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10 Controversial Medical Questions Answered by Dr. Dalrymple

Where do you stand on these challenging ethical and scientific debates?

Theodore Dalrymple


March 15, 2014 - 8:00 am
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From August 2012:

1. Is obesity a disease or a moral failing?

And what are we to make of the fact that an affliction of the rich is now predominantly a problem of the poor?

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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All Comments   (9)
All Comments   (9)
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More than half of these questions would simply go away if everyone (or their family or close friends as needed) paid for their own health care. For the remainder - perhaps excerpting parental responsibility for an obese child - it is sufficient for everyone to have their own opinion and act accordingly.
46 weeks ago
46 weeks ago Link To Comment
There's so much PC BS on most topics that it's startling to hear or read TS, "true speak." Thanks, Doc.
46 weeks ago
46 weeks ago Link To Comment
RE: Obesity & RE:Healthy Diet. I know 17 people with Hypo-Throidism, & most continue to gain weight eating healthy low cal diets with lots of aerobic exercise. I doubt most overweight people have this, but some do have a medical reason for obesity, likely a small minority. Those who simply choose a poor diet likely fall into one of these categories...1) I will eat what I want (needs immediate & constant gratification). 2) Too uninformed (or ill informed) to make intelligent choices. 3) Too poor to buy healthy food (the price, per calorie, of junk food has dropped, while the cost of real food has skyrocketed). If most people would eliminate all processed foods made with white flour & white sugar, & replace that with a MUCH SMALLER amount of whole grains than the food pyramid recommends & eat mostly lean sources of protein + lots of organic produce, they would naturally loose weight. For weight loss to be permanent, you have to make permanent changes!! "Let thy food be medicine & let thy medicine be food"...Hippocrates
46 weeks ago
46 weeks ago Link To Comment
Here in NV our absurd Medical Marijuana laws require a patient to break the law BEFORE they can comply with it. First, you have to break the law & illegally obtain the seeds. Then you apply for a Medical Marijuana card ($50.00), then pay another $50.00 for an "Illegal Contraband Tax Stamp", (no I'm NOT making that up). Then you have to "grow your own". Once "your crop comes in" FINALLY have your medicine. As a patient who laid in bed CRYING AND SCREAMING IN AGONIZING PAIN FOR MONTHS ON END, because pain pills don't work on me, NOT opiates & NOT NSAIDS, I can tell you that "witch hunt" leveled against Medical Marijuana is merely "cover" to TORTURE cancer patients like me. I choose not to break the law, because there's no telling when/who the Fed. Gov't. will turn on next & my Hubby is a legal immigrant, here on a Green Card from I SUFFERED!! The freely available (by RX) dangerous, highly addictive, toxic narcotics & their horrific side-effects they "experimented on me with" are what we should be worried about...NOT a plant that grows out of the ground!!
46 weeks ago
46 weeks ago Link To Comment
With the understanding that people should be free to obtain help for obesity, addiction, and all health issues at any age, but cannot demand that others pay for this treatment (Charity given by others is ok and encouraged), my take is as follows. Let the debate begin.

1. Obesity is neither a disease nor a moral failing
2. Alcoholics should not be denied available medical care
3. Psychiatric illnesses merit treatment as much as physical illnesses
4. Doctors sometimes are guilty of giving pain killers to addicts who con them
5. Elderly should not be denied available medical care
6. Marijuana can be a medicine, with side effects
7. Nutrition is important to health
8. Drug addiction is not like non-addiction illnesses but addicts should be treated
9. Obese children are not victims of child abuse
10. Parents should vaccinate their children
46 weeks ago
46 weeks ago Link To Comment
Interesting that the author chose only one vaccine to discuss pros and cons.
46 weeks ago
46 weeks ago Link To Comment
He must be in on the CONSPIRACY!!!!!!!
46 weeks ago
46 weeks ago Link To Comment
A government funded psychiatrist on an NHS pension in on 'the conspiracy'? No. Not possible.
45 weeks ago
45 weeks ago Link To Comment
Thank you, Doctor, for this thoughtful and objective article. These are two qualities that in tandem are virtuous but rarely encountered today.
46 weeks ago
46 weeks ago Link To Comment
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