At least once a week, I have lunch with my colleague, Margaret McLean. Usually, Margaret's lunch consists of something like two apricots and a Health Valley granola bar. Usually, my lunch is a burrito. Did I mention that Margaret is quite a bit slimmer than I am?
Another salient fact about Margaret is that she is the director of biotechnology and health care ethics at the Markkula Center for Applied Ethics, where we both work. Recently, she's been raising an interesting question: As we understand more about the relationship between personal behavior and health—take overeating and heart disease as an example—should we hold individuals accountable for the consequences of their own behavior?
That question is raised by recent reports on the added cost to health care providers of treating obese patients: daily rentals of $90 for a bed, $24 for a commode chair, $40 for a recliner chair, $25 for an oversize stretcher, for example. And we know that obesity is a risk factor for many serious illnesses that strain our health care system.
These costs—both in money and resources—are not exacted from the overweight patient but are spread around to everyone who uses the system. A concrete example is the need to send as many as three ambulance crews when a very overweight patient has to be transported to a hospital.
As Margaret puts it, "If three ambulances are responding to a single call in order to lift and carry, then that is two ambulances which would otherwise be available. If there is a need for them, then there is likelihood of harm as emergency help is delayed."
Although my own extra poundage does not necessitate extra ambulance crews, I have a family health history that dictates concern about weight. Both of my parents required bypass surgery, and my mother died of congestive heart failure. My burrito lunches may increase the risk that I will suffer similar problems.
To Margaret, "The issue is that the risk is never assumed only by individuals but also by society." She draws an analogy to smoking, where, she argues, "one way or another, the community has to pay," both in terms of dollars to treat the smoker's lung cancer and the consequences of secondhand smoke. "Where can potential harm to others trump individual choice-of what to eat, to drink, to smoke?" she asks
For me, it's that word choice that raises problems. Choice around some of these behaviors is simply easier for some of us than for others. Think, for example, of all the people who have struggled valiantly to lose hundreds of pounds, only to gain them back-depressingly the experience of an overwhelming number of dieters.
The May New England Journal of Medicine may contain one clue as to why. The stomachs of people who have lost weight on diets apparently produce more of an appetite-boosting hormone called ghrelin. This little demon not only makes successful dieters very hungry but it also slows metabolism and reduces fat-burning. It's yet another of the myriad explanations why recidivism among dieters is nearly universal.
To me, this is an important context for the essentially moral question, Should obese people be held accountable for the consequences of their excess weight? If Margaret is satisfied with her oat cakes and apples, and I am starving on the same diet, is she a better person? Should our social policies around health care tax me for my failure to discipline an appetite Margaret does not even appear to experience and assess her, as someone who is more responsible, at a lower rate?
And what about other health-related behaviors, where I have no trouble with self-control? I have never been truly drunk in my life; alcohol puts me to sleep before it produces whatever rush of pleasure some people obviously experience from it. Is my healthy liver, then, the consequence of my own virtue?
I see how easily these questions can turn into a kind of biological determinism. It's the modern-day, pop science version of "The devil made me do it": My physiology makes me fat, (or alcoholic, or addictive)—and I can't control it. Obviously, we have an obligation to do our best with the biological hand we've been dealt.
In addition, society does have a valid interest in limiting certain behaviors, even if the propensity toward them is biologically driven. "Clearly," Margaret says, "we force (through law) modification of risky behaviors, e.g., no drinking and driving, wear a helmet on your Harley. But what about those behaviors which carry a more subtle risk to self and others-like eating French fries? Are individuals responsible for their own well being then? Should we 'tax' such risky behaviors in order to discourage them and/or treat the outcomes of individual poor choice?"
Before we answer that question, I think we need to acknowledge that we're in a very early stage of understanding the scientific underpinnings of good health, especially around nutrition and appetite. Recently, a New York Times Magazine cover story raised the question, "What If It's All Been a Big Fat Lie?" in reference to the AMA's longstanding dietary recommendations to lower fat and increase carbohydrates. A lot of us plump folks are now wondering if the very actions we've taken to lose weight haven't, in fact, made us fatter and hungrier.
So, let's not tax French fries to pay for oversize operating tables until we know more about the relationship between eating behaviors and disease. And, when we do have enough information to make policy in this area, let's be compassionate about the appetites, failings, and bad habits that will, in one way or another, be the death of us all..
A shorter version of this article appeared in the San Jose Mercury News, July 14, 2002.
Miriam Schulman is Director of Communications at the Markkula Center for Applied Ethics, Santa Clara University.