scroll to top
0

Mobile Menu

Header Layout

EBSCO Auth Banner

Let's find your institution. Click here.

Page title

A Matter of Justice: "Fat" Is Not Necessarily a Bad Word.

  • Academic Journal
  • The Hastings Center report [Hastings Cent Rep] 2020 Sep; Vol. 50 (5), pp. 11-16.
  • English
  • This essay argues that the discrimination that fat patients face is an issue of health justice. Insofar as this is the case, bioethicists and health care providers should not only care about it but also work to dismantle the systematic, institutional, social, and individual factors that are contributing to it to ensure that fat patients receive high-quality health care, free of stigma and discrimination. The essay discusses a variety of ways in which fat patients are discriminated against and considers the false assumptions that fuel such discrimination. It concludes by considering the structural and social issues that contribute to fatness and pushes health care providers to abandon the assumption that being fat is an individual moral failing. Ultimately, the paper argues, "fat" is not necessarily a bad word, nor one that health care providers should avoid.
    (© 2020 The Hastings Center.)
Additional Information
Publisher: Wiley-Blackwell Country of Publication: United States NLM ID: 0410447 Publication Model: Print Cited Medium: Internet ISSN: 1552-146X (Electronic) Linking ISSN: 00930334 NLM ISO Abbreviation: Hastings Cent Rep Subsets: MEDLINE
Publication: 2012- : Malden, MA : Wiley-Blackwell
Original Publication: Hastings-on-Hudson, N. Y., Institute of Society, Ethics and the Life Sciences.
On June 18, 2013, the American Medical Association further entrenched the medicalization of obesity by elevating it from a risk condition to a disease. This decision aligns with the way that obesity is understood by the World Health Organization, the U.S. Food and Drug Administration, the National Institutes of Health, and the American Association of Clinical Endocrinologists. For an excellent discussion of this framing of obesity, in particular, how problematic the body mass index measurement is, see A. Reiheld, “With All Due Caution: Global Anti-obesity Campaigns and the Individualization of Responsibility,” IJFAB: International Journal of Feminist Approaches to Bioethics 8, no. 2 (2015): 226-49, at 228-32.
Microaggressions can be defined as verbal, behavioral, or environmental slights or snubs that are mostly unintentional, fueled by bias and stereotypes, and directed against members of marginalized groups.
See R. Puhl and K. D. Brownell, “Bias, Discrimination, and Obesity,” Obesity Research 9, no. 12 (2001): 788-805; R. M. Puhl and C. A. Heuer, “The Stigma of Obesity: A Review and Update,” Obesity 17, no. 5 (2009): 941-64; K. D. Brownell et al., eds., Weight Bias: Nature, Consequences, Remedies (New York: Guilford Press, 2005).
For a discussion of this myth, see S. M. Phelan et al., “Impact of Weight Bias and Stigma on Quality of Care and Outcomes for Patients with Obesity,” Obesity Reviews 16, no. 4 (2015): 319-26, at 321.
J. C. Chrisler and A. Barney, “Sizeism Is a Health Hazard,” Fat Studies 6, no. 1 (2017): 38-53.
On the so-called moral failings of fat people, see C. Pausé, “Live to Tell: Coming Out as Fat,” Somatechnics 2, no. 1 (2012): 42-56; A. Jutel, “Weighing Health: The Moral Burden of Obesity,” Social Semiotics 15, no. 2 (2005): 113-25.
See R. Puhl and K. D. Brownell, “Ways of Coping with Obesity Stigma: Review and Conceptual Analysis,” Eating Behaviors 4, no. 1 (2003): 53-78; R. M. Puhl and C. Heuer, “Obesity Stigma: Important Considerations for Public Health,” American Journal of Public Health 100, no. 6 (2010): 1019-28; S. H. Kim and L. A. Willis, “Talking about Obesity: News Framing of Who Is Responsible for Causing and Fixing the Problem,” Journal of Health Communication 12, no. 4 (2007): 359-76; C. Crandall and M. Biernat, “The Ideology of Anti-fat Attitudes,” Journal of Applied Social Psychology 20, no. 3 (1990): 227-43; Reiheld, “With All Due Caution.”.
