We like innocent patients. You know, the ones who take care of their health and suffer from bad luck, not bad judgment. This type of sympathy shapes how people receive care, even if they have the same injury or illness as someone else. Consider, for example, the different levels of public sympathy between people with Type 1 and Type 2 diabetes. Media narratives often portray people with Type 1 diabetes blameless because of their genetics or an autoimmune disorder, while people with Type 2 diabetes made bad choices about diet or not exercising. It shouldn’t be too surprising, then, that people with Type 2 diabetes often experience less care or concern from healthcare providers.
This reality sits uncomfortably with another commitment to moral equality, roughly the idea that every patient deserves respect and the same level of care. I started working on moral innocence in healthcare to figure out how we bridge this gap: how do we get people to care about “not innocent” patients? But the more I developed my answer in “Medicine and Moral Innocence,” the more I recognized two other kinds of moral innocence: one was aspirational and reflected an idealized vision of what the world and people in it could be like, another type of moral innocence was more “developmental” and associated with “coming of age” which influences how people think about risk, preventative healthcare, and recovery. So, part of my ongoing research program is figuring out how best to incorporate these types of moral innocence into medicine given that they are unlikely to go anywhere.
One intuitive answer is to eliminate moral innocence from medicine altogether. This reaction is rooted in the way social commentators used to talk about “innocent victims” during the HIV/AIDS crisis. Although never an official category by healthcare agencies, innocent victims were people with HIV/AIDS who the public felt sorry for: the unsuspecting woman who contracted HIV from a dishonest partner, the infant who contracted HIV during pregnancy, birth, or breastfeeding, or the person who contracted HIV from a blood transfusion. The “innocent victim category” encapsulated the public’s belief that these people didn’t “do anything wrong” but still contracted HIV because someone else did “do something wrong.” Unsurprisingly, these “wrongdoers” were people society already stigmatized and marginalized: men who had sex with men, intravenous drug users, sex workers, and Haitians.
These public attitudes shaped how people with HIV/AIDS (did not) receive care. Federal agencies were slow to allocate funding, prioritize surveillance, or even make public health announcements about the emerging epidemic. Even when epidemiologists discovered that HIV could not be transmitted through casual contact, many hospitals and providers created obstacles for patients with HIV/AIDS with restrictive admissions, disingenuous referrals, or outright patient dumping.
Admitted patients with HIV/AIDS often were sequestered to other parts of the hospital, had their food left cold in the hallway, or did not have regularly clean linens. While many healthcare providers heroically rose to the occasion, others did not. Douglas Shenson recounts that a gloveless intern who was doing a blood draw on a patient with HIV told Shenson, “don’t worry, if you lead a clean life, you’re not going to catch this disease.” I won’t go through the rest of the parade of horrors, but the idea is that appealing to moral innocence in medicine is too toxic because it stigmatizes the “wrongdoers” and promotes these kinds of harms.
I wasn’t sure what to say, then, about the Ryan White HIV/AIDS Program (RWHP). Initially designed to help lower-income and un(der)insured people with HIV/AIDS afford treatment, RWHP expanded to cover counseling, hospice, childcare, food, and transportation services. It’s easily one of the most significant pieces of AIDS healthcare legislation and still enjoys strong bipartisan support despite a high budget (2025 was about $2.5 billion). As I explain in the paper, it is highly unlikely that RWHP would have passed without appealing to the moral innocence the public associated with Ryan White, the program’s namesake. I also argued that while White never appealed to the “innocent victim” rhetoric, he did embody a more aspirational kind of moral innocence that people found inspiring. For example, even though White was initially demonized in his hometown when people found out he had AIDS, White continued to appeal to people’s better nature by advocating for AIDS education, which would help teach others that people with AIDS just wanted to get back to living their lives.
Given that RWHP has helped people who otherwise likely would have died live, and live longer, there has to be some viable place for moral innocence in medicine. I developed a two-step process in the paper, where, roughly, step one is to find the poster child that the public cares about to initially secure the resources and then, step two, continue to expand those resources so that everyone can access them regardless of their method of contraction (which circles back to the broader value of moral equality).
But White’s public persona contrasted with a third kind of moral innocence. Instead of contrasting with blame or culpability, this other kind of moral innocence indicated a naïve trust that pat moral rules would keep someone safe. For example, we teach children pat moral lessons, like “bad guys never win” or “you can be anything if you work hard enough,” knowing full well as adults that bullies don’t always get held accountable or that effort without opportunity (and luck) isn’t enough. Children are, of course, just learning moral rules, so simple ones are developmentally appropriate, but there is also a pretty common desire among parents to make their kid’s childhood as magical as possible, which requires a simplified moral universe.
Philosophers who study this kind of “developmental” moral innocence stress that we outgrow it by adulthood because hardly anyone could luck into the circumstances needed to sustain the naïve moral framework. Losing this moral innocence is painful, but philosophers disagree about exactly why. Sometimes it happens because someone experiences evil or has to discard cherished beliefs. Other times it means someone recognizes that they are capable of evil. Or it might mean accepting that vulnerability is simply part of what it means to be in relationships with other people.
That conclusion, about there being so few “developmentally innocent adults,” seems right to me as a general psychological description. Yet, the more I read narratives from the “innocent victims,” the more it seemed like this kind of moral naivety persisted into adulthood, at least in a more localized sense. I touch on this point in the paper, but the basic idea is that surprise and shock are common elements in these narratives. The reasoning was that by doing the conventionally “right” thing, getting married, not doing drugs, etc., people were supposed to be insulated from HIV/AIDS, and so part of the outrage when they contracted it was that they didn’t believe it could happen to them.
It’s easy to look back on this historical point as something we know better about now, but I’m starting a new project exploring how that same kind of outlook shows up in other localized ways. People who get mammograms know that people get breast cancer. But the repeated messaging and medical narratives around mammograms as what responsible patients do inadvertently lead to the belief that doing the responsible thing is doing the safe thing. So, it’s always the other person who gets breast cancer, not “me.” The surprise and shock from a breast cancer diagnosis isn’t based in recognizing that something statistically unlikely happened; it’s partly based in recognizing that the “I did what I was supposed to do, so this shouldn’t have happened to me” did not provide the protection someone believed it did. This kind of moral reasoning, I think, is not indicative of how adults reason about the world in general, but it does show that different types of moral innocence permeate how we think about medicine and illness.
Kurt Blankschaen
Kurt Blankschaen is Associate Professor of Philosophy at Daemen University. He primarily works on how marginalized communities access healthcare resources, what it means to be an ally to the LGBTQ+ community, how cultural narratives around marginalized identities affect individuals’ well-being, and how religious values (especially from Natural Law theory) inhibit or enhance LGBTQ+ flourishing.
