Back in the late 1990s, Dr. Jerome P. Kassirer and Dr. Marcia Angell, both former editors-in-chief of The New England Journal of Medicine, wrote an editorial in the journal about the “dark side to this national preoccupation” with weight loss, with failed attempts often leaving dieters blaming themselves for being undisciplined and self-indulgent, and feeling guilt and self-hatred.
In their column, Kassirer and Angell acknowledged that being overweight is indeed correlated with substantial medical morbidity but they also noted that obese people were often “criticized with impunity” by those “critics merely trying to help them.” They added: “Some doctors take part in this blurring of prejudice and altruism when they overstate the dangers of obesity and the redemptive powers of weight loss.”
They also speculated about whether being overweight was actually “a direct cause of those illnesses associated with it"—an idea as controversial then as now—but they added, “few would claim that becoming obese is consistent with optimal health.”
The World Health Organization calls obesity a “global epidemic.” About 1.5 billion adults worldwide are overweight and at least 500 million are obese as defined by body mass index (BMI), according to its most recent statistics. Some researchers predict that these numbers will increase substantially in the next 15 years. Ironically, even as our population has grown increasingly overweight, there is still considerable prejudice—and overt discrimination—against those who are weight-challenged, even among the professionals who work with this population. (See my previous blog, “We Hold Those Truths to be Self-Evident...”)
Herein lies the conundrum: Given the prejudice against the overweight and obese, what measures can or should be taken to stem the increasing obesity rates? In the name of public health, is it ever appropriate to stigmatize and shame people into losing weight?
Bioethicist Daniel Callahan, writing in the Hastings Center Report (2013), suggests that there is a place for so-called “fat shaming” to attempt to overcome this epidemic. He suggests three major strategies:
- “Strong and somewhat coercive public health measures” (taxing sugared drinks, banning unhealthy food advertising to children, posting calorie information in restaurants, and reducing the costs of healthy foods through government subsidies);
- Childhood prevention programs (working through lunch programs, providing exercise opportunities in school and working through parents to discourage sedentary activities such as TV watching at home);
- Most controversially, “social pressure on the overweight.” Callahan believes that “whether they recognize their own role or not, (the public) need to understand that obesity is a national problem, one that causes lethal disease.” His solution is social pressure “that does not lead to outright discrimination,” or what he calls “stigmatization lite.” He suggests a series of questions that could be asked to “nudge” people in the right direction: “If you are overweight or obese, are you pleased with the way you look?” for example, or, “Fair or not, do you know that many people look down upon those excessively overweight or obese?"
In a recent article in the journal Biothethics (2014), medical ethicist Christopher Mayes takes issue with Callahan. He explains that Callahan sees obesity not just as a clinical or personal issue but frames it as an “ethical issue with social and political consequences,” in which obese people not only harm themselves but others as well, because of their increased economic costs to society. The problem is that obesity is far more complicated than mere individual choice—there are social, cultural, environmental, and biological variables to consider as well.
In general, coercing individuals toward healthy behaviors is mostly ineffective and potentially harmful in that it may increase stigmatization.
Although sociologist Erving Goffman prominently wrote of stigma in the 1960s, there is still no widely accepted definition of the term. It is a cultural phenomenon that involves an us-vs.-them mentality, in which people distinguish and differentiate themselves from others seen as having undesirable characteristics. Stigma can be a potent source of social control that can result in both the loss of status in a community, as well as overt discrimination. Those stigmatized often resort to attempts at concealment. This may happen with a disease that is not always evident like HIV/AIDS or epilepsy. Concealment, though, is not an option for the overweight and obese.
Law professor Scott Burris, writing in the Journal of Law, Medicine, and Ethics (2002), raised the provocative question of whether there can ever be “good stigma,” as in the ongoing campaign against smoking, in which the activity was deliberately stigmatized and transformed “from being a glamorous activity” into “antisocial self-destruction.” The dangers of smoking were emphasized and smokers were stigmatized as the habit became socially unacceptable and even restricted in most public places.
Burris, however, writes that stigmatizing a person because of an addiction or disease is an “offensive” form of “social warfare” that does not belong in campaigns for public health. This was even addressed in the 1962 Eighth Amendment (“cruel and unusual punishment”) decision by the Supreme Court in Robinson vs. California regarding alcoholism. The Court found it "barbarous” to allow “sickness to be made a crime and [to permit] sick people to be punished for being sick.” But Burris does distinguish between actually stigmatizing people and labeling behaviors, such as smoking, unsafe sex, and overeating as “bad.” "Criticism and negative attitudes," he says, "are not stigma.”
Bottom line: There is no straightforward answer, in the name of public health, to the question of how paternalistic a society should be in its attempts to “protect” citizens from unhealthy behavior. But certainly shaming, prejudice, and discrimination have no place.