EXECUTIVE SUMMARY

Evidence suggests that providers are frequently biased against obese patients, and patients are harmed as a result. Experts say bioethicists can do the following:

  • Become aware of the ubiquity and negative effects of weight stigma.
  • Be attentive to provider attitudes or healthcare system practices which support stigma or bias toward obese patients.
  • Provide grand rounds or education sessions to highlight research findings and patient experiences.

A growing body of research reveals that clinicians are frequently biased against obese patients — and that patients are harmed as a result. In a notable study of nearly 2,700 adults, 69% reported weight stigma from physicians.1

“We have consistent data that weight stigma is prevalent in healthcare settings — including, but not limited to, physicians. We also have mounting data that weight stigma causes harm,” reports Scott Kahan, MD, MPH, director of the National Center for Weight and Wellness. Kahan is chair of the clinical committee for The Obesity Society and is leading a project to create an ethical framework for obesity care.

“In addition to emotional harm, weight stigma has been shown to affect physical health: increased blood pressure, increased stress hormones, and increased blood vessel reactivity,” says Kahan. Recent studies suggest that stigma increases unhealthful eating behaviors and decreases motivation for exercise.

“The core ethical principles of beneficence, nonmaleficence, and justice are all relevant when it comes to appropriate and nonjudgmental care of all patients,” says Kahan.

Duty to care for “all in need”

If the clinician is not able to be objective with the goals of care because they have a bias regarding a patient’s weight, “then their duty is to bring in others to help ensure they are providing appropriate interventions,” says Nneka O. Sederstrom, PhD, MPH, FCCP, FCCM, director of the Office of Ethics at Children’s Hospitals and Clinics of Minnesota in Minneapolis.

The “easy out” of transferring care to another provider is simply not acceptable in this case, says Sederstrom. According to Sederstrom, this would be no different than if the provider chose not to care for a patient due to their race, age, or gender. “They are not able to walk away because they object to the person’s size,” says Sederstrom. “A provider’s duty is to care for all in need — not pick and choose only those that they believe are worth it.”

Amy M. VanDyke, PhD, system ethicist at Mount Carmel Health System in Columbus, OH, says the experience of stigma by the patient from their doctor diminishes the likelihood of benefit from the relationship. “It can, in fact, cause both physical and emotional harm in the process,” says VanDyke.

Biased physicians may view patients who struggle with weight as lazy, sloppy, or having low intelligence. “When these attributions are unreflectively accepted by doctors, this can quite understandably cause patients to react negatively,” VanDyke says.

With regard to overweight or obese patients, physicians can fail to respect autonomy in the following ways, says VanDyke:

Physicians may fail to address or even acknowledge a patient’s obesity.

“Patients are denied the opportunity to avail themselves of assistance and education about associated and potentially serious medical problems related to their weight,” says VanDyke.

Physicians may fail to discuss all possible treatment options for weight loss.

“The patient may not see certain options as being viable or, conversely, may not be motivated to take alternative actions — which are less invasive — to avoid the more invasive options,” says VanDyke.

Physicians might attribute symptoms unrelated to obesity to the patient’s weight.

If a patient feels stigmatized by their physician, he or she might delay seeking care until later in the disease process when treatments may be less effective.

“As it is known that overweight and obese patients are disproportionately burdened by some forms of cancer and other diseases, it is especially important that such patients undergo routine surveillance,” says VanDyke.

Bioethicists should be aware

Kahan says at a minimum, bioethicists should become aware of the ubiquity and negative effects of weight stigma. “Weight stigma is so ingrained in our society that I fear that many bioethicists harbor stigmatizing beliefs and judgments about persons with obesity,” says Kahan.

Kahan experienced this while on a panel with a leading academic bioethicist. “I was shocked when he suggested that we should consider intentionally shaming people to lose weight, similar to what had been done in the tobacco world to shun people to stop smoking,” he says. “I can’t think of anything more inappropriate or counterproductive.”

Bioethicists have a moral obligation to be attentive to provider attitudes or healthcare system practices which inadvertently or directly support stigma or bias toward obese patients, says VanDyke. She urges bioethicists to utilize the following approaches:

Highlight research findings and patient experiences in this area with grand rounds or graduate medical education sessions.

“Gently challenge the prevailing attitudes and practices which may be stigmatizing to patients,” says VanDyke.

Write articles on how stigma and bias marginalizes patients at an unhealthy weight.

“This can impair utilization of healthcare services even when sufficient access is present,” says VanDyke. “It ultimately harms a patient’s prospects for a healthy life.”

REFERENCE

  1. Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity 2006; 14(10):1802-1815.

SOURCES

  • Scott Kahan, MD, MPH, Johns Hopkins Bloomberg School of Public Health/National Center for Weight and Wellness, Washington, DC. Phone: (202) 223-3077. Email: kahan@jhu.edu.
  • Nneka O. Sederstrom, PhD, MPH, MA, FCCP, FCCM, Director, Office of Ethics, Children’s Hospitals and Clinics of Minnesota, Minneapolis. Phone: (612) 813-6159. Fax: (612) 813-6807. Email: Nneka.Sederstrom@Childrensmn.org.
  • Amy M. VanDyke, PhD, System Ethicist, Mount Carmel Health System, Columbus, OH. Phone: (614) 546-4065. Fax: (614) 546-3875. Email: Amy.VanDyke@mchs.com.