Not long ago I bought a book, published in 1922, titled Syphilis of the Innocent. Needless to say, the title implied a corollary: for if syphilis could be contracted by the innocent (as, for example, in the congenital form of the disease), it could also be contracted by the guilty.
In general, however, physicians do not inquire after the morals of their patients, except in so far as those morals have immediate pathological consequences. They do not refuse to treat patients because they find them disgusting, because they find them unappealing, because they are appalled by the way they choose to live. They try to treat them as they find them; they may inform, but they do not reprehend.
However, in practice things are sometimes more complex than this ecumenical generosity of spirit might suggest. According to an article in a recent edition of the New England Journal of Medicine, some doctors have been turning away patients on the grounds that they were too fat (one physician suggested that she did so because, ridiculously, she feared for the safety of her staff once the patients weighed more than 200 pounds), or that their children have gone unimmunized. Is such discrimination by physicians legitimate or illegitimate, legally or morally speaking? Is there not a danger that physicians may hide behind pseudo-medical justifications to express their personal prejudices or to coerce patients into doing what the physicians think is good for them?
Week 11 of my second 13 week season: low-carb diet and more exercise, tracking my weight, blood glucose, and body fat. You can follow me at my 13 Weeks Facebook page for daily updates, and you can join Fitocracy (free!) and follow my daily exercise, and maybe even start tracking your own. And yes, I have been slack with the exercise this last couple weeks. Gimme a break, I had a car wreck.
Last week, Glenn Reynolds linked an interesting article in The Atlantic with a fascinating animated map.
Using CDC data, the map shows reported incidence of obesity by state starting in 1985. The reporting didn’t get started uniformly, but as you watch the progress, there is an obvious increase until by 2010 every state is reporting “high” obesity rates.
This image has some obvious problems — among other things, the definition of “obesity” here is using body mass index (BMI), which has flaws we’ve talked about before — but it still makes the point that people in the U.S. have been gaining weight for quite a while now.
There are a lot of reasons for this. Among other things, we’ve gotten to the point that pretty much everyone can afford to get enough to eat. As has been pointed out before, this was the first country in history in which the poor people are the fattest. But I noticed something else: if you watch it carefully, the increase in obesity, first in deeper blue then a sort of funny beige color, and then on to red, starts in the early ’90s. I went looking for historical summaries of the Department of Agriculture’s “food pyramid” and found several (see, eg, this.)
It’s an interesting coincidence that this increase in obesity started roughly at the same time that the U.S. government started to advocate low-fat, high-carb diets. I remember that period pretty clearly, because I thought it was wonderful. Entenmann’s came out with no-fat pastries — the no-fat cherry coffeecake was one of my favorites — I could eat as much rice as I wanted, pasta was good and more pasta was better, as long as you didn’t use butter because of the evil saturated fat and cholesterol. But margarine, rich in transfats made by hydrogenating corn oil, was much better.
Oddly, this didn’t seem to do much about my weight. I was a vegetarian for a number of those years, and while I lost weight during the relatively short interval in which I was vegan, I also had mood swings and health problems until I added back at least eggs and dairy.
Recently I was asked by BBC radio to discuss (in three minutes flat) the question of whether morbidly obese children were the victims of abuse by their parents. By coincidence, the Lancet of that week published an editorial on the psychological abuse of children and what doctors could or should do about it.
Nothing illustrates better than child abuse the tendency of ill-defined but nevertheless meaningful concepts to spread beyond their original signification to include more and more phenomena. The evolutionist Richard Dawkins has even suggested that to bring up children in any particular religious faith is a form of child abuse, since the child’s subsequent freedom to choose his beliefs according to the evidence is thereby impaired: in which case the history of all previously existing societies is not that of class struggles, as the Communist Manifesto has it, but of child abuse.
The editorial in the Lancet referred to a report on the psychological maltreatment of children by the American Academy of Pediatrics, the general drift of which was that such maltreatment is protean in nature and has bad effects upon children later in life, from mental illness and criminality to inability to form close relationships and low self-esteem. Maltreatment is dimensional rather than categorical: at what point does “detachment and uninvolvement” give way to “undermining psychological autonomy”?
Likewise “restricting social interactions in the community” can be a form of maltreatment, but so can failure to do so, in so far as association with undesirables might “encourage antisocial or developmentally inappropriate behavior.” Parenthood is thus a constant navigation between various Scyllas and Charybdises, and is rarely entirely successful. Surveys show that about one in sixteen people in Britain and America consider themselves to have been the subject of psychological abuse in childhood. I count myself as among the abused.
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.