S
saucywench
I was prompted by chocolate desire's thread on "my worst doctor visit ever," and subsequent replies, especially those of Anguisette and rainy, to do a little online research. I didn't have a particular goal in mind, except to learn whether any medical research on "obesity" existed that was free from bias. (Yeah, I know--good luck with that.) I plugged the search term "medical ethics and obesity" into Google and began rummaging around. I was stopped cold in my tracks when I ran across the article below. I have to say that I was stupefied to realize that a reputable medical journal, as I presume the Medical Journal of Australia to be, would even find this article suitable for publication. And--get this--it was written by a DERMATOLOGIST.
This guy leads off with a lot of things that I have little or no argument with. And then he zaps us with his brilliant insight.
For those of you who don't want to wade through the whole thing, I have denoted the absurd parts in blue.
Comments, anyone? (I'm still speechless.)
Obesity and virtue. Is staying lean a matter of ethics?
Self-control of one's own weight might be described as a form of bioethics
John N Burry
MJA 1999; 171: 609-610
An estimated 97 million adults in the United States are overweight or obese, a condition that substantially raises their risk of morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and endometrial, breast, prostate, and colon cancers. Higher body weights are also associated with increases in all-cause mortality. Obese individuals may also suffer from social stigmatization and discrimination. As a major contributor to preventive death in the United States today, overweight and obesity pose a major public health challenge.
-- Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults.1
In 1992, 30% of the female and 44% of the male population of Australia were overweight or obese.2 More recent studies indicate that the prevalence has risen to 34% and 48% and is continuing to rise.3,4 Overweight is defined as a body mass index (BMI; kg/m2) greater than 25 and obese as a BMI of 30 or greater.
In a 15-year cohort study of middle-aged men, the BMI associated with the lowest morbidity and mortality was 22.5 The relationship of BMI to blood lipids, blood cholesterol, blood pressure and blood sugar confirms the worth of scientific measurement and of knowing one's optimum BMI. A BMI of 22 is not optimal in all individuals, because
. . . not all types of obesity are hazardous. Individuals with peripheral obesity -- ie, fat distributed subcutaneously around the gluteofemoral region and in the lower part of the abdomen -- are at little or no risk of the common medical complications of overweight.6
Nonetheless, most individuals with a BMI over 25 are entering into the zone of increased health risks. Among these people, the life-threatening diseases associated with being overweight regress if weight is lost. Loss of weight will reduce blood pressure and heart size and negate the need for drug control.7 Excess prepregnancy weight may adversely affect the child8 and obesity is more likely in offspring if parents are obese.9 The burden of illness and the need, demand and costs for medical services would be reduced if fewer people were overweight.10,11
Yet the trend is all the other way, and many authors have suggested that orthodox medicine does not have a solution to the problem:
Most doctors feel that the treatment of obesity is unsatisfactory . . . It is not at all surprising that people who live long enough and who have unlimited access to palatable food (especially fatty food) are very likely to become obese.12
Currently the long term results of most weight loss programs are poor, no matter which approach is taken.2
. . . the modification of diet and exercise patterns . . . is . . . either impossible, impractical or not achievable for a great many individuals . . .13
. . . for both the patient and the physician, the treatment of obesity remains a frustrating and usually unsuccessful endeavour, with a failure rate of up to 95% at 5 years.14
The treatment of fatness does not work. Indeed if all doctors practised evidence-based medicine, half the dieticians in any one country would be out of a job. Diets don't work, commercial clinics have rarely published unselected results, psychological therapies either do not work or are in their infancy, surgery has an appreciable mortality and in any case has been reserved for the morbidly obese and 5HT-release and uptake inhibitors have been withdrawn because of the risk of cardiac fibrosis.15
"Darwinian medicine"16,17 regards obesity as a prime example of an abnormality arising from the evolutionary history of Homo sapiens. In this perspective, human beings become fat because they are ill-adapted to the circumstances of perpetual plenty and physical leisure in modern society, which are very different from the more strenuous circumstances prevailing during tens of thousands of years of adaptation:
Human motivations and metabolism are programmed to store fat reserves in times of plenty for later times of shortage. A tendency to minimize physical activity may also be adaptive for minimizing expenditure of such reserves. The variability in these processes may be great, with some individuals, who have thrifty genotypes, now especially vulnerable to obesity. They store calories more efficiently than others, but never benefit from the episodes of famine to which they are especially adapted. Attempts to restrict food intake voluntarily may be interpreted by the regulatory mechanism as uncertain food availability; in such situations, binges of eating would be adaptive.16
Thus, regarding the evolutionary perspective and the clinical evidence, we can agree with Proietta that, "barring famine, obesity is with us to stay".2 Nor are cure-all drugs likely to be found for obesity. Leptin, a genetic product associated with weight regulation, has been identified, but its complex functions within the body suggest that the use of analogues to control weight would be fraught with dangers of side effects.18 The diet drugs fenfluramine and dexfenfluramine were recently withdrawn because of a relationship to heart valve abnormalities.19 We must hope that the recently introduced Sisyphean drug orlistat20 (reminiscent of that "legendary diet drug which was nothing but a live tapeworm"21) might be of good and lasting value, but, on the grounds of probabilities, it is likely to suffer the same fate. In any event, drug therapies intended for the extremes of obesity cannot be seen as a solution for the 30%-40% of the population who are overweight.
Instead, the remedy would appear to be to eat less and exercise more, but this apparent simplicity begs the question of how to change the eating habits of populations. Control of weight, no matter that some have a genetically determined potential to acquire and retain more weight in comparison with others,22 remains a matter of self-control and personal responsibility.
This responsibility is related to personal health and the health of offspring, and to the health costs and the healthy functioning of the general community. The responsibility is fulfilled by maintaining a BMI of somewhere between 22 and 25. In a liberal society, fulfilling this responsibility must be a matter of voluntary behaviour, as "personal autonomy, the right to choose one's own way of life for oneself, is the supreme value."23
Self-control of one's own weight might be described as a form of bioethics.
However, obesity is often associated with a low standard of living.24 Exercising personal responsibility involves a minimum social, economic, political and educational understanding if the socially disadvantaged are to afford and to choose those foods necessary to maintain an optimum weight. I do not wish to deny that there are social elements to the problem, but we need a motivating framework for those who have practical autonomy yet cannot control their weight.
Aristotle's Nicomachean ethics, which is addressed to students who are presumed to have an adequate education and a solid foundation of good habits, is one of the classics of moral philosophy. The Ethics is directed to the formation of character and discusses those admirable human qualities that fit a man for life in an organised civic community and make him a good citizen:
Perhaps the truest way of conceiving Aristotle's meaning is to regard a moral virtue as a form of obedience to a maxim or rule of conduct accepted by the agent as valid for a class of recurrent situations in life. Such obedience requires knowledge of the rule and acceptance of it, as the rule of the agent's own actions.25
Thus, attaining an optimum weight can be seen as flowing from the acceptance of the maxim that one "should" have a BMI between 22 and 25. In medical practice, on these principles, it would be immoral not to advise overweight patients to lose weight26 -- but, more importantly, the medical practