection. Perhaps technology, which is facilitating telemedicine and at-home employment, might help here as well. Until self-driving cars are perfected, human contact is essential if we need a ride. But Skype or a cellphone on speaker would allow another person to keep us company without leaving their home, not only to take notes and know what's going on, but also to demonstrate to medical providers that someone cares about us.

Another possibility is to learn as much as possible about the standard treatment for a particular condition. Of course, there might be good reasons for deviating from the standard, or we could be mistaken about what's wrong with us. All the same, having that information can lead to more productive conversations with medical providers about what they're recommending.

With respect to coronavirus in particular, treatments are likely to keep changing as physicians learn more about this disease. Perhaps the best we'll be able to do is to ask why a particular course of action is being proposed, or not proposed: for instance, testing, hospitalization, or treatment. We might also seek clarification on what the alternatives would be, and why those alternatives are not being recommended. Since someone with a serious case of coronavirus might be unable to carry on a discussion, it might be a good idea to discuss these concerns in advance with a friend, and suggest acting as each other's advocate if the need arises.  

As part of the research for an earlier article, I asked social workers at three hospitals what advice they'd offer single patients who require inpatient care. Acknowledging that singlist attitudes do exist, all three suggested contacting the hospital's social workers or patient advocates in advance, to ask advice and get them involved. For office visits, it might be worth opening a similar dialogue with a nurse practitioner or physician assistant. Those connections could be particularly important if individual workers seem to be ignoring legal requirements or official hospital policy.

My final suggestion is a matter of personal philosophy, offered for whatever it may be worth. To me, it's important to find the right balance between two extremes: excessive deference and fear of offending on the one hand, and hair-trigger resentment and defensiveness on the other. Having needed more medical care in the last few years than I would have liked, I've lost count of the number of times health care workers have expressed singlist assumptions. When I push back, as I don't hesitate to do, those attitudes rarely prove to be either intentional or irreversible. To me, these issues need to be aired, respectfully and without rancor, both in research and as they arise in real life. It's also critical to find alternatives when persistent singlism threatens actual harm.

If there's a perfect solution, I don't know what it is. I thus offer information and suggestions not as a final answer, but to start a conversation, while looking forward to hearing what others think.

About the author

Joan DelFattore is a professor emerita at the University of Delaware. She published three books with Yale University Press about freedom of speech, and now writes about issues facing unpartnered adults in American health care. Follow her on Twitter @joandelfattore.