Obesity: where ethics and policy collide

When you hear the word "obesity", what do you think? Do you think about someone with no will power? Someone who’s a drain on the health care system? Do you think parents are negligent if they have a child who’s obese? Do you think we need to take more draconian public-policy measures to prevent and reduce the incidence of obesity?

For many people it’s a black-and-white issue: Obesity needs to be stamped out and society should do everything within its means to reach this goal.

Not to gloss over the health implications of obesity, but I think it’s more nuanced than this. Although it’s not often recognized, there is in fact an ethical dimension to how our society confronts obesity. This intersection of ethics, public policy and individual autonomy is explored this month in a fascinating in-depth edition of Virtual Mentor, the American Medical Association Journal of Ethics.

The journal’s editor, Dr. Fatima Cody Stanford, explains why the topic is so important right now:

It has been widely acknowledged that improvements in American health made by the success of tobacco cessation efforts are under threat from the climbing rate of obesity and obesity-related conditions such as type 2 diabetes mellitus and hypertension. As the topic of obesity takes center stage, ethical treatment, diagnosis, and legislation have become more necessary than ever.

At the individual level, the ethical issues start in the exam room. I don’t think doctors do their patients any favors by avoiding discussion of problems with weight, especially if the patient’s weight might be contributing to a chronic condition. It’s important to recognize, however, that physicians are as prone as the rest of society to bias and stereotypes, and that their biases can unwittingly erode the relationship with the patient.

Consider the case of "Mrs. Williams," outlined in one of the Virtual Mentor commentaries that addresses weight-related stigma and physician bias. Mrs. Williams has been hospitalized multiple times for health issues complicated by her weight. Her doctor tells her that her health will improve if she loses weight; she’s frustrated because she feels all her health issues are being blamed on her weight. When things aren’t going well, the authors write, the common reaction is for physicians to pass some of the blame back to the patient:

Mrs. Williams provides grist for this reaction, since she has an obvious risk factor – her extreme obesity – and has not responded to advice to lose weight. It is important for her caregivers to step back from their emotional reaction to her criticism and her lack of response to their well-meaning advice and decide whether they can examine their own motivations and feelings of inadequacy, put themselves in the patient’s shoes, and do a better job partnering with her in this effort.

There is in fact a significant weight bias among health care professionals and it often spills over into their interactions with patients, explains this Virtual Mentor commentary that examines weight-related stigma, particularly in the doctor’s office and in the hospital. Do health care professionals have an ethical duty to be aware of the extent to which weight bias has shaped their patients’ perceptions of how they’re treated within the health care system? The authors believe the answer is yes.

The issues get especially gnarly when it comes to public policy. By focusing on psychological, rather than sociological, factors for obesity, U.S. policy is misguided at best and ineffective at worst, suggests this essay that contrasts the U.S. approach with that in the U.K.:

We blame the individual – sloth and gluttony are the causes of obesity – and conclude that individual medical treatment is needed if the individual cannot change. In contrast, the U.K. views the problem from a sociological perspective, instituting systemic changes to the toxic food environment felt to contribute to obesity in their nation.

So should we enact more laws – taxing sugary soft drinks, for instance – or does this smack of paternalistic government intervention? To what extent can we – or should we – legislate people’s choices and behavior? Not everyone agrees that policymakers ought to get involved in telling the public what they should eat or how active they should be, explains yet another of the Virtual Mentor commentaries:

Dietary behavior – and to some extent, physical activity – are intensely personal and are influenced by numerous factors, including genetics, biology and environment. At issue is the perpetual tension of pluralistic democracies: identifying an appropriate balance between individual liberty and the well-being of the community as a whole.

At a time when the public discussion about obesity is often characterized by sanctimony and blame, it’s worth reading this entire edition of Virtual Mentor for a more thoughtful perspective.

When we talk about obesity, how much of the conversation is influenced – even unconsciously – by bias? In our zeal to do something about obesity, are we actually helping people or are we just haranguing them? At what point do we cross the line from supporting people to dictating how they should live? How can we address obesity without sacrificing respect for individuals and for their autonomy? How can we do it in a way that’s genuinely beneficial, using strategies proven to be effective? Tough ethical questions, all of these, but questions that need to be asked.

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