The bias against single people that I call “singlism” is pervasive. The stereotyping, stigmatizing, and marginalizing of single people, and the discrimination against them, shows up in the workplace, the marketplace, the classroom, and the boardroom; in politics, the military, and in the laws of the land; in places of worship, in psychotherapy, and in the medical establishment; in advertising, popular culture, and in everyday life.
Often, though, when I talk about singlism, other people are dismissive. They say it doesn’t really exist and even if it does, it is no big deal. Well, it does exist, and sometimes it is a very big deal. A just-published series of three studies suggests that in the realm of medical decision-making, it may even be a matter of life and death.
The studies, reported in the article “Marital privilege: Bias against divorced patients in medical decision-making” in the journal Group Processes & Intergroup Relations, were about adding patients to organ transplant lists and whether people use marital status as a factor in deciding whether a patient should get included on a list. They do use it, and in a very prejudicial way. They recommend married patients for the transplant list more than divorced patients or patients who show up for an evaluation appointment without a spouse or an ex-spouse.
In the studies, Satia A. Marotta and Keren Ladin of Tufts University created biographical sketches of different patients. That way, the married, divorced, and single patients could be described in ways that were identical except for their marital status. For example, all the patients were deemed medically suitable for a transplant. None of them had substance abuse issues or mental health illnesses and all had health insurance. In those key ways, and others as well, the divorced and single patients were just as qualified for the transplant as the married patients. But they were not as likely to be recommended for the transplant, nor were they considered as deserving as the married patients.
In the sections that follow, I will describe in more detail how the studies were conducted, what the authors found, and how, in my opinion, we should think about the findings.
How the Studies Were Conducted
In three studies, participants read a story about a 42-year-old patient who wants to get a kidney transplant. In the story, the patient arrives at the transplant-evaluation appointment either with a spouse or an ex-spouse, or the patient is dropped off by a friend who does not stay. That’s how participants learn that the patient is either (1) married, (2) divorced, or (3) perhaps is single and has never been married (though that is only implied).
The Story about the Patient Needing the Transplant
Except for the mention of marital status (and in some of the studies, the patient’s gender, race, or employment status), the stories about the patient were always the same. Using the female patient as an example, she is always described as someone who has already been cleared by the medical team as medically fit for a transplant. She has no history of substance abuse or mental illness. She has health insurance. She asked a lot of questions during the appointment and was optimistic about the transplant, even knowing that it could take years to get one even if she did get listed.
She needed a transplant because she got hit by a car five years ago while jogging near the local university. She experienced chronic, severe knee pain and the painkillers she was prescribed damaged her kidneys. She wanted to resume her active lifestyle.
In the story, she arrives 30 minutes late, and apologizes, saying that the person who drove her had to work later than expected. Regardless of whether the patient was described as married, divorced, or whether no spouse or ex was mentioned, it was noted that she “is very independent and prefers not to be a burden to others” and that she has “a neighbor who is willing to help her with picking up prescriptions, travel to appointments, and meal preparation.”
How the Stories Differed, Other Than the Marital Status of the Patient
In one of the studies, the patient was always a woman and her caregiver, if any, was a man. In another study, the patient was a woman in half of the stories and a man the other half; the caregiver was always someone of the other sex. In a third study, the patient was always a woman, but her race and employment status were varied. Half the time she was described as White, the other half as Black. Within each of those categories, half the time she was described as employed and the other half as unemployed. In that third study, it was noted that the patient’s friends and family members hosted a fundraiser and raised $10,000 to help with her medical expenses. The third study did not include the patient who apparently had no spouse or ex-spouse. Participants judged only married or divorced patients.
Who Were the Participants?
Participants in all three studies were recruited using Amazon’s Mechanical Turk, a crowdsourcing website. In the first study, 397 people participated; 400 participated in the second and 512 in the third.
In each of the studies, about a third of the participants were married (33%, 38%, and 32% in studies 1, 2, and 3 respectively). The smallest percentage were divorced (22%, 5%, and 10%). The others were single and had never been married (32%, 43%, and 42%).
The average age of the participants was 39 in one of the studies and 37 in the other two. There were about the same number of women and men in two of the studies, and more women than men in the third. In two of the studies, most of the participants were White (77% and 75%). In the third, 54% of the participants were White, 41% were Black, and the others were from a variety of different groups.
The Judgments the Participants Were Asked to Make about the Patient and Caregivers
Each participant read just one of the stories. Afterwards, they recorded their judgments. Most importantly, they indicated their degree of agreement with these two statements:
- “The patient whose profile I reviewed deserves to be added to the waiting list.”
