05/19/2009 01:50 pm ET | Updated May 25, 2011

Shunning The Obese.


Thin is "in." Obese people are shunned. The obese associate with each other, marry, and have obese children. Obesity is major national health concern.

What should we do? Is obesity a: discriminatory bias; an illness or eating disorder; an acceptable life style choice; or an irresponsible one? The proper answer depends on who is viewing.

Individual Viewpoint
Dr. Ben Kazie asserts the perspective of the individual provider: doctor, nurse, or social worker. That individual makes no value judgment regarding a patient. Whether the sick person is an injured terrorist captured while planting a bomb; a 450-pound woman with diabetes, bad joints and heart disease; or a serial killer, the care provider simply does her or his best. In as much as the provider is human and may have negative feelings and judgments about the patient, these are put aside to offer best possible care. The professional care provider is non-judgmental and considers only the welfare of the individual.

Whether obesity is an illness or a choice by individual is a non-issue to me. One must draw the line somewhere. Yes, there are people who have glandular and/or genetic conditions that force them to eat-to-obesity but they are a tiny fraction of the obese population that could choose to eat reasonably but does not.

From the provider perspective, whether obesity is an addiction or choice makes no difference. Either way the true healer offers care. The issue becomes muddy from the pediatrician's standpoint. Most children are not genetically predisposed to be obese. This is a learned behavior. When a child sees obese parents, their body type becomes the child's body image.

If a parent poisons a child with drugs, the pediatrician has a moral and legal responsibility to protect the child. What if the "poison" is food? Where do you draw the line between acceptable parenting practices and child abuse by facilitating over-eating?

Systems Viewpoint
From the viewpoint of the system, a person who decides to smoke and eat-to-obesity has chosen to consume over time more health care resources than someone who is an appropriate-weight non-smoker.

The distinction in viewpoint - provider versus system - is critical. The caregiver does whatever is best for the patient. The system does what is best for the system. The provider is (partly) responsible for the patient. The system is (partly) responsible for all patients, not one individual.

Questions: Can something be right for the individual and wrong for the system? Can something be wrong for the individual and right for the system? Yes to both. Most important: who is ultimately responsible for your health: you, your doctor, or the system? [I hope, I hope, this is rhetorical.]

For any (repeat any) system to be stable meaning that it will not collapse, there must be feedback. Feedback is the linkage between consequences and the one whose choice produced those consequences. Right now, our country is struggling to find a way to connect (link) the financial meltdown with those who caused it. For healthcare-the-system, the problem is connecting financial consequences (costs) with one who chooses to be more expensive. This leads to the conclusion that "fat people should pay more." Any system that lacks effective feedback risks bankruptcy and collapse. Such a system is also unfair to those who choose not to consume excessively.

(Beware of the converse rationale: if fatter is sicker and more expensive, then the thinner you are, the healthier and less costly. Not so. Just ask any physician or even the man-in-the-street looking at the ridges in the clavicles of otherwise beautiful Keira Knightley. Both extremes - fat and thin; obese and Lara Flynn Boyle camera-ready - are unhealthy for the person and costly for the system.)

What should be done about obesity depends on who you are.
• Individual providers should offer all appropriate care.
• Healthcare system should connect person who chooses with consequences of their choice.