Discrimination against unmarried adults has been well documented with respect to such issues as taxes, conditions of employment, and political rhetoric. Less well understood is discrimination affecting medical decisions that may be — literally — a matter of life or death.
Since the 1980s, dozens of studies[1] in peer-reviewed medical journals have demonstrated that patients receiving cancer care in the United States are significantly more likely to survive if they are currently married than if they are widowed, divorced, or never married. A likely contributor to that discrepancy in survival is a notable disparity in treatment. Compared with married patients, those who are unmarried are significantly less likely to receive surgery or radiotherapy, even when researchers account for such factors as age, income level, stage of cancer, and tumor characteristics.
Among the most common speculations offered by medical researchers to explain the association between marital status and aggressive cancer treatment is the assertion, presented without evidence, that unmarried patients lack the will to live[2] — or as some researchers phrase it, they lack “a fighting spirit.”[3] As a result, these researchers claim, unmarried patients do not want, and cannot tolerate, challenging cancer treatment. Moreover, these medical researchers assert — again without evidence –that single adults are not good candidates for surgery or radiotherapy because of their tendency to be depressed, socially isolated, or unable to follow medical instructions. Entirely lacking is any glimmer of recognition that physicians who share the same cultural biases that influence this body of medical literature might be more likely to offer surgery or radiotherapy to a patient who is married than to one who is unmarried.
Even articles published in prestigious medical journals[4] present social biases as self-evident facts requiring no authentication. When sources are cited at all, they usually fall into one of three categories: earlier medical articles making similarly unsubstantiated claims; studies that demonstrate the importance of something like mental health or the ability to follow instructions, with nothing to validate the belief that unmarried adults are necessarily deficient in these areas; or studies demonstrating the importance of social support. Since these medical researchers explicitly equate social support with marriage, they misinterpret research based on broad-based, multifactorial social connectedness as if it proved the unique importance of marriage. Ironically, some of the psychological and sociological studies most often cited in these medical articles explicitly deny[5] that any one type of relationship can be used to define social support. Indeed, some of them[6] do not even mention the words “marriage,” “marital,” or “spouse.”
The most probable explanation for this blatant misuse of sources by otherwise competent researchers is confirmation bias: a heuristic, or mental shortcut, that predisposes individuals to undervalue or ignore evidence that conflicts with their preconceived views. Consider, for instance, a study[7]of almost a million patients conducted by researchers at top cancer centers, some of whom had previously co-authored articles attributing the undertreatment of unmarried patients to the patients themselves. These researchers drew on a massive National Cancer Institute database to determine, among other things, how many married patients and how many unmarried patients declined surgery or radiotherapy when those treatments were offered to them. The results showed that 0.52 percent of unmarried patients and 0.24 percent of married patients declined surgery, while 1.33 percent and 0.69 percent, respectively, declined radiotherapy.
In a jaw-dropping example of confirmation bias, the authors of this study ignored the salient fact that more than 99 percent of unmarried patients accepted surgery when it was offered, and more than 98 percent accepted radiotherapy. Rather, the difference of less than one percent between unmarried patients and married patients in a direction that aligned with the researchers’ pre-existing bias was trumpeted as a major outcome of the study. Totally overlooked was the unwelcome reality that refusal rates of less than 1 percent or 2 percent make nonsense of the often repeated claim that unmarried patients as a group do not want aggressive cancer treatment.
Although my own research has focused on the United States, evidence suggests that the same biases affect cancer treatment elsewhere. As an example, Nina Cavalli-Bjorkman, an oncologist at Uppsala University in Sweden, has documented the stereotyping of single patients[8] in Scandinavian cancer care. Also of concern is a statement by the Canadian Cancer Society entitled “If You Are Single and Have Cancer.” In language so patronizing that it could almost be mistaken for a parody, this statement offers solace and simplistic advice to poor, lonely singles. It acknowledges neither that many single adults have strong support networks, nor that some patients who lack practical or emotional support are married. As a result, a well-intentioned effort to assist cancer patients who feel alone is limited in its usefulness by the conflation of social support with relationship status. In addition to relying on an overgeneralized and outdated understanding of contemporary single life, the statement implies that married adults are not expected to have issues with social connectedness, whereas some of them might truly need help in this area.
Even if unintentional, the negative bias toward unmarried patients reflected in this medical literature is deeply harmful. So powerful is the underlying cultural ideology that not only medical authors, but peer reviewers and editors, fail to notice any difference between the actual results of a medical study and the unsubstantiated speculations of its authors, based on social beliefs that lie far outside their field of expertise. As a result, stereotypes of single life that have been thoroughly debunked[9] by extensive psychological and sociological research continue to flourish in publications intended for physicians who determine which patients are, or are not, appropriate candidates for lifesaving cancer treatment.
About the author
Joan DelFattore, Ph.D., is a professor emerita at the University of Delaware. She is the author of three books published by Yale University Press as well as dozens of articles about freedom of speech. Since 2016, she has been publishing about the choice to live single in a couples-oriented culture, particularly with respect to health care. Her articles have appeared in the New England Journal of Medicine, the Washington Post, the Philadelphia Inquirer, and Psychology Today, among many others.
[1] DelFattore J. Death by stereotype? Cancer treatment in unmarried patients. N Engl J Med 2019;
381:982-985 DOI: 10.1056/NEJMms1902657.
[2] Wang L, Wilson SE, Stewart DB, Hollenbeak CS. Marital status and colon cancer outcomes in U.S. Surveillance, Epidemiology and End Results registries: does marriage affect cancer survival by gender and stage? Cancer Epidemiol 2011;35:417-22.
[3] Liu L, Chi Y-Y, Wang A-A, Luo Y. Marital status and survival of patients with hormone receptor-positive male breast cancer: a Surveillance, Epidemiology, and End Results (SEER) population-based study. Med Sci Monit 2018;24:3425-41.
[4] Aizer AA, Chen M-H, McCarthy EP, et al. Marital status and survival in patients with cancer. J Clin Oncol 2013;31:3869-76.
[5] Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: A meta-analytic
review. PLOS Med 2010;7:e1000316. doi:10.1371/journal.pmed.1000316.
[6] Uchino BN. Social support and health: a review of physiological processes potentially
underlying links to disease outcomes. J Behav Med 2006;29:377-87.
[7] Aizer AA, Chen M-H, Parekh A, et al. Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiation Oncol Biol Phys 2014;89:756-64.
[8] Cavalli-Björkman N, Glimelius B, Strang P. Equal cancer treatment regardless of education
level and family support? A qualitative study of oncologists’ decision-making. BMJ
Open 2012;2:e001248. doi: 10.1136/bmjopen-2012-001248.
[9] DePaulo, B. The social lives of single people. Living Single. Psychology Today, 17 May 2019.
