Combating obesity raises ethical concerns

Physicians have obligation

Obesity may be the most difficult and elusive public health problem this country has ever encountered, according to a 2013 Hastings Center Report.1 The report, which argued that combating obesity requires changing patterns of food and beverage commerce, personal eating habits, and sedentary lifestyles, got a “very hostile response,” says Daniel Callahan, PhD, the report’s author and senior research scholar and president emeritus of the Hastings Center in Garrison, NY. “A number of people complained not only about my article, but also that we were having a discussion about obesity at all. They said, in effect, it was stigmatizing those of us who are obese.”

The fact that some 67% of people are either overweight or obese, and that this figure has remained static over the years, is evidence that a new approach is needed, argues Callahan. “We have to start with the premise that obesity is a serious problem medically and socially,” he says. “We’ve been working in this country for well over 25 years now to deal with the problem of obesity, but have made no real progress at all.”

Talking about health hazards was an effective approach to combat smoking, but this approach has not been as effective with obesity, says Callahan, noting that some programs consider getting 10% of participants to lose weight and keep it off as a success. “I find there is a very strong flavor that runs through the whole field of public health, with the exception of smoking, that, ‘Whatever the problem, don’t blame the victim,’” he says. “In one sense, that is a very valid idea. If you demean the people who have the condition, then they won’t come in for treatment.”

However, the concept of personal responsibility cannot be discounted altogether, says Callahan. “We’ve got to find some way to get obesity taken seriously which does not stigmatize those who are already obese, but as a prevention strategy, to go after the people becoming obese and stop it before it goes too far and becomes more or less irreversible,” he says.

Several studies have shown that physicians rarely bring up the topic of obesity with overweight patients.2-4 “It is not something they tend to talk with patients about,” he says. Doctors might not feel obesity is a high priority, might find obesity difficult to talk about, or might lack time and training to counsel patients effectively.

“We need to find ways of breaking through this reluctance on the part of physicians and provide them with training to do a good job, or to effectively suggest someone else for the patient go to for help,” Callahan says. “It’s a difficult conversation to have, but talk about it we must.”

Callahan considers it an ethical obligation of physicians to point out to patients that they are obese, even if the patient is probably already aware of it, and to say to the patient that it is important he or she should do something about it. In addition, the physician should offer counseling if he or she can provide this effectively or, otherwise, should refer the patient to another physician.

“This can be a bit more delicate with specialists who are treating a patient for some other condition, and note the obesity,” acknowledges Callahan. “If I went to my orthopedist for my painful shoulder, it would be remiss of her not to point out what looks like a melanoma on my face. The same would be true of obesity. ‘If you haven’t already, you should talk with your regular doctor about that.’”

A personal choice?

While cigarettes and alcohol may be viewed as harmful products — and, thus, differentially taxed or banned — food as a generic class cannot be similarly addressed, says Desiree Lie, MD, MSED, clinical professor of family medicine and course director for the Professionalism and the Practice of Medicine course at the Keck School of Medicine of the University of Southern California in Los Angeles.

Obesity now accounts for almost 21% of U.S. health care costs, and an obese person incurs medical costs that are $2,741 higher than if he or she were not obese, which translates into $190.2 billion per year, according to a recent study.5

The ethical question of whether being obese is a personal choice or a health threat to self and society with a high cost — and, hence, amenable to public mandate or legislative control — is the basis of the challenge for clinicians and public health scientists, says Lie.

“Add to that the stigma of obesity, and the bias and stereotyping that obese persons encounter, and the push-back becomes even greater,” she says. “Education about its consequences remains the mainstay to combat the obesity epidemic. It needs to begin early — right from infancy. To be effective in the long term, physicians should make ‘becoming obese’ truly a personal informed choice made by patients.”

Research on the role of food marketing in long-term adverse effects on health, and legislative action to support informed decision-making about foods, such as food labeling and restriction of soda size, needs to continue, urges Lie. “This story and debate needs to be constantly in the public eye, because otherwise the food lobbyists will have their day,” she says. “It would be good, for example, if the Surgeon General’s office continued to make this issue visible.”

References

1. Callahan D. Obesity: Chasing an elusive epidemic. Hastings Center Report 43, no. 1 (2013):34-40.

2. Forman-Hoffman V, Little A, Wahls T. Barriers to obesity management: A pilot study of primary care clinicians. BMC Family Practice 2006;7:35.

3. Kusher RF. Barriers to providing nutrition counselling by physicians: A survey of primary care practitioners. Prev Med 1995;24(6):546-552.

4. Moore H, Summerbell CD, Greenwood DC, et al. Improving management of obesity in primary care: Cluster randomised trial. BMJ 2003;327:1085.

5. Cawley J, Meyerhoefer C. The medical care costs of obesity: An instrumental variables approach. J Health Econ. 2012;31:219-230.

Sources

• Daniel Callahan, PhD, Senior Research Scholar, The Hastings Center, Garrison, NY. Phone: (845) 424-4040. E-mail: callahand@thehastingscenter.org.

• Desiree Lie, MD, Clinical Professor, Keck School of Medicine, University of Southern California, Los Angeles. Phone: (626) 457-4074. E-mail: Desiree.Lie@health.usc.edu.