Joan DelFattore, Ph.D.
Professor Emerita, University of Delaware
“You have no husband?” asked the oncologist, his voice full of concern. “No,” I replied. Nor do I have children or other immediate family. “Then how will you manage?” he exclaimed.
The answer was a strong network of friends, cousins, colleagues, and neighbors — but when I tried to tell him that, he interrupted to describe the treatment he had in mind. Although the standard of care was combination chemotherapy, and I was healthy except for the cancer, he proposed to give me just gemcitabine to avoid harsh side effects with, as he put it, “someone in your situation.”
As a baby boomer who’s been single by choice all my life, I’m no stranger to the stereotyping of unmarried adults. Still, I’d naively assumed that medical care would be a safe harbor, and it came as a shock when that oncologist couldn’t envision functional support outside traditional family structures. I was outraged and frightened by his belief that in my case, although perhaps not in the case of a patient with a family, it was more important to minimize side effects than to provide the most effective chemotherapy.
The risk of undertreatment was life-threatening, because I’d been diagnosed with stage four gallbladder cancer, which had a two-year survival rate of about 2%. I’d found a surgeon willing to operate despite the high risk of recurrence, and he’d removed all the visible tumors. Still, microscopic cancer almost certainly remained, and I needed the best possible chemotherapy to have any chance of preventing a recurrence. It was thus a great disappointment when the medical oncologist I consulted, as soon as I’d recovered from surgery, proposed to give me just gemcitabine. His refusal even to discuss friend-based support was especially frustrating after the surgeon had readily accepted it, and it had worked well as I recovered from the operation.[youtube https://www.youtube.com/watch?v=b8qJ6Nhz6LM&w=640&h=360]
I promptly moved on to a different oncologist, who, I later learned, had lived on her own for years before marrying. She focused on the specific services I would need, and satisfied that competent adults would provide them, she gave me gemcitabine and oxaliplatin. Although the side effects were indeed challenging, I got through it with the help of my friends.
All of that happened in 2011, and so far there’s been no recurrence. Of course, I’ll never know what the outcome would have been with just gemcitabine, but certainly my chances would have been lower.
Being an experienced researcher, I felt impelled to learn just how common it is for physicians’ social beliefs to influence the treatment of patients with non-traditional support systems, and the results of that research recently appeared in theNew England Journal of Medicine. Since the data I found apply specifically to marital status, further research is needed to explore related issues, such as living alone and the absence of immediate family. But here’s what we do know.
First, cancer patients who are currently married are significantly more likely to receive surgery or radiotherapy than those who are divorced, separated, widowed, or never married.
Second, that’s not a shocking new discovery. Between 1987 and 2019, dozens of medical articles have reported a significant association between marital status and treatment rates. Those statistics are drawn from the Surveillance, Epidemiology, and End Results (SEER) program, a National Cancer Institute database that tracks millions of patients.
Third, the significance of that discrepancy in treatment rates has been obscured for more than thirty years by medical researchers’ unsubstantiated social assumptions.
To take one example, medical researchers routinely speculate, without evidence, that unmarried adults lack a “fighting spirit” and have less will to live, and thus prefer to avoid challenging treatment. But according to a study of almost a million cancer patients, only 0.52% of unmarried patients declined surgery when it was offered, and 1.33% declined radiotherapy. Although the results for married patients were even lower, unmarried adults cannot be considered likely to refuse treatment based on rates below 1% and 2%.
Another common explanation for the undertreatment of unmarried cancer patients is that the absence of a spouse signifies a lack of social support. In attempting to justify that conflation, medical researchers mistakenly interpret psychological and sociological studies of multifaceted social support as if they applied solely to marital status, even when the studies themselves explicitly repudiate single-factor assessments of social support. Ironically, some of the studies most frequently cited to support the primacy of marriage don’t even mention the words “marriage,” “marital,” or “spouse.”
