An Ethicist Asks: Is Obesity Acceptable?

The Symbol of Welcome Is LightIn a provocative post on Medscape, medical ethicist Arthur Caplan tells us that he doesn’t believe in literally calling out people with obesity and shaming them. But, he says, we can’t give in to acceptance. Obesity is just too harmful to health.

What Exactly Does That Mean?

We find ourselves scratching our heads over his words. What does it mean to say that a complex chronic disease like obesity is “not acceptable”? Would we tell someone that their type 2 diabetes is not acceptable? How about someone with lung cancer?

Can we tell someone that they have an unacceptable, but chronic, health condition and expect that they will not feel shame?

Of course, some people like to argue that obesity isn’t really a chronic disease. That it’s a harmless physical characteristic defined solely by size and weight. And that is simply wrong. Obesity is a disease of excess adiposity harmful to health. Documentation of the considerable harm is solid, as Caplan notes.

Obesity Care Providers Beg to Differ

Nonetheless, asserting that obesity is unacceptable presents problems. First off, we have to deal with facts. It’s a fact that close to 40% of Americans have enough excess fat to harm their health. Obesity is a problem that is here and it’s showing no signs of receding. We have no choice but to accept that fact.

Secondly, it turns out that acceptance based therapy is one of the most promising new developments in behavioral treatment for obesity. Professor Michelle Cardel tells us that this approach can be exceptionally effective. Through techniques of acceptance and commitment to valued goals, people can achieve good outcomes. It’s a promising way to manage – though not necessarily cure – the chronic disease of obesity. Self-compassion helps, too.

But in Caplan’s argument against acceptance, Cardel finds a strong undercurrent of shame:

I have no doubt that Dr. Caplan is well intentioned. He states that he does not believe we should shame people based on their weight status. Yet, this article is a clear example of weight shaming. He states that “we should not concede that being fat is normal because it is unhealthy.”

His statements give further support for the idea that if you are of large body size, you are not normal, and therefore less worthy. The message places blame on the individual and has a dehumanizing effect. He rejects explicitly saying things like: “Aren’t you embarrassed? Don’t you have any self-respect?” But very similar sentiments are implicit in his recommendation to denormalize obesity.

Obesity is a chronic disease. Asking if it’s okay to have obesity is simply the wrong question to ask. It only serves to dehumanize people who are living with it.

Click here for Caplan’s commentary. Note that you’ll need to login (registration is free) to Medscape to access it. For more on acceptance based obesity care, click here.

The Symbol of Welcome Is Light, painting by Norman Rockwell / WikiArt

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May 17, 2018

10 Responses to “An Ethicist Asks: Is Obesity Acceptable?”

  1. May 17, 2018 at 8:14 am, Angela Meadows said:

    Hi Ted,

    I agree with your point here about the Caplan piece, obviously. But must take my usual stance on ‘obesity as disease’. Your definition of obesity, and one that is used by some organisations but still, rarely, by HCPs or policy makers, is circular. Obesity is a disease because it is defined as a level of fat that is associated with ill health, presumably heart disease, hypertension, T2DM and the like.

    But, other people may have the same level of adiposity but not have other health problems. And other people may have lesser levels of adiposity and suffer some or all of those health problems. The weight itself is not the health problem. Using your own definition, the health problem is the comorbidities that a given individual suffers from.

    So when you’re talking about treating with good outcomes but not curing, you’re talking about improvements or resolution of the actual health problems, but without significant changes in weight status. Surely this is an acceptable outcome. If a person is fat but without metabolic dysfunction, is this still a disease? Even by your definition, it is not.

    • May 17, 2018 at 10:17 am, Ted said:

      Thanks, Angela. As usual, I agree with most of what you say.

      You’ve come very close to describing what defines obesity. It’s really the failure of normal metabolic homeostasis that leads to the accumulation of visceral adipose tissue. Fat tissue builds up in and around vital organs like the liver. That in turn sets up other problems linked to systemic inflammation promoted by visceral adiposity. This includes diabetes, heart disease, certain cancers, and liver disease. Those complications are the result of obesity, not the definition of obesity.