- “I would recommend that the patient whose profile I reviewed be added to the transplant waiting list.”
Participants were asked about their impressions of the support the patient had. Specifically:
- “How much do you agree that the patient has adequate social support?”
- “How concerned would you be about their ability to care for an organ if they were granted a transplant?”
- “How durable do you perceive the patient’s relationship to their caregiver to be?”
In addition, participants indicated their perceptions of how responsible, punctual, appreciative, competent, personable, mentally healthy, and financially stable the patient seemed to be. They indicated how engaged the patient seemed to be in the process, and how knowledgeable they seemed about the transplant process. Answers to all those questions were averaged together to create a measure of the patient’s overall competence. Participants who read about a married or divorced patient were asked the same questions about the spouse or ex-spouse. Again, the answers were averaged to create a measure of the caregiver’s overall competence.
About the patients, the participants were asked, “how concerned would you be about their ability to care for an organ if they were granted a transplant?”
The Findings from the Studies
In response to just about every question, participants privileged the married patients over the unmarried ones. The stories about the married, divorced, and single patients were identical except for their marital status, but the married patients were consistently favored and given the benefit of the doubt.
Who Got Recommended for the Transplant List?
The most important results were about the recommendations for adding patients to the transplant waiting list. Averaged across the three studies, the married patients were more strongly recommended for the transplant list than the divorced patients. Patients who were presumably single (they showed up to their evaluation appointment without a caregiver) were only included in the first two studies. The married patients were favored over them, too. Interestingly, the divorced patients were no more likely to be recommended for the transplant list than the single patients.
The question of whether the patient deserved to be on the waiting list was similar to the question of whether the participant would recommend the patient for the waiting list, and the results were similar, too. Again, the married patients were considered more deserving than everyone else, and the divorced patients were not judged as any more or less deserving than the single patients.
In one of the studies, the patient’s race was specified as either White or Black. When participants were judging White patients, they saw the married patients as more deserving of the transplant than divorced patients. When they were judging Black patients, though, they did not see any difference in deservingness between the married and divorced patients.
Also in just one of the studies, the patient was described as either employed or unemployed. The employed patients were more strongly recommended for the transplant list and they were judged as more deserving of the transplant. This bias occurred despite the fact that many patients who need a transplant may be too ill to work.
Who Was Judged as Having Social Support?
Across the three studies, the married patients were judged to have the best social support. In the two studies that included patients who were single, they were presumed to have the least adequate levels of social support. Divorced patients were believed to have less support than married patients, but more than single ones.
When asked about the durability of the patient’s relationship to the caregiver (spouse or ex-spouse), participants judged the married patients as having a much more durable relationship than the divorced patients.
The married patients were also judged as having more competent caregivers. Even though the stories describing the married and divorced patients were identical except for their marital status, participants thought the spouses were more competent, responsible, punctual, appreciative, personable, mentally healthy, financially stable, engaged, and knowledgeable (when all those judgments were averaged together) than the ex-spouses.
Which Patients Were Judged as Most Competent?
When asked about their concerns about the patient’s ability to care for the organ if they got the transplant, participants were less worried about that for the married patients than for the unmarried ones. For the other measure of competence (the one that averaged over judgments of responsibility, punctuality, and so forth), the married, divorced, and single patients were all evaluated about the same.
Just How Much of a Bias Are We Talking About?
Imagine if the overall chances of any one person getting put on the transplant list were 50-50. (They aren’t – it is just easier to use that assumption to understand the degree of bias.) Results from the three studies suggest that married patients would have a considerably better chance of getting on the transplant list – about 57% instead of just 50%. The divorced patients would have a notably lower chance – about 43% instead of 50%.
(For the statistically inclined: I came up with these percentages by using the effect size of d = .27 for the difference between married and divorced patients, and converting it to BESD, the binomial effect size display, as described by Robert Rosenthal. The effect sizes for comparisons of the single patients to the married or divorced patients were not reported, so I could not come up with comparable estimates for them.)
But the Participants in the Studies Don’t Make the Actual Transplant Decisions
As important as I believe this research to be, I would be even more impressed if the participants making the judgments included the people who really do make the decisions – or the rules – about who gets transplants. Marotta and Ladin note that “in transplant centers, listing decisions are often made in group meetings consisting of transplant surgeons, social workers, and specialists, and cover several patients.” The participants in the three studies, though, were ordinary people, not recruited for their expertise in medical decision-making.