In reality, research shows that many unmarried adults are far from isolated, with more friends, closer relationships with extended family, and stronger community ties than spouses tend to have; and support from those sources can be very effective.
Of course, some patients really are too socially isolated to handle challenging treatment, but conflating that condition with unmarried status conflicts with the evidence. Moreover, as Bella DePaulo and I pointed out in an earlier Health Psychologist article, marriage does not guarantee access to medical caregiving. Spousal support varies with marriage quality, and women are less likely to be available for 24/7 caregiving than they once were. Spouses may be self-employed or paid only when they work, or they may have health problems or other responsibilities — or they may simply be unable to cope.
Clearly, a better approach would be to ask all patients about their access to such services as rides, meals, in-home caregiving, and emotional support. When I’ve made that suggestion to groups of physicians, a frequent objection has been that appointments are already too short and burdened with mandatory check-offs. But imagine, if you will, an older adult male patient with a history of smoking, heavy drinking, and obesity who needs a medication that can’t be given to diabetics. No reputable physician would withhold the medication on the untested assumption that the patient’s history may suggest diabetes. Rather, the physician would order a blood panel and review the results as a matter of course, even though that process would take at least as much time as it would to ask about a patient’s access to functional or emotional support.
So the point, really, is not whether there’s time to ask particular questions, but whether they seem necessary; and some providers may perceive that need only with respect to physical conditions. But when inaccurate assumptions lead to withholding optimal treatment from a patient who could have handled it, that patient suffers the same harm regardless of the nature of the assumptions.
Given these complexities, how might health psychologists contribute to a solution? An obvious suggestion is to advocate for objective assessment of functional and emotional support when that’s relevant to medical decision-making — for instance, with respect to organ transplants. Moreover, many medical schools have courses about implicit bias, sometimes taught or influenced by health psychologists. Such courses should address non-traditional support systems, as should continuing education programs, discussions of institutional policies, and other venues where implicit bias is relevant.
Health psychologists could also encourage and conduct research into this form of implicit bias and its impact on patients, including not only marital status but also living alone and the absence of immediate family.
More fundamentally, health psychologists could help physicians understand how implicit bias actually works. Psychiatrist Jonathan Metzl, director of Vanderbilt University’s Center for Medicine, Health, and Society, observed in an interview that physicians may mistakenly view implicit bias as a source of blame and shame, to be remedied by an act of will. Rather, he suggested, it should be recognized as a normal element of human cognition, allowing physicians “to get [biases] out on the table, talk about what’s influencing a particular decision. It’s good to be self-aware of one’s own assumptions.”
In pursuit of that goal, health psychologists might raise awareness of specific mental shortcuts, or heuristics, likely to influence attitudes toward non-spousal social support. An example is the availability heuristic, which involves disproportionate reliance on what comes most readily to mind, including personal experience and cultural perspectives. That heuristic surfaced in interviews I conducted with authors of medical articles documenting the association between marital status and cancer treatment. When I asked open-ended questions about their understanding of social support, most responded by describing how their wives motivated them to seek medical care. One quipped, “Nagging wives save lives.” They gave no sign of recognizing that they’d substituted an easier question — “What is your own source of social support?” — for more complex questions involving their understanding, or even their awareness, of factors remote from their own experience.
Another heuristic that regularly appears in the medical articles I examined is outgroup homogeneity — the tendency to see members of an outgroup as sharing similar characteristics. It’s related to the representativeness heuristic, in which people think in terms of stereotypes without considering the size of the relevant population. Given that 45% of U.S. adults are unmarried, no undifferentiated, stereotyped portrayal can possibly be a useful way of thinking about almost half the adult population.
Without doubt, social connectedness is a legitimate concern in determining medical treatment, and it needs to be objectively assessed in all patients, regardless of marital status. As researchers, teachers, and members of treatment teams, health psychologists are uniquely placed to reduce the potentially life-threatening risk of undertreatment associated with the absence of a spouse.