In his article, “Obesity: Chasing an Elusive Epidemic,” published in the Hastings Center Report, Daniel Callahan posits that obesity is so widespread and embedded in our culture that most if not all efforts to combat it have failed, and failed miserably. Change, in a large and most revolutionary sense, is required, or as he puts it, “an edgier strategy is needed.” That strategy is three-pronged: “strong and most likely somewhat coercive public health measures mainly by government but also by the business community; childhood prevention programs; and social pressure on the overweight.”
We should all be concerned about obesity and its consequences for individual and public health. No one opposes better education about nutrition or the availability of affordable and healthy food choices for all. There is a legitimate role for government and business in combatting this problem, and childhood is as good a place to start as any. But using social pressure to shame the obese is, well, shameful.
It is wrong to assume that all obese people are the same and that they are obese for the same reasons. It may well be that some are obese as a result of poor lifestyle choices, although even among those, one needs to be careful to assess how much choice actually exists. Poverty may make the choice of cheap carbohydrates a necessity if one is to avoid actual hunger. Beyond those whose obesity is the result of willful couch-potato behavior and sugary sodas (though one should ask whether it is really willful or is rather the result of some pathology), I am not sure what science knows about why people become and remain obese.
Perhaps I should be clearer. From personal experience, unless my health care providers are uneducated and in possession of fraudulent medical and related professional degrees, I can say that science knows very little. I have lived most of my life as a thin person, but after cancer treatment and menopause (more or less simultaneously), I found myself gaining weight. My body mass index hovers in the “overweight” range, but only a millimeter or two this side of “obese.” In the past 10 years, I have sought solutions to my weight gain from a family doctor, an internist, and three highly qualified nutritionists. I eat well and exercise. Apart from genetics, no one has a reason for my weight gain; no one has been successful in finding a diet or exercise program that has produced results. I know that there are others like me out there.
Shame will not help me, and it should not be used on me. Shaming presumes that all obese people are engaging in shameful behavior. It is impossible to judge from looking at a person why she is the size she is, or whether behavior that may cause weight gain is entirely within a person’s control.
Callahan falls back on his own experience as a former smoker, claiming that the “force of being shamed and beat upon socially” was instrumental in his breaking the habit, even more influential than threats to his health. And he was not alone. He credits the success of the antismoking campaign to its “turning what had been considered simply a bad habit into reprehensible behavior.” He acknowledges that blaming the victim has not been effective in other public health initiatives and that the antismoking campaign might have been an outlier in this regard. But he then goes on to suggest kinds of social pressure that might be brought to bear on the obese – not outright discrimination, but what he calls “a kind of stigmatization lite.”
He is a little vague as to what forms that social pressure ought to take, but he believes that leaving individuals to address their problems on their own is insufficient. This is where the “edgier strategy” of social pressure comes in. Somewhat ambiguously, he writes that most people who are already overweight and obese “are already lost,” yet later he states that there may be some hope. Obese people who don’t realize that they are obese need a “shock of recognition” that comes from “a carefully calibrated effort of public social pressure.”
I suspect that Callahan might be correct in his assessment that stigmatization was an effective strategy to get some people to quit smoking. Putting aside for the moment the very real issue of addiction to tobacco and its curtailment of real choice, smoking is a behavior. As such, it can be identified and made the object of shame. Lung cancer and emphysema may be the result of smoking, but is there any among us who think shaming is appropriate for those who suffer from these, or any, diseases? In Callahan’s view, if shame is to be heaped, it might be reserved for the actual behavior of buying and drinking extra-large sodas or eating daily at fast food establishments, or engaging in perennial couch-sitting. Obesity, like lung cancer, is not a behavior, but rather, could be the result of certain behaviors. To simply point and shame a large person is to shame the result, not the behavior itself.
But this may be a quibble that misses the larger point. Even if we wanted to stigmatize behavior, we the public are seldom in a position to judge someone else’s food habits as reprehensible; we simply do not know enough about an individual’s story: does he always get fries with that? Is this my first and only donut this year, or do I eat them by the dozen? Or, in my case, does my overweight condition persist not because of, but in spite of, my healthy behaviors?
“Stigmatization lite,” really? Full of ignorance and judgment, short on compassion, and probably on results.
Susan B. Apel is a professor at Vermont Law School and director of its General Practice Program. She is also an adjunct professor at the Geisel School of Medicine at Dartmouth.