Obesity and healthcare: I won’t treat you until you lose weight

Benjamin Perez

Brown University

Publication date: May 17, 2015

An elderly woman in her early 60’s, Ida Davidson went to see her doctor for a routine check up on a seemingly normal day (Cross, 2012). What might have otherwise been a typical doctor visit turned into a shocking revelation when Davidson’s doctor, Dr. Helen Carter, refused to provide treatment (Cross, 2012). The reason? Davidson was overweight. After having witnessed her colleagues sustain serious injuries from caring for obese patients, Dr. Carter has started to refuse treatment to anyone who weighs over 200 pounds, claiming “my office is unable to accommodate a certain weight and we put a limit on it” (Cross, 2012). Seemingly shocked by the situation, Davidson told news reporters “I have never heard anything so ridiculous in my life…She didn’t care about my health that day. I think she just cared that I was a liability to her and maybe too much work” (Cross, 2012). Davidson was not alone. Across the United States and around the world, more and more physicians are finding it acceptable to deny medical treatment to obese individuals, sparking a contentious debate about how we should deliver healthcare to the obese.

The discussion of healthcare in the context of obesity is especially relevant in the international dialogue about the recent obesity epidemic, which has burgeoned into one of the world’s most pressing public health challenges. Since 1980, the global obesity rate has almost doubled (WHO; qtd. in Neyal, 2013). According to the Center for Disease Control (CDC), over a third of Americans are obese (CDC; qtd. in Cross, 2012). In 2010, high body mass index (BMI) has surpassed childhood underweight as a risk factor for mortality and morbidity worldwide (Lim et al., 2010; qtd. in Neyal, 2013). Indeed, obesity is intimately tied to a wide variety of serious medical conditions such as cardiovascular disease and diabetes, culminating in an annual economic burden of $147 billion to the United States (CDC; qtd. in Neyal, 2013). The severe health consequences due to obesity and their economic costs compel the need to slow or halt the global rise in obesity, prompting the search for more efficacious public health policies. In this search for better healthcare policies to reduce obesity, one controversial question has arisen: should we deny healthcare to obese individuals?

A significant population of physicians, such as Dr. Carter, supports policies to withhold treatment from the obese. First, Dr. Carter argues that such policies may be an effective tool to motivate weight loss among obese individuals. Referring to her own patients who lost weight after having been denied care, Dr. Carter claims, “I’ve had at least two people be very motivated” (Cross, 2012). Second, Dr. Carter argues that since obesity is a condition borne out of personal choice, such as poor diet and exercise, society is not obligated to pay for obesity’s health costs. She believes that if the patients do not lose weight, “I’m paying the cost of other people’s choices”, driving her to reject obese patients (Zimmerman, 2012; qtd. in Eyal, 2013). Importantly, Dr. Carter is not the only physician who believes that doctors should have the right to deny care to the obese. The American Medical Association (AMA), a major organization comprised of physicians in the United States, claims that doctors have the right to choose whom they care for, stating “both patients and physicians exercise freedom in choosing with whom to enter into a patient-physician relationship” (AMA; qtd. in Cross, 2012). The AMA therefore implies that choosing not to serve obese patients is an ethically sound policy, since doctors have the freedom to choose their patients. Outside of the United States, the right to deny healthcare to the obese has also found major support. According to a recent survey administered in the United Kingdom, 54% of surveyed doctors responded yes to the question, “Should the NHS (National Health Service) be allowed to refuse non-emergency treatment to patients unless they lose weight or stop smoking?” (Campbell, 2012; qtd. in Neyal, 2013). As a whole, a significant population of doctors around the world supports the right to deny healthcare to obese individuals, arguing that rejecting obese patients compels them to lose weight, forces individuals to be responsible for their own health, and represents a physician’s freedom to choose whomever they want to serve.

