Aren’t messages to increase physical activity and eat healthier, even if provided with a ‘nudge’ (fat tax, BMI report cards, etc.), a reasonable and necessary step in the interest of promoting public health and tackling obesity?
It turns out that things are less clear than you may think, especially if you consider the ‘ethics’ of such measures and their implications for those, who these measures seek to educate and change for the better.
Thus, a comprehensive analysis of the surprisingly problematic ethics of some of the public health approaches to obesity prevention, by the medical ethicist Inez de Beaufort and colleagues, from the University of Rotterdam, published in the latest issue of OBESITY REVIEWS, makes a most enlightening and thought-provoking read.
In their paper, the researchers look at 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluate their ethically relevant aspects.
As the authors point out, while efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, may appear ‘ethical’ as they are aimed at improving individual and public health, enabling informed choice and diminishing societal costs, they also raise potential ethical objections against such efforts.
The long list of potentially ethically problematic aspects identified include:
- Effects on physical health (of proposed interventions) are uncertain or unfavourable;
- There are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination;
- Inequalities are aggravated;
- Inadequate information is distributed;
- The social and cultural value of eating is disregarded;
- People’s privacy is disrespected;
- The complexity of responsibilities regarding overweight is disregarded;
- Interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding Freedom of private enterprise or regarding policy choices by schools and other organizations.
Whether or not the ‘ethical’ incentives to combat the obesity epidemic should ‘automatically’ override the potential ethical constraints, is less than clear.
The complexity of some of these ‘well meant’ initiatives can have unintended ethically problematic consequences: e.g. ‘demonizing’ candy, fast food, or chocolate milk can ostracize the child, who consumes these foods because of socioeconomic or other constraints. Oversimplistic and unrealistic messages about the benefits of diet and exercise can not only reenforce obesity bias and stigma but also lead to disengagement by the very individuals, for whom these messages are intended.
Blame, shame, and punish (tax) approaches to combatting obesity (implicit in many public health interventions) are ethically problematic not only because of lack of evidence of their effectiveness but also because such measures are unlikely to lead to positive and constructive solutions for the targeted individuals.
Thus, the authors recognise an urgent need to develop an ethical framework to support decision makers in balancing potential ethical problems against the need to do something.
Clearly, the need to kicking tires around the ethics of programmes to target obesity, is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a program may hamper its effectiveness.
As I have noted before, the principle of First Do No Harm, should apply as much to public health interventions as to individual care.
ten Have M, de Beaufort ID, Teixeira PJ, Mackenbach JP, & van der Heide A (2011). Ethics and prevention of overweight and obesity: an inventory. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (9), 669-79 PMID: 21545391
As I was flying out to the 4th Annual Obesity Network Obesity Boot Camp yesterday (more on the camp later), I happened to read this week’s Globe Essay by Arthur Kleinman titled, “Health Care’s Missing Care”.
Arthur Kleinman is professor of medical anthropolgy at Harvard University and in his essay, he deplores the loss of caregiving in today’s clinical practice. He calls this the lost art of medicine, displaced by ever-more emphasis on economically-driven concepts of “evidence-based” rationalisation and increasing reliance on science and technology for diagnosis and treatment.
“What time has been allotted for aquiring this skill [of caregiving] in medical school and residency training? What has been done to evaluate future doctors’ skills in this respect? Has medicie turned its back on the medical art and the thousands of years of humanistic approaches to medical practice?”
In his essay he focuses on the frail and elderly, but much of what he discusses is as applicable to my bariatric patients, as it is to patients in many other fields of medicine:
“…for example, we can say that caregiving begins with the ethical act of acknowledging the situation of the sufferer, affirmig his or her efforts and those of family and friends to respond to pain and impairment, and demonstrating emotional and moral solidarity with those efforts.”
“It moves on to involve the physician in pain management, symptom relief, treatment of other “intercurrent” diseases (such as depressive disorder) that may arise during the first disease, and judicious management of the use of pertinent technology and control of unnecessary or futile interventions.”
“It includes working with a network of other health care professionals (such as physical therapists, occupational therapists, nurses, social workers, and home health-care assistants), and family and network of care givers.”
“It means spending real time with patients, empathically listening to their illness narratives, eliciting and respondig to their explanatory models, and engaging the psychosocial coping processes involved in enduring or ending life.”
I can only concur with Kleinman as he concludes that,
“The physician’s art – now so circumscribed by bureaucratic, political and economic forces – turns on both the professionalization of these inherently human resources and the impact of their routine use on the doctor’s own moral life.”
Working in a clinic where we currently look after over 1,500 patients (not to mention the over 2,000 patients on the waiting list) struggling with body weights, not seldom well over 400 lbs, these words ring only too true.
While we may not have the “magic bullet” for severe obesity, we can certainly offer compassion and understanding on how living with this cruel and devastating condition requires unbelievable daily courage and struggle.
Let us never forget who we serve!
Station Dushesnay, Quebec
As I have blogged before, the scarce availability of access to evidence-based treatments for obesity within the public health care system is resulting in ever increasing “weighting” lists for bariatric services.
