Ethical Dilemmas In Obesity Prevention

Who, in the light of the obesity epidemic and its myriad consequences, could possibly object to public health messages and other measures that would target obesity?

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.

AMS
Edmonton, Alberta

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