On the other hand, Dr. Nir Eyal, an Associate Professor in Global Health and Social Medicine at the Harvard Medical School, argues that under no circumstances should society deny healthcare to obese individuals. First and foremost, Dr. Eyal claims, “society would benefit tremendously from nurturing the notion that healthcare is a basic and an inalienable right” (Eyal, 2013). Eyal suggests that denial of medical treatment to the obese would therefore violate the fundamental right of individuals to have access to healthcare. Expressing Dr. Eyal’s view that healthcare is a fundamental right, Davidson exclaims “I have never heard of anything like that. I thought doctors are supposed to help you” when she was rejected by her doctor (Cross, 2012). Second, Dr. Eyal argues that obese individuals are often stigmatized for their weight, and thus, denial of healthcare to the obese would perpetuate this social stigma. Ultimately, this social stigma worsens the obesity epidemic by discouraging healthy behavior. He tells us, “We also face a substantial problem of stigma against obese patients. Rejection by doctors, with its penal undertones and implicit threat of remaining with no social support, might exacerbate that. Augmented stigma may undermine, instead of [facilitate], healthier eating” (Eyal, 2013). Lastly, Dr. Eyal argues that although refusing care to obese patients may seem to incentivize weight loss, the policy actually impedes weight loss by preventing patients from accessing the clinical resources they need. While Dr. Eyal supports the use of “carrots” and “sticks” to induce weight loss, he proposes, “any conditional incentive for healthy choice should be in a currency other than the basic means to that healthy choice” (Eyal, 2013). Rather than using access to healthcare as a “carrot” or “stick”, Dr. Neyal suggests other forms of rewards such as “iPods or museum tickets or maybe even cash to patients who lose weight” (Eyal, 2013). As a whole, Dr. Neyal believes denying healthcare to the obese is a flawed policy that can only worsen the public health challenge of resolving modern trends in obesity.

The rising epidemic of obesity and its burden on the healthcare system have led to the controversial debate of whether healthcare should be denied to obese individuals. On one hand, some doctors argue that denying medical treatment to the obese may serve as an effective “stick” to drive weight loss in obese patients. These doctors also argue that obesity reflects lack of personal responsibility, resulting in the belief that healthy individuals are not obliged to be responsible for somebody else’s poor personal choices. Above all, the AMA states that doctors have the freedom to choose whom they serve, giving physicians the flexibility to deny healthcare to obese individuals. On the other hand, Eyal argues that healthcare is a basic human right that should never be denied, and that punishing obese patients by denial of treatment will only exacerbate the obesity epidemic. Specifically, Eyal advances the argument that any form of “carrot” or “stick” used by the healthcare system to compel weight loss should not prevent obese patients from accessing the healthcare they need. Indeed, Eyal is correct that rejecting the obese is a wrong healthcare policy, as it unfairly punishes obese individuals by making the limited assumption that obesity is strictly a personal problem of unhealthy lifestyle. However, Eyal’s reliance the “carrot and stick” to induce weight loss does not sufficiently address all of the social and cultural factors that perpetuate the obesity. These factors, such as the social stigma against obese individuals, hinder the way doctors treat obese patients as well as the ability of obese individuals to follow the doctor’s advice regarding weight loss. Ultimately, we cannot approach the obesity epidemic by rejecting the obese or relying the “carrot and stick” system to compel weight loss. Instead, we need to transform the sociocultural attitudes that surround obesity in order to bring about a long lasting cure to the obesity epidemic. Careful evaluation of the relationship between healthcare and obesity will lead us towards development of more effective and ethically sound policies to combat obesity, a pressing health dilemma that faces the world.

