Poorsickalone is the name of my practice.

I am an independent healthcare ethicist.

I work one-on-one with patients navigating a problem I call “medical disenfranchisement.”

“Medical disenfranchisement” describes the systematic exclusion of vulnerable persons from healthcare.

It’s what happens when a person is denied healthcare goods and services because of who that person is.

Those who experience medical disenfranchisement describe a chronic inability to get the healthcare they need. The phenomenon seems to follow them wherever they go, even across seemingly disconnected healthcare providers, systems, and settings.

More often than not, medical disenfranchisement is not one single instance or incident, but a recurrent pattern of dismissal that occurs across diverse parties, settings and medical circumstances over time.

The methods of medical disenfranchisement vary widely. In some cases, diagnostics and treatments fall short of the standard of care. In others, patients are prematurely discharged or never admitted. Some patients have endured repeated stalking and provocation by security, leading to removal from healthcare facilities due to "belligerence." Alarmingly, some patients have experienced demonstrably false accusations of abusive conduct towards healthcare providers.

At times, instances of medical disenfranchisement are subtle. For instance, a physician can affix harmful labels or notes to a patient’s chart that will ensure that patient can find no refuge from discrimination wherever medical records are shared. Some patients experience low-grade assaults on their integrity and capacity throughout their medical encounters — as when a patient is treated as though they are “crazy.”

Alternatively, medical disenfranchisement can present as practices that meet the standard of care but which are problematic in the context of highly vulnerable patients. For example, the development of a discharge plan for a patient with no home and significant mobility disability is disenfranchising.

The exclusions of disenfranchisement can occur on the basis of any aspect of personal identity, social location, or circumstance. That said, medical disenfranchisement prefers a certain set of “types.” It especially favours circumstances of extreme socioeconomic vulnerability. Those at an increased risk include:

• Persons who use drugs

• Persons who are experiencing homelessness or NFA (no fixed address)

• Persons without formal government identification

• Persons who live in poverty

• Persons who are unemployed

• Persons who receive assistance from social services, such as the Ministry of Social Development and Poverty Reduction (MSDPR) supplements or who are enrolled in the Medical Services Plan Premium Assistance program (MSP Premium)

• Persons with criminal records or outstanding arrest warrants

• Persons engaged in survival sex work

• Persons with psychotic disorders in the context of drug use

• Patients diagnosed with stigmatized or poorly understood health conditions

• Persons with disabilities

• Persons seeking support from medical practitioners in applications for social assistance including provincial and federal disability benefits

• Persons who have high Adverse Childhood Experiences (ACE) scores

• Patients who are alone — that is, who do not have strong kinship networks, especially in legally recognized forms

• Persons previously institutionalized under the Mental Health Act

• Patients previously flagged as behaviorally problematic, belligerent, violent or disruptive in medical records — especially those with histories of “code whites”

• Persons with adiposity-based chronic disease or obesity

• Persons with chronic, seronegative health conditions diagnosed “on exclusion”

• Persons who are of indigenous descent or status

• Persons who are of indigenous descent who lack formal status or who are globally indigenous

• Persons whose temperaments are deemed unvirtuous as when physicians complain patients show insufficient “gratitude” or docility

The existence of multiple, intersecting features of identity— features known as protected grounds, such as race, gender, and sexuality— intersect with these lesser documented risk factors in ways that increase one’s total risk for disenfranchisement.

Anyone who “gatekeeps” in medicine— that is, anyone with power to restrict or mediate a person’s access to healthcare — has the capacity to participate in acts of medical disenfranchisement. Potential participants of disenfranchisement include healthcare administrators such as receptionists; healthcare providers such as physicians, pharmacists and nurses; allied healthcare providers such as social workers and therapists; and law and order professionals, including police and security who work in medical settings.

Culpability for one’s participation in acts of disenfranchisement can vary widely; not everyone who participates is aware that they are participating in systemic oppression. Many believe themselves to be trying to help and struggle to understand and accept that they participate, however inadvertently, in harm. Even a patient may be effectively recruited to the project of their own disenfranchisement as they internalize certain scripts and fall into certain harmful dynamics.

However, it should be stressed that you don’t need any “bad guys” to get medical disenfranchisement— and that if there are bad guys, these actors alone do not account for the problem.

That’s because medical disenfranchisement is a systemic harm— also known as a “structural violence.” This type of harm happens when different parts of a system all work together in ways that cause the harm. No single force or person is responsible. 

In this way, medical disenfranchisement is perhaps best conceptualized as a form of oppression. According to the philosopher Marilyn Frye, “the experience of oppressed people is that the living of one’s life is confined and shaped by forces and barriers.” To be oppressed, in this definition, is to live as a caged bird. One’s “motion and mobility are restricted”; a life is “shaped and reduced.” On this analogy, note that each individual rung of the cage is not, on its own, sufficient to entrap. Disparate parts together make the cage.  

Medical disenfranchisement is similar in its shape. The forces that come together are disparate and may seem unrelated — but diverse circumstances collude so that the patient is at once locked out of healthcare, and locked into a life of unnecessary pain and limitation. 

The cage of medical disenfranchisement can be made up of factors such as harmful cultural discourses, beliefs and values; certain medical knowledge and clinical practice standards; various local institutional norms; the politics within and among medicine’s professional associations; prevailing political ideologies; and current health system governance and policy. 

citation:
Marilyn Frye, The Politics of Reality (Crossing Press, 1983).

Medical disenfranchisement is as consequential as healthcare is vital: healthcare can make a life, and disenfranchisement can break one.

The systematic exclusion of an individual from healthcare services leads to complications such as debilitating pain, preventable infirmity, humiliation, irreversible disablement, and premature death.

The patients I have worked with who have suffered medical disenfranchisements have lost limbs that adequate wound care might have saved; have laboured to breathe through fluid-filled lungs that antibiotics would have cleared; and have died, because they were not admitted to clinic upon presenting initially to the ER just days earlier, asking for help.

Such harms make life and death unbearable.

These physical harms are compounded by the more invisible but no less real injuries to person’s sense of self— what can be termed a person’s “subjectivity.”

The global health scholar Seye Abimbola argues that to undermine a person’s ability as a “knower”— that is, to dismiss a person’s perceptions of their own reality and experience — is to assault human dignity. This is what I term “subjectivity injury.”

Medical disenfranchisement’s consequences go further still. Beyond the physical and the psychological harms they cause, the phenomenon of medical disenfranchisement harms our society. Medical disenfranchisement both colludes with and compounds other axes of precarity, such as poverty and homelessness, driving the growing crisis of the class of the destitute sick.

Source: Seye Abimbola, "Epistemic Dignity" (The Lancet, 2025).

While the current landscape of healthcare professions fails to address medical disenfranchisement adequately, it is my firm belief that medical disenfranchisement can be fought and that lives can change. Poorsickalone is purpose-built to address this problem and to support patients who insist on asserting their right to appropriate healthcare.

Learn more about what we can do together here.