See M. Dean, “Eating Identities, ‘Unhealthy’ Eaters, and Damaged Agency,” Feminist Philosophy Quarterly 4, no. 3 (2018): 1-26.
C. Pausé, “Rebel Heart: Performing Fatness Wrong Online,” M/C Journal 18, no. 3 (2015): http://www.journal.media-culture.org.au/index.php/mcjournal/article/viewArticle/977.
For an excellent discussion on character flaws attributed to fat people, see R. Kukla, “Shame, Seduction, and Character in Food Messaging,” in The Oxford Handbook of Food Ethics, ed. A. Barnhill, T. Doggett, and M. Budolfson (New York: Oxford University Press, 2018), 593-613. Also see Dean, “Eating Identities.” For a discussion of the problematic ways that fat people are portrayed in media imaging-what Charlotte Cooper calls “headless fatties”-that contribute to the inhumane ways that fat people are thought of and treated, see C. Cooper, “Headless Fatties,” 2007, http://charlottecooper.net/fat/fat-writing/headless-fatties-01-07/.
R. Gay, Hunger (New York: Harper Collins, 2017), 120-21.
Ibid., 273-74. For another personal account of problematic assumptions that health care providers make about fat people, namely, that because they're fat, they're not healthy or athletic, see “Dialogues on Disability: Shelley Tremain Interviews Alison Reiheld,” Biopolitical Philosophy, September 18, 2019, https://biopoliticalphilosophy.com/2019/09/18/dialogues-on-disability-shelley-tremain-interviews-alison-reiheld/. This article also discusses common assistive devices like wheelchairs, crutches, and resting walkers that are not built to actually assist fat bodies. Similarly, many medical devices like CT scanners and magnetic resonance imaging machines cannot fit fat bodies. Also see Phelan et al., “Impact of Weight Bias,” 321-22.
See the work of Ragen Chastain, who discusses the inability of fat people to counter assumptions about their “bad” eating habits, lack of exercise, and poor health status. She calls this phenomenon the “but but but syndrome” (“But But But Syndrome,” Dances with Fat [blog], June 14, 2011, https://danceswithfat.wordpress.com/2011/06/14/but-but-but-syndrome/).
On fat people's avoidance of health care settings, see C. A. Drury and M. Louis, “Exploring the Association between Body Weight, Stigma of Obesity, and Health Care Avoidance,” Journal of the American Academy of Nurse Practitioners 14, no. 12 (2002): 554-61; on fat people delaying or avoiding health care, see C. L. Olson, H. D. Schumaker, and B. P. Yawn, “Overweight Women Delay Medical Care,” Archives of Family Medicine 3, no. 10 (1994): 888; K. Malterud and K. Ulriksen, “Obesity, Stigma, and Responsibility in Health Care: A Synthesis of Qualitative Studies,” International Journal of Qualitative Studies on Health and Well-Being 6, no. 4 (2011): 8404; Phelan et al., “Impact of Weight Bias”; on fat people being treated badly because they are fat, see Pausé, “Live to Tell.”.
N. K. Amy et al., “Barriers to Routine Gynecological Cancer Screening for White and African-American Obese Women,” International Journal of Obesity 30, no. 1 (2006): 147-55; Drury and Louis, “Exploring the Association”; Olson, Schumaker, and Yawn, “Overweight Women”; Pausé, “Live to Tell.”.
T. Andreyeva, R. Puhl, and K. D. Brownell, “Changes in Perceived Weight Discrimination among Americans, 1995-1996 through 2004-2006,” Obesity 16, no. 5 (2008): 1129-34.
S. Lewis et al., “How Do Obese Individuals Perceive and Respond to the Different Types of Obesity Stigma That They Encounter in Their Daily Lives? A Qualitative Study,” Social Science & Medicine 73, no. 9 (2011): 1349-56; Puhl and Brownell, “Ways of Coping.”.
See, for example, J. A. Lee and C. Pausé, “Stigma in Practice: Barriers to Health for Fat Women,” Frontiers in Psychology 7 (2016): doi:10.3389/fpsyg.2016.02063; Malterud and Ulricksen, “Obesity, Stigma, and Responsibility”; Phelan et al., “Impact of Weight Bias”; F. Rubino et al., “Joint International Consensus Statement for Ending Stigma of Obesity,” Nature Medicine 26 (2020): 485-97.
Phelan et al., “Impact of Weight Bias.”.
K. A. Gudzune et al., “Physicians Build Less Rapport with Obese Patients,” Obesity 21, no. 10 (2013): 2146-52.