Would the results of these studies generalize to actual transplant decision-makers? Research on singlism suggests that the stereotyping and stigmatizing of single people, and discrimination against them, is not limited to people of particular ages, genders, countries, or even marital statuses. Often, singlism is practiced unselfconsciously and unapologetically. Even more relevant are indications that medical professionals may be biased against single people, and in the particular ways underscored as significant in these transplant studies – doctors seem to assume that single people do not have social support and married people do. My fear, then, is that the people who make decisions about transplants are in fact biased against single people.
What Matters, Marital Status or What People Associate with Marital Status?
To try to understand more about what’s going on when people privilege married patients over divorced patients in their recommendations for transplants, the authors conducted what is called a “mediation analysis.” They already knew that married patients were seen as having more adequate social support than divorced patients. They also knew that the married patients’ relationship with their caregiver was seen as more durable, and that the married patients’ caregivers were seen as more competent. In addition, they knew that the participants were less concerned that the married patients might engage in problematic behavior in the future.
The next step was to see whether those perceptions were linked to transplant recommendations. They were. When participants thought that a patient had more adequate social support, they were more likely to recommend that the patient be added to the transplant list. When they thought the patient’s relationship with their caregiver was more likely to endure, and when they thought the caregivers were more competent, they were more likely to recommend the transplant. And when they were concerned that the patients might not do a good job of caring for their organ in the future, they were less likely to recommend the transplant.
Once all those different factors were taken into account, marital status no longer mattered (at least with regard to the comparison of married patients to divorced patients – the single patients were not included in these analyses). That means that what was important was not marital status per se, but what the participants associated with it. They thought that married people had better social support, a more enduring relationship with their caregiver, and a more competent caregiver, and they thought married people would behave better in the future. It was for those reasons that the participants were more likely to recommend the married patient than the divorced patient for the transplant.
Organs Are Scarce, So Why Not Use Social Support as a Criterion, and Marital Status as an Indicator of Its Availability?
Among the official criteria for whether patients will qualify for a transplant is their level of social support. In a different study, Keren Ladin and her colleagues estimated that about 10% of patients are excluded from transplant waiting lists because they are deemed to have inadequate social support.
Importantly, there is no standardized measure of social support used in the evaluation process. Instead, what counts is the judgment of the person doing the evaluation – probably a social worker, psychiatrist, or psychologist. Most likely, those mental health professionals have the same biases as the participants in the three studies I’ve been describing. They probably think that married people have the best social support, and single people the worst, with divorced people in between.
The tragic irony of that belief is that it is probably exactly wrong. When I reviewed dozens of studies comparing the social ties of single people to those of married people, I concluded:
“Compared to married people, single people have more friends and bigger social networks. They do more to maintain their relationships with their friends, relatives, neighbors, and coworkers. They also get more happiness and emotional fulfillment from the time they spend with their friends and relatives.”
It is true, of course, that friends, relatives, neighbors, and coworkers are not obligated to be there for one another in times of need the same way spouses are. The norms and expectations are different. Couples often look to each other – and sometimes no one else – when they need help. But there are risks to that insularity. It can be difficult when one person takes on all, or nearly all, of the caregiving responsibilities – especially for someone so ill, they need a transplant.
Medical decision-makers need to be reminded of something that should be obvious: Marriage is no guarantee of social support. Husbands or wives may be too ill or incapacitated to step into the role of the caregiver, or unable to do so for some other reason. Or they may just not be very good at it. The relationship itself could be rocky, and that, too, could undermine a spouse’s willingness to provide care as well as the quality of any care that is provided.
In contrast, when a person has a circle of friends and relatives willing to help, that can be a sturdier and more resilient arrangement than relying primarily on just one person. Different people can help out in their preferred ways and at their preferred times, and no one person is likely to feel unduly burdened.
In my research for How We Live Now: Redefining Home and Family in the 21st Century, one of the people I interviewed was a lifelong single woman in her 70s who had no children and was living alone. When she became seriously ill, 49 people stepped forward to help her. They called themselves “Lucy’s angels.” I wonder what would happen if one of those people showed up at an evaluation appointment with Lucy if she needed a transplant – or if all 49 did.
Probably few people have the depth and breath of social support that Lucy did. Still, her story illustrates the absurdity of assuming that married people have adequate social support and single people do not. It also underscores the utter injustice of jumping from that faulty assumption to the recommendation that married people should have priority over single people in getting life-saving medical procedures.
Among people of every marital status, some really do lack adequate social support. That’s an even more profound issue. In the system as it currently stands, they will probably be left to die.
[Notes: (1) The opinions expressed here do not represent the official positions of Unmarried Equality. (2) I’ll post all these blog posts at the UE Facebook page; please join our discussions there. (3) For links to previous columns, click here.]
About Bella DePaulo
