This paper examines a paradox arising in connection with an underexamined form of discrimination: socioeconomic discrimination. Recent evidence from the United States suggests that discrimination on basis of social class in health care delivery is common. Patients from poorer backgrounds, for example patients receiving care paid for by welfare programs, receive lesser quality care. Should such class discrimination be legally regulated?
It is generally believed that economically left- and right-wing convictions can unite in condemning paradigmatic forms of direct and indirect discrimination, e.g., race/caste/sex discrimination. However, we challenge this picture. We argue that it is difficult to condemn paradigmatic forms of direct discrimination and at the same time embrace the sort of economically regressive policies that in effect amount to indirect discrimination against the poor. This includes the myriad of policies which exacerbate unfair social determinants of health ranging from housing policies, infrastructure policies, education policies to health policy. Our argument appeals to the fact that each of the following three claims seem appealing:
P1. Paradigmatic discrimination should be prohibited by law.
P2. If direct paradigmatic discrimination should be prohibited by law, then so should indirect paradigmatic discrimination.
P3. If indirect paradigmatic discrimination should be prohibited by law, then so should indirect socioeconomic class discrimination.
However, together they entail a very radical claim:
C. Hence, indirect socioeconomic class discrimination should be prohibited by law.
C would allow for substantial litigation on health policy and social policy more broadly – in effect it would allow for many policies causing social gradients in health outcomes to be challenged. Our main aim is not to defend C, but to show that we need to respond to it in one way or another which for many will require significant revisions of their beliefs.
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