See M. R. Hebl and J. Xu, “Weighing the Care: Physicians’ Reactions to the Size of a Patient,” International Journal of Obesity 25, no. 8 (2001): 1246-52; M. M. Huizinga et al., “Physician Respect for Patients with Obesity,” Journal of General Internal Medicine 24, no. 11 (2009): 1236-39.
Phelan et al., “Impact of Weight Bias,” 321.
G. Foster et al., “Primary Care Physicians’ Attitudes about Obesity and Its Treatment,” Obesity Research 11, no. 10 (2003): 1168-77, at 1174.
A. C. Saguy, “If Obesity Is a Disease, Why Are So Many Obese People Healthy?,” Time, June 24, 2013. See also N. Boero, “Obesity in The Media: Social Science Weighs In,” Critical Public Health 23, no. 3 (2013): 371-80.
M. Hobbes, “Everything You Know about Obesity Is Wrong,” Huffington Post, September 19, 2018.
J. P. Kassirer and M. Angell, “Losing Weight-an Ill-Fated New Year's Resolution,” New England Journal of Medicine 338 (1998): 52-54.
K. D. Hall et al., “Energy Balance and Its Components: Implications for Body Weight Regulation,” American Journal of Clinical Nutrition 95, no. 4 (2012): 989-94.
See A. E. Bombak, “The ‘Obesity Epidemic’: Evolving Science, Unchanging Etiology,” Sociology Compass 8, no. 5 (2014): 509-24; P. Campos et al., “The Epidemiology of Overweight and Obesity: Public Health Crisis or Moral Panic?,” International Journal of Epidemiology 35, no. 1 (2006): 55-60.
A. J. Tomiyama, B. Ahlstrom, and T. Mann, “Long-Term Effects of Dieting: Is Weight Loss Related to Health?,” Social and Personality Psychology Compass 7, no. 12 (2013): 861-77.
T. Mann et al., “Medicare's Search for Effective Obesity Treatments: Diets Are Not the Answer,” American Psychologist 62, no. 3 (2007): 220-33.
G. Kolata, Rethinking Thin: The New Science of Weight Loss-and the Myths and Realities of Dieting (New York: Farrar, Straus and Giroux, 2007), 122.
Puhl and Heuer, “Obesity Stigma.”.
For an excellent summary of this research, see Puhl and Heuer “Obesity Stigma,” 1023. Also see Phelan et al., “Impact of Weight Bias,” 320-22, and Rubino et al., “Joint International Consensus.”.
American Psychological Association, “Fat Shaming in the Doctor's Office Can Be Mentally and Physically Harmful,” press release, August 3, 2017, https://www.apa.org/news/press/releases/2017/08/fat-shaming. This press release describes research reported that day by Joan Chrisler and Maureen McHugh during the symposium “Weapons of Mass Distraction-Confronting Sizeism” at the 125th Annual Convention of the American Psychological Association, in Washington, DC.
A. Morrow, “The Ninety-Five Percent: Fighting Neoliberalism and Fatphobia Together,” Food, Fatness, and Fitness: Critical Perspectives (blog), February 2, 2016, http://foodfatnessfitness.com/2016/02/02/fighting-neoliberalism-and-fatphobia-together/; A. Morrow, “The Foodscape Argument: When Fatphobia Poses as Radical Social Critique,” Food, Fatness, and Fitness: Critical Perspectives (blog), June 21, 2016, http://foodfatnessfitness.com/2016/06/21/foodscape-argument-fatphobia-poses-radical-social-critique/; Puhl and Heuer, “Obesity Stigma.”.
D. Callahan, “Obesity: Chasing an Elusive Epidemic,” Hastings Center Report 43, no. 1 (2013): 34-40.
See T. Inge, quoted in C. Sieczkowski, “‘Fat-Shaming’ Strategy Pushed by Bioethicist Daniel Callahan to Help Curb Obesity,” Huffington Post Science, January 24, 2013; C. J. Pausé, “Die Another Day: The Obstacles Facing Fat People in Accessing Shame-Free and Evidence-Based Health Care,” Narrative Inquiry in Bioethics 4, no. 3 (2014): 135-41.
Puhl and Heuer, “Obesity Stigma.”.
Ibid., 1022. On stigmatization and binge eating, see J. A. Ashmore et al., “Weight-Based Stigmatization, Psychological Distress, & Binge Eating Behavior among Obese Treatment-Seeking Adults,” Eating Behaviors 9, no. 2 (2008): 203-9.
Puhl and Heuer, “Obesity Stigma.”.
“Dialogues on Disability: Shelley Tremain Interviews Alison Reiheld.”.
However, the strictures of this short essay require me to limit myself to the issue of justice.