First, let us begin by evaluating the claim that healthcare should be denied to the obese on the basis of social responsibility. Dr. Carter claims that if obese patients do not lose weight, “I’m paying for other people’s choices”, implying that obesity is a preventable condition borne out of poor lifestyle choices (Cross, 2012). As a result, society does not have the obligation to pay for the health consequences of obesity since an obese individual failed to make healthy personal decisions. Indeed, it is universal knowledge within mainstream clinical medicine that eating junk food and lack of exercise are two of the most well documented contributors to obesity. However, it is important to also recognize that diet and exercise are not the only contributing factors towards obesity. Outside of lifestyle choices that individuals have control over, genetic heredity has also been shown to play important roles in the etiology of obesity. According to a review article written by three faculty members of Imperial College London, evidence from genomics research has shown that obesity is a highly heritable trait, identifying several genes and mutations that are linked to obesity (Walley, Blakemore, and Froguel 2006). These findings unveil the unexpected complexity of obesity on a genetics level, leading to the modern hypothesis that certain genetic defects predispose individuals to increased risk of obesity (Walley, Blakemore, and Froguel 2006). The functional significance of genes in obesity means that just because an individual is obese does not necessarily mean that he or she failed to make healthy decisions. As a result, denying healthcare to obese individuals on the assumption that they failed to make unhealthy decisions unfairly punishes those who may have had less control over their weight due to genetic factors.

Recognizing the importance of genetics in obesity, let us now discuss only the individuals who are obese solely due to personal choices. Are they still responsible for their own failures to uphold a healthy lifestyle? At the heart of this question is the belief that society should not be responsible for an individual’s conscious choice to participate in self-harming activities. In the case of obesity, individuals harm themselves by eating a poor diet and living a sedentary lifestyle, and thus do not deserve treatment. However, unhealthy diet and lack of exercise are not the only types of self-harming behavior. People smoke and drink even though they are aware of the health consequences from nicotine addiction and alcoholism. Football players put themselves at risk for injuries when they decide to play the physically demanding sport. The doctor is then confronted with a difficult question: who deserves healthcare the most, the obese man who regularly eats fast food, the smoker with lung cancer, the alcoholic whose liver is failing, or the football player who damaged his brain? Considering the endless possibilities of self-harming behavior, it is exceedingly difficult to figure out where to drawn the line between what is considered a problem deserving of care and what is not. Most importantly, denying healthcare on the condition of social responsibility overly deviates away from the fundamental principles of medicine. As Eyal points out, “society would benefit tremendously…from a culture in which doctors do not discriminate between patients but take them largely on the basis of medical need” (Eyal, 2013). Eyal suggests that since the archetypically selfless physician considers all patients who suffer from health issues deserving of virtually unconditional medical care, doctors should treat patients regardless of whether or not they consciously made poor decisions. As a result, rejecting healthcare on the basis of social responsibility severely contradicts with the altruistic duties of a doctor. Ultimately, it is medically unethical to reject treatment from the obese as we search for transformative solutions to the global obesity problem.

While Dr. Eyal’s argument that “any conditional incentive for healthy choice should be in a currency other than the basic means to that healthy choice” seems to be a reasonable and ethically sound “rule of thumb”, his dependence on rewards and punishment to compel weight loss is still not the best approach to combatting obesity (Eyal, 2013). As much as obesity is a medical problem, we also need to realize realize that obesity is significantly influenced by sociocultural factors, which cannot be directly addressed by Dr. Eyal’s simple system of “carrots” and “sticks” (Eyal, 2013). Indeed, he admits, “we also face a substantial problem of stigma against obese patients”, recognizing that the social stigma against obesity is an important issue that needs to be addressed (Eyal, 2013). Unfortunately, doctors partially contribute to this stigma. Based on a previous study showing that physicians have less respect for obese patients (Huizinga et al., qtd. in Gudzune et al., 2014), Johns Hopkins University researchers found that doctors were also less likely to provide encouragements such as “You are doing really well” when they communicate with obese patients, indicating that the social stigma against obesity adversely affects the way doctors interact with patients (Gudzune et al., 2014). For a physician, communication is they key to providing social support for patients as they try to lose weight, as the researchers point out, “patients want and need help from their primary care physicians in the complex and difficult realm of lifestyle change and weight management” (Gudzunne et al., 2014). When the social stigma against obesity compromises this communication, the patients cannot find the support they need from their doctors, placing further emotional and psychological stress that makes it more difficult for them to lose weight. Moreover, even if doctors implement creative carrots and sticks to motivate weight loss, obese individuals are not likely to be swayed by rewards and punishments if they still feel socially stigmatized by their own doctors. Ultimately, the biased treatment of obese patients by doctors represents a sociocultural challenge that needs to be addressed in order to combat obesity.