      That takes us to defining a good outcome for a chronic disease like diabetes or obesity. A person who has well-controlled diabetes still has that chronic disease, even if they have reduced their A1C to a level in the normal range with diet, exercise, and medications.

      Likewise, someone who has managed to achieve and maintain a 5-10% weight loss, resulting in significant improvements to metabolic complications of obesity, still has obesity. They’re just managing it well. The same would be true for the friend that Michelle Vicari describes in this tweet. She has done very well in managing obesity and her health is good. Remission and control are possible. Cures not so much.

  2. May 18, 2018 at 12:14 am, Michael said:

    I’m struck by the idea of what’s normal vs. what’s shameful.

    One day I hope it will be generally accepted that obesity is a normal response by predisposed people in an abnormal (obesogenic) environment.

    The shame felt by or directed at people with obesity should be no more than the shame of skin cancer.

    • May 18, 2018 at 2:54 am, Ted said:

      Thanks, Michael. Well said.

  3. May 22, 2018 at 10:10 pm, M said:

    I’m continually horrified by the idea that anything positive towards people with obesity is the same thing as encouraging, “promoting”, or “normalizing” obesity. All of these are used as some kind of moral panic, as if fat people are running around shoving cheesecakes down thin people’s throats because fat people want everyone else to be fat.

    The further argument is that there’s tons of science that shows that being fat is bad, so it’s ok to tell fat people that they’re bad, too. These arguments are really nothing new, and have been used to excuse bigotry for ages.

    If you want to help someone improve themselves, you start by treating them with kindness and dignity. There’s still a long way to go in the medical world to reach the point where patients with obesity are no longer seen as non-compliant and lazy and gluttonous. The American Pediatrics Association is ahead of the curve here, with their push for weight-neutral health. Once practitioners start accepting similar ideas and, for too many of them, stop seeing fat people as a waste of their time, perhaps the rest of the world will start following along.

    • May 23, 2018 at 12:05 am, Ted said:


  4. May 25, 2018 at 10:20 am, Doug said:

    I think your response to Caplan’s piece is a bit off the mark. My read of his commentary is that he is making a distinction between population-level obesity and individual-level obesity, though he did not use exactly those terms. He is arguing, and I think most of us would agree, that obesity is a population-wide health problem that we should not just accept as normal. We are all concerned about obesity because it is associated with adverse health outcomes; if we were able to wave a wand and eliminate obesity, we would do so because it would no doubt improve the health and well-being of the population. That is NOT to say that people who are obese should be erased or that they are bad people or deserving of shaming. Caplan says plainly that people who are obese do not deserve shaming. So let’s not jump to a response driven by outrage and continue our work to help people who are obese lead healthy lives and just as importantly, work to eliminate the root causes of obesity.

    • May 25, 2018 at 11:41 am, Ted said:

      Individuals make up a population, Doug. The members of the population whom you describe as “obese” might have a different view about your work to “help” them “lead healthy lives.”

  5. May 25, 2018 at 10:30 am, Katherine Flegal said:

    Caplan says “After all, if 40%-50% of Americans are overweight, then it’s clear that a lot of us struggle to solve and cope with this problem.” Almost 70% of the US adult population is classified as overweight or obese, of whom 37% are obese and about 33% are overweight not obese. So I wonder where Caplan is getting his numbers from. Incidentally, of white men, about 74% are overweight or obese, and for men in the age range 55 to 74, over 76% are overweight or obese.

    This makes me wonder whether Caplan really has any expertise in obesity anyway or is just making pronouncements without doing research to back up some of the things he says. He also says “We have many weight-associated health issues, and the only solution to these issues is to get us to try to lose weight. That is not something that is arguable or that the facts don’t bear out. It’s simply true. ” I wonder how he would then explain the remarkable fall in cardiovascular mortality rates over the decades during which obesity prevalence was also rising. His commentary seems somewhat amateurish.

    • May 25, 2018 at 11:44 am, Ted said:

      Points well made, Katherine.