Thus, as in other cases, where the demand for medical and/or surgical interventions seriously outstrips the availability of services, the ethical dilemma of distributing these limited services in the most equitable and acceptable fashion is clearly evident.
In this context, a recent article by Govind Persad and colleagues from the Department of Bioethics at the US National Institutes of Health, published in a recent issue of The Lancet is a very worthwhile read.
As Persad and colleagues discuss, there are eight commonly used ethical principles for allocation of scarce resources, which can be divided into four categories based on their core ethical values:
1) Treating people equally (lottery, first-come-first-served)
2) Favouring the worst-off (sickest first, youngest first)
3) Maximising total benefits (save the most lives, prognosis or life years)
4) Promoting and rewarding social usefulness (instrumental value, reciprocity)
As discussed in the article, none of these principles satisfy all ethical requirements in that they are either insufficient (i.e. ignore some morally relevant considerations) or fundamentally flawed (by recognizing irrelevant considerations).
Thus, for example, a simple lottery may result in the chance allocation of a scarce resource to someone who has only 4 months of life to gain vs. someone who may gain 40 years.
Similarly, first-come-first-served principles ignores relevant differences between individuals and tends to favour people who are wealthier, better informed, or better connected (e.g. to their referring physician).
Treating the sickest first may result in allocation of treatments to people, who have the worst prognosis and therefore the least long-term benefit.
Treating the youngest first would divert all of the resource to infants and young children, when most people may agree that saving the life of a young mother may be more important than saving the life of a 2 year-old.
If the focus is on saving most lives, how would you rate saving the life of one 20 year-old, who may gain 60 years vs. saving the life of five 70 year-olds, who may gain 10 additional years of life each?
Prioritization of people who have a high instrumental value (e.g. health care workers) or reciprocity for people who have “paid their dues” (e.g. veterans) also raises inherent ethical issues.
Thus, according to Persad and colleagues, none of these commonly used principles are fully adequate. In their paper, they propose a “complete lives system”, which incorporates five ethical principles: youngest first, prognosis, save the most lives, lottery and instrumental value.
As laid out in their paper, this system would prioritise adolescents and young adults over infants but also takes into account prognosis, in cases where the worst-off can benefit a little, but better-off people can benefit substantially more from the same intervention. It would enable more people to live complete lives whereby introducing a lottery for roughly equal recipients ensures that no individuals – irrespective of age or prognosis is fully abandoned.
Based on this concept, individuals between roughly 15 and 40 years of age, who have yet to live “complete” lives, get the most substantial level of care, whereas the youngest and oldest have a lower chance of getting that care.
For various reasons described in the paper, this system is least vulnerable to corruption and provides a disincentive for referrers to misrepresent the actual health of their patients.
Obviously, even this system is not perfect and can draw objections from some. Nevertheless, the authors argue, that this system of “complete lives” is theoretically the best framework that balances widely held values: giving priority to the worst off, maximising benefits and treating people equally.
Certainly a topic that will continue to be hotly debated as we continue wondering how to best manage an ever growing waiting list for bariatric care.
Yesterday I attended a talk by Angus Dawson, Senior Lecturer and founding Director of the Centre for Professional Ethics, Keele University, UK, who is currently a Visiting Professor, Centre for Ethics, University of Toronto.
His presentation with the title: “Ethical Obesity Policy: Paternalism, Preference Change and the Good Life” was part of the University of Alberta Health Law Institute Research Seminar series.
Dawson’s basic thesis was that when it comes to preventing obesity simply providing information does not work, some form or “paternalism” (not to use the term coercion) will be required to help people change behaviours.
This is in contrast to what is happening where most policy makers (and some public health workers) still treat obesity as a matter of individual choice and focus their prevention efforts at individuals rather than addressing this issue at the more complex system level.
This is unfortunate because there is little evidence that a key contributer to the obesity epidemic is indeed epistemic or lack of knowledge – therefore trying to remedy obesity by providing knowledge does not address the root cause of the problem.
In fact, Dawson argues, there is no evidence that people today are less knowledgeable about healthy behaviours than previous generations, nor are they weaker willed or more prone to obesity by “choice”.
Rather, the obesity epidemic is a consequence of systemic factors such as removing physical activity from the workplace, less time to spend at home with the family, less physical demands on commute and travel and industrialisation of our food supply.
Thus, obesity is not a result of people making poor choices but rather the result of societal changes that leave most individuals with little choice (but to become obese or fight weight gain by swimming against the stream).
This raises the issue of collective action: individuals are limited in their choice by the choices that the majority makes. For e.g. if you live in a neighbourhood where people prefer to eat at fast food restaurants and drive cars then you may have no choice but to also eat fast food and drive a car unless you are prepared to leave your neighbouhood to find a healthier restaurant and are willing to risk being run over on your bike.
Getting the majority to change their behaviour is unlikely to happen without some form of paternalism, which raises the ethical dilemma of how much individual “freedom” society as a whole is willing to sacrifice for the common good.
Examples that were cited included laws requiring the use of seat belts or helmets – issues that are surprisingly still contended by some who reserve “the right to be foolish”.
Overall, not much that I have not heard before but certainly a nice summary of how complex some of the issues around obesity prevention actually are.
When it comes to obesity prevention – don’t hold your breath!