The Hoe Cake

“Let Them Choose Not to Eat Cake…”

Let them choose is a seductive maxim for guiding health policy. In one sense, it seems perfectly reasonable. You get to choose. We respect personal agency.  But it can also be quite punitive. You made your choices, now you have a chronic disease. You’re on your own. Sorry. A new paper in the Future Healthcare Journal explains both sides of this coin. In Ohio, the state has put this into policies for doling out COVID-19 vaccines.

Drawing a Line Based on Fault

If you want a vaccine in Ohio right now because you have a medical condition that puts you at risk, you might or might not qualify. Congenital heart disease is in. Other forms – like heart failure – are out. Asthma is in, COPD is out. And of course, obesity is out.

Initially, the state gave the vaccine to people with type 1 diabetes, but not to those with type 2. But that created a fuss. So this week the state made up a whole new category for people with type 2 diabetes and kidney disease. They called it phase 1D. All of this is out of line with guidance from the U.S. Advisory Committee on Immunization Practices. But it lines up with a view that some diseases are more worthy than others – that some people deserve blame for health problems while others get a free pass. The health department explains it thusly:

“When it came to defining medical conditions for phased population prioritization, Ohio focused on congenital disorders that Ohioans were born with, or developed in early childhood.”

Cleveland.com calls this scheme shockingly biased. The chair of bioethics at Case Western Reserve University calls it “a notoriously problematic move.”

 Impact on Health and Equity

In their new paper, John Coggon and Jean Adams describe the political appeal of a blame-based public health strategy for obesity. They also explain why it is a poor ethical choice:

“To explore a question of values and policy, we may be interested in health outcomes and inequalities (as opposed, say, to formally shared equality of opportunity, caught in a shrug of the shoulders and an observation that in principle everyone is free to exercise more and choose healthier food).”

In short, though blame and shame appeal to some of the darker impulses of humanity, they are not terribly effective for promoting health. They do little to improve public health. They can, however, do much to increase health disparities, which are already quite large. We don’t need that.

Click here for the new paper by Coggin and Adams and here for an earlier analysis by Adams. For more on the Ohio situation, click here and here.

The Hoe Cake, painting by Horace Pippin / WikiArt

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March 12, 2021

2 Responses to ““Let Them Choose Not to Eat Cake…””

  1. March 13, 2021 at 10:03 am, David Brown said:

    Excerpt: “Tackling obesity is not just about an individual’s effort, it is also about the environment we live in, the information we are given to make choices; the choices that we are offered; and the influences that shape those choices.”

    In one sentence, Coggin and Adams have framed the problem correctly. The reason why the obesity remains intractable has to do with influences that determine the quality of food available to the public.

    Later on in the paper they mentioned “powerful industrial organisations with entrenched financial interest and (often) significant political influence, advocating against effective public health interventions… the best interventions may be impeded by matters that are not legitimate (eg given conflicts of interest, unwarranted scope for political influence).”

    Those “powerful industrial organizations” would include the edible oils industry, food manufacturers, agribusiness, and the pharmaceutical industry. It would be naive to suppose that these global financial titans do not influence the content of textbooks and the policies formulated by bureaucrats employed by government agencies.
    http://www.drjaywortman.com/blog/wordpress/2012/06/14/this-is-how-it-works/

  2. March 13, 2021 at 11:46 am, Ted said:

    I agree that they have framed this question well. I also agree that bias creeps into the information ecosystem. I think that bias comes from many sources – from industry, academics, and activists alike. Bias is intrinsic to our human nature. Curiosity and objectivity are the only antidotes I know.