Obesity – being very fat – is a condition that is at the much disputed border between medicine and moral weakness. No one doubts that being very fat is bad for you, that is to say has deleterious consequences as far as pathology and life expectancy are concerned, to say nothing of aesthetics, but is it a disease in itself, and are doctors their patients’ keepers? To this no final answer can be returned, for it lies not in the realm of physic but of metaphysic. One answers as much according to one’s philosophical predilections and presuppositions as to empirical evidence.

Many people take obesity as a mass phenomenon (if I may be allowed a little pun of doubtful taste), not just among the American but among the world population, as evidence that people are not really responsible as individuals for what they put into their mouths, chew, and swallow, but rather victims of something beyond their control. If they are not so responsible, of course, it is rather difficult to see what they are or even might be responsible for. But the impersonal-forces point of view is well expressed in an editorial in a recent edition of the New England Journal of Medicine by a public health doctor and an expert in “communication,” by which I suppose is meant advertising and propaganda.

The concern [about the increasing obesity of the population] prompted the recent Institute of Medicine (IOM) report, “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.” The groundbreaking report and accompanying HBO documentary, “The Weight of the Nation,” present a forceful case that the obesity epidemic has been driven by structural changes in our environment, rather than embrace the reductionist view that the cause is poor decision making by individuals.

There follow in the editorial, as perhaps one might expect, a few paragraphs of managerialese, whose only moral principle is that it is vital not to stigmatise the fat because then they might feel bad about being fat. It is a bad thing, ex hypothesi, to be fat, but apparently an even worse one to feel bad about being fat – a feeling that might, I suppose, lead fat people to eating more Krsipy Kreme doughnuts. Once a certain point is reached, then, people are not fat because they eat, but eat because they are fat. Nietzsche would have found this reversal of causative relationship interesting.

As everyone knows, there has been another historical reversal: obesity was once the problem of the rich, but now, epidemiologically speaking, it is a problem of the poor. Curiously enough, in the light of a general denial of personal responsibility for conduct, there have of late been increasing attempts by doctors and public health authorities to pay, or to bribe, the poor into behaving healthily, for example by giving up smoking. There have even been experiments to get drug addicts to give up by means of payment, either in cash or in kind. A certain success has been claimed for these methods; and thus, as the British Medical Journal put it in the same week as the NEJM editorial, “Using cash incentives to encourage healthy behaviour among poor communities is being hailed as a new silver bullet in global health.”

But cash payments can work only if people are capable of making choices. How then do we resolve the contradiction? I hesitate to quote a doctor of philosophy rather than of medicine, but here is what Karl Marx had to say:

Men make their own history, but not just as they please; they do not make it under circumstances chosen by themselves, but under circumstances directly encountered, given and transmitted from the past.

Only public health doctors and experts in communication are free of such constraints, and they make history for other people.


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