Shame, Blame and Cultural Humility

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In recent posts (Cultural Humility and Language and Cultural Humility) I shared that cultural humility begins with recognizing our own silent assumptions that act as blinders. These blinders can inhibit the way in which we glimpse the world through the eyes of others. At times they can cause us to blame patients, shaming individuals in the process.

The blinders of health care which can lead to blame and shame derive from a fundamental cultural assumptions of Western culture– I am in charge and thus have personal responsibility for all aspects of my life. How do these assumptions show up in health care and how do they at times cause blame and shame?

Consider how you think about the relationship of lifestyle to prevention and wellness. Our language related to illness, as I wrote about in “Language and Cultural Humility” tends to make use of military metaphors – health care battles disease. In contrast, when we think about prevention we tend to use a personal responsibility framework embodied in the term “lifestyle choices.”

We assume based on ample evidence that eating the right food in the right amount and exercising regularly prevents problems such as obesity, high blood pressure and heart disease. Don’t get me wrong – focusing on how changes in lifestyle can prevent health problems is useful, but too often we move beyond the evidence and invoke the personal responsibility blinders embedded in the term “lifestyle choices” to judge those who are overweight, smoke or lead sedentary lives. We reason that if regular exercise and a good diet help prevent health problems, and if everyone is personally in control and responsible for their behavior, than obesity or other “evidence” of not following an “ideal lifestyle” must flow from weak-willed lack of disciplined choices. This structure of thinking is equivalent to viewing obesity as a character flaw which then leads to blame and shame.

“Lifestyle choices” represents our Western cultural blinders of control and personal responsibility. We silently say to ourselves that “it is all about the choices we make.” The term also reflects biases flowing from a culture of affluence. We silently assume that everyone can afford fruits and vegetables rather than macaroni and cheese or that regular exercise need not need compete with more basic needs to make it day to day.

I do not intend to diminish “agency,” the sense that our decisions matter. I am suggesting that “agency,” though important, can act as a cultural blinder leading to judgment, shame and blame.

Avoiding the judgmental shame/blame trap implicit in “lifestyle choices” requires us to recognize our deep- seated cultural biases and to replace judgment with curiosity. As an example, the personal responsibility framework is one of many ways to view prevention issues. Like other frameworks it is not right or wrong, rather simply more useful (when it helps prevent health problems) or less useful (when it leads to judgmental blame). Another alternative viewpoint to personal responsibility is that obesity is a species problem which develops from humans being separated from the cycles of famine that marked most of our history. In this viewpoint, humans developed metabolic defenses to cope with famine and now that we have have moved beyond the environment for which we evolved to handle, obesity occurs.

Do you at times judge yourself or others for what you consider ‘lifestyle choices”? Reading this blog, do you find yourself irritated and wanting to assert: “but prevention is about choices and personal responsibility”? (If so, you may have a cultural blinder). Please use comments below to describe your deep-seated cultural biases.

6 thoughts on “Shame, Blame and Cultural Humility”

  1. David, you are discussing a really important topic regarding culture and personal behaviors that we are sure is completely the fault of the patient (eating excessive calories, not enough exercise, etc.). Tuberculosis, seizures, and many other illnesses were also previously blamed on the patient. Allopathic medicine is basically a dominator, parent/child model, and that model works fine with acute care problems (such as acute infections, appendicitis, CVA, and MI). But for us to continue to use that model with chronic problems – rather than a collaborative, adult/adult model – is probably a significant oversight in today’s healthcare system.

    1. Thank you Bill. Perhaps our biggest cultural blinder (outlined in my blog entitled Cultural Humility) relates to the medical/Western/Cartesian mind- body split

    1. Thank you Brock. The link you sent is an interview with JD Vance about his book, Hillbilly Elegy. I just finished the book this weekend. Amazing book that helped me to understand a perspective quite different than my viewpoint. I think it is a very important book to read- particularly given the divides in our country

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