Although doctors should treat all patients fairly and equally to help alleviate the social stigma against obese individuals, the solution to obesity not only encompasses doctors who treat patients with less bias but also a major shift in public attitude. Recently, perceptions about body weight have drastically changed. Potentially a backlash against the negative bias towards obese individuals, there is now a growing social acceptance of obesity. However, this social acceptance does not mean that society is now more empathetic towards obese individuals. Rather, being overweight and obese is now viewed as normal. Research conducted by the Federal Reserve Bank of Boston in collaboration with Florida State University found that there is an increased tendency of women to incorrectly perceive their weight as “about right”, even though they are overweight as indicated by body mass index (Burke, Heiland, and Nadler 2010). The researchers also referred to a previous finding that showed 48% of obese individuals considered their own weight to be socially acceptable (Rand and Resnick, 2000; qtd. in Burke, Heiland, and Nadler 2010). Thus, the researchers commented, “people may be less likely to desire weight loss than previously, limiting the effectiveness of public health campaigns aimed at weight reduction” (Burke, Heiland, and Nadler 2010). Indeed, because obesity is now increasingly being viewed as normal, well-intentioned health advices regarding weight loss can be misinterpreted as personal attacks. This new attitude about obesity is dangerous to public health, as it can makes obese individuals complacent to the point where they disregard the health consequences of obesity. Ultimately, increased social acceptance of obesity is limiting our progress in resolving the obesity epidemic, compelling the need for campaigns or educational programs to remind the public that obesity is an international dilemma that needs to be resolved.

Although a significant population of doctors now support the denial of treatment to obese patients, it is imperative that we refrain from rejecting any type of patients, since all medical needs are deserving of a doctor’s attention. Thus, we shift our focus from asking should we deny healthcare to the obese to a rigorous discussion on development of solutions to the obesity epidemic. From the doctor’s perspective, we need better programs to train doctors how to better communicate with obese patients so that they feel socially and emotionally supported in their endeavor to change lifestyle and lose weight. From the patient’s perspective, we need to change the public attitude that obesity is normal, emphasizing the serious nature of the health consequences that come with being obese. Given that over a third of Americans are now obese, as well as the rise of obesity prevalence around the world, the obesity epidemic is a major international public health challenge that wrecks havoc on individuals, families, and society. Everyone deserves the right to be healthy, and a rigorous discussion about the relationship between obesity and healthcare will unveil innovative and transformative solutions that can more effectively resolve the global obesity challenge. It is therefore in the best interest of society that we develop more efficacious public policies to face the obesity epidemic head on.

References

1) Burke, M. A., Heiland, F. W., & Nadler, C. M. (2010). From “overweight” to “about right”: evidence of a generational shift in body weight norms. Obesity, 18(6), 1226-1234.

2) Cross, P. (2012, August 24). Doctor refuses to treat overweight Shrewsbury patient.

3) Eyal, N. (2013). Denial of treatment to obese patients—the wrong policy on personal responsibility for health. International journal of health policy and management, 1(2), 107.

4) Gudzune, K. A., Beach, M. C., Roter, D. L., & Cooper, L. A. (2013). Physicians build less rapport with obese patients. Obesity, 21(10), 2146-2152.

5) Walley, A. J., Blakemore, A. I., & Froguel, P. (2006). Genetics of obesity and the prediction of risk for health. Human Molecular Genetics, 15 (suppl 2), R124-R130.

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