See, for example, D. Lupton, Fat (New York: Routledge, 2018); M. Wann, “Fat Studies: An Invitation to Revolution,” foreword to The Fat Studies Reader, ed. E. Rothblum and S. Solovay (New York: New York University Press, 2009), xi-xxv; and the work of fat activist and blogger Ragen Chastain, specifically in her blog, Dances with Fat (https://danceswithfat.org). Yet note that many fat people eschew the term “fat” precisely because it is still laden with fat stigma, efforts of fat activists notwithstanding. I'm grateful to a Hastings Center Report reviewer for pushing me to make this point.
Lupton, Fat, 6.
Wann, “Fat Studies,” xiii.
Ibid.
L. R. Vartanian, “‘Obese People’ vs. ‘Fat People’: Impact of Group Label on Weight Bias,” Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity 15 no. 3 (2010): e195-e198.
Morrow, “The Foodscape Argument”; Puhl and Heuer, “Obesity Stigma”; R. P. Wildman et al., “Obese without Cardiometabolic Risk Factor Clustering and the Normal Weight with Cardiometabolic Risk Factor Clustering: Prevalence and Correlates of 2 Phenotypes among the U.S. Population (NHANES 1999-2004),” Archives of Internal Medicine 168, no. 15 (2008): 1617-24. Such prejudice also obscures the so-called skinny unhealthy: non-overweight individuals who, despite their body size, are what's been called “metabolically obese”; see N. Ruderman et al., “The Metabolically Obese, Normal-Weight Individual Revisited,” Diabetes 47, no. 5 (1998): 699-713; A. D. Karelis et al., “Metabolic and Body Composition Factors in Subgroups of Obesity: What Do We Know?,” Journal of Clinical Endocrinology & Metabolism 89, no. 6 (2004): 2569-75.
See Hobbes, “Everything You Know”; Wildman et al., “Obese without Cardiometabolic Risk Factor”; and A. J. Tomiyama, “Misclassification of Cardiometabolic Health When Using Body Mass Index Categories in NHANES 2005-2012,” International Journal of Obesity 40, no. 5 (2016): 883-86.
J. P. Rey-López, “The Prevalence of Metabolically Healthy Obesity: A Systematic Review and Critical Evaluation of the Definitions Used,” Obesity Reviews 15, no. 10 (2014): 781-90; Wildman et al., “Obese without Cardiometabolic Risk Factor.” Though there might be some instances in which losing weight would be beneficial to a patient (such as someone waiting for a knee replacement whose ailing knee is having trouble supporting their current weight and would do better and cause less pain supporting a lighter body) or necessary (such as someone with type II diabetes), the worry is that, too often, being overweight is the go-to diagnosis when it's not necessarily even related to the real issue at hand (see, for example, Phelan et al., “Impact of Weight Bias”).
P. Muennig, “The Body Politic: The Relationship between Stigma and Obesity-Associated Disease,” BMC Public Health 8, no. 1 (2008): doi:10.1186/1471-2458-8-128.
See M. S. Himmelstein et al., “The Weight of Stigma: Cortisol Reactivity to Manipulated Weight Stigma,” Obesity 23, no. 2 (2015): 368-74; N. A. Schvey, R. M. Puhl, and K. D. Brownell, “The Stress of Stigma: Exploring the Effect of Weight Stigma on Cortisol Reactivity,” Psychosomatic Medicine 76, no. 2 (2014): 156-62; and Phelan et al., “Impact of Weight Bias.”.
K. A. Matthews et al., “Unfair Treatment, Discrimination, and Ambulatory Blood Pressure in Black and White Adolescents,” Health Psychology 24, no. 3 (2005): 258-65.
B. Major, D. Eliezer, and H. Rieck, “The Psychological Weight of Weight Stigma,” Social Psychological and Personality Science 3, no. 6 (2012): 651-58.
See C. J. Pausé, “The Ethics of Fat Stigma in Public Health,” Journal of Law, Medicine, and Ethics 45 (2017): 510-17, at 512, and Phelan et al., “Impact of Weight Bias,” 319.
Muennig, “The Body Politic”; Morrow, “The Foodscape Argument”; Puhl and Heuer, “Obesity Stigma.”.
See Kukla, “Shame, Seduction, and Character,” and Dean, “Eating Identities.”.
For an excellent discussion (and critique) of these environmental factors, as well as other situational factors that contribute to how we eat and how much, see Megan Dean's article “Eating Identities,” especially pages 17-20. Dean also discusses how the “unhealthy eater” label results in serious and enduring harms to agency: specifically, deprivation of opportunity, infiltrated consciousness, distorted action, and blocked identities. Moreover, she discusses how the label is much more likely to be attributed to some people (members of marginalized groups) rather than to others.
See, for example, Phelan et al., “Impact of Weight Bias,” 16; M. S. Faith and T. V. Kral, “Social Environmental and Genetic Influences on Obesity and Obesity-Promoting Behaviors: Fostering Research Integration,” in Genes, Behavior, and the Social Environment: Moving beyond the Nature/Nurture Debate, ed. L. M. Hernandez and D. G. Blazer, Institute of Medicine Committee on Assessing Interactions among Social, Behavioral, and Genetic Factors in Health (Washington, DC: National Academies Press, 2006), 236-80. Also see Morrow, “The Foodscape Argument,” footnote 1, for a very interesting discussion of the complex reasons that body size has been increasing.
A. L. Dannenberg et al., “The Impact of Community Design and Land-Use Choices on Public Health: A Scientific Research Agenda,” American Journal of Public Health 93, no. 9 (2003): 1500-8; K. M. Booth, M. M. Pinkston, and W. S. C. Poston, “Obesity and the Built Environment,” Journal of the American Dietetic Association 105, no. 5 (2005): 110-17.
Puhl and Heuer, “Obesity Stigma.”.
E. A. Finkelstein, C. J. Ruhm, and K. M. Kosa, “Economic Causes and Consequences of Obesity,” Annual Review of Public Health 26 (2005): 239-57.
J. Guthman, “Too Much Food and Too Little Sidewalk? Problematizing the Obesogenic Environment Thesis,” Environment and Planning A 45, no. 1 (2013): 142-58.
For an excellent intersectional analysis that links anti-fat bias to ageism, racism, xenophobia, classism, and sexism (in addition to the neoliberal value of personal responsibility), see Morrow, “The Foodscape Argument.” Also see Morrow, “The Ninety-Five Percent”; Pausé, “The Ethics of Fat Stigma in Public Health,” 511-12; and R. Chastain, “No, We Can't Agree to Disagree about Fat-Shaming (or Any Kind of Oppression),” Dances with Fat (blog), June 23, 2020, https://danceswithfat.org/2020/06/23/no-we-cant-agree-to-disagree-about-fat-shaming-or-any-kind-of-oppression/.
For an account of the myriad ways in which women are not believed with regard to their claims to pain, see M. Dusenbery, Doing Harm: The Truth about How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick (New York: HarperCollins, 2018).
Michael Hobbes discusses this case in “Everything You Know about Obesity Is Wrong,” Huffington Post, September 19, 2018.
For a thoroughly intersectional analysis of body size, race, and sexuality, see B. D. Wilson, “Widening the Dialogue to Narrow the Gap in Health Disparities: Approaches to Fat Black Lesbian and Bisexual Women's Health Promotion,” in The Fat Studies Reader, ed. E. D. Rothblum and S. Solovay (New York: New York University Press, 2009), 54-64.
A. Reiheld, “What Does It Mean to Treat Fat Patients Well?,” presentation for the hospital ethics committee at Atrium Health CHS NorthEast, Concord, NC, March 12, 2019.
For the most compelling argument that I've read that we ought to consider weight stigma both as a social justice issue and as a priority in public health, see Puhl and Heuer, “Obesity Stigma.” In particular, Puhl and Heuer's three normative conclusions are very much worth following: that weight stigma ought to be addressed in obesity interventions and that anti-stigma messages ought to be incorporated into obesity prevention campaigns, that obesity prevention efforts should extend and be coordinated beyond the individual level to help reverse the societal and environmental conditions that create obesity in the first place, and that legislation should be enacted to prohibit weight-based discrimination (pp. 1024-25).
Keywords: clinical ethics*; delivery of health care*; fatness*; health justice*; weight stigma*
Date Created: 20201023 Date Completed: 20210818 Latest Revision: 20210818
20220902
10.1002/hast.1180
33095479

banner_970x250 (970x250)

sponsored