Considering the Consequences of Vulnerability.
Labeling populations as vulnerable is in vogue across many research communities including cancer nursing. Despite widespread use, vulnerable and vulnerability are terms employed without definitive conceptual definitions. They are commonly applied to indicate a sense of comparatively heightened risk. Indeed, “at risk” is often used as a synonym for vulnerability. Comparisons employed in conferring vulnerability are generally unspoken and imprecise. Older people and children are compared with young and midlife adults. People currently receiving or living after cancer treatment are compared with those not diagnosed with cancer. People with specific cancer or comorbid diagnoses are compared with others who have diagnoses judged less risk-laden. Current applications of vulnerable imply 3 consequences. These consequences lie in framing vulnerability as a trait, neglecting strengths and advantages that counterbalance vulnerability, and endorsing “healthism” with use of vulnerability. Such results are problematic, creating repercussions that limit the value of our science. First, present use implies that vulnerability is a trait acquired with a cancer diagnosis, multimorbidity that includes cancer, or a phase of life like childhood or elderhood. Traits and states hold a firm position in behavioral and health sciences as Chaplin and colleagues argued.1 Traits are a permanent characteristic that suggests predictive value. States are contextual and can thus be manipulated or managed. Positing that people living with or after cancer assume a permanent vulnerability overgeneralizes and misstates the effects of diagnosis and treatment. Moreover, vulnerability is a human state in which any individual may find themselves. It is not a trait borne by populations by virtue of perspectives on heightened risk profiles. Available resources and supports, along with preparation, mediate the extent to which any vulnerability results in harm. Acknowledging vulnerability as a state and defining the context of that state are keys to forward-thinking research. Second, application of the term vulnerable to groups of interest belies their individual and shared strengths and advantages. Viewing people as simply vulnerable contradicts our nursing focus on holism and person-centeredness. Vulnerability is invariably presented without consideration of these converse qualities. Appellation of it underscores a focus on problems that result, rather than on prevention, management, or mitigation. Such emphasis makes a holistic view of the individual or population difficult. It risks depersonalization in failing to recognize that every person is vulnerable in diverse ways across the arc of their lifespan. In daily life, individuals, families, and communities turn to strengths and advantages they possess when facing a threat magnified by vulnerability. Moreover, focusing on vulnerability alone places solutions to problems that it creates firmly in the researchers’ hands. To include appraisal of strengths and advantages endorses an innate capacity to moderate vulnerability with internal assets and contextual resources. Precisely defining the specific state of vulnerability while considering strengths and advantages that balance it equilibrates power between participant and researcher. Third, using vulnerability as a trait without consideration of the balance found in strengths and advantages suggests a “healthist” view of people living with and after cancer. Defined by Crawford2 and expanded upon by Cheek,3 healthism escalates medicalization and places disproportionate responsibility for health states with the individual.2,3 The individualism of healthist views precludes robust considerations of social and particularly environmental and commercial determinants of health. Further, healthism emphasizes understanding vulnerability as a trait, reinforcing the social power of those who apply the label of vulnerable to others. Healthism threatens both the personhood and agency of those to whom it is applied. Further, healthism reinforces power sought by those who apply it to others. It intersects with and promotes other biases. Healthism frequently amplifies ageism and ableism among many other discriminatory junctures. Although often inadvertent, using vulnerability in research risks inequity. Dismantling the healthism of vulnerability promotes equity and belonging in research, suggesting new possibilities for public and patient engagement. The cancer trajectory poses many states of vulnerability from the biological to the social and existential. Yet, as nurses, we know that people living with and after cancer, as well as those dying with it, manage their vulnerabilities through strengths and advantages that even they often did not know they possessed. Isn’t it time our research better reflected their personhood, agency, and resilience rather than simply focusing on their vulnerability?
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