Diagnosis and the Dole: The Function of Illness in American Distributive Politics

This article argues that the concept of illness has certain properties that make it a convenient administrative device for managing a need-based redis-tributive system in a society whose primary distributive system is based on work. These properties—cultural acceptance of illness as a legitimate excuse for not working, objective standards for identifying illness, and restrictiveness—have led to the widespread use of illness as an eligibility criterion for many social benefits, including cash transfers, services, privileges and exemptions. Paradoxically, the traditional rationales for using illness as one of the keystones of categorical welfare policy are eroding, yet welfare programs based on illness certification are growing rapidly. To explain this anomaly, the author suggests that medical certification as a distributive mechanism serves certain latent political functions, such as allowing welfare programs to be responsive to political unrest, siphoning off opposition to controversial policies by the granting of medical exemptions to intense opponents, and reducing political conflict by using physicians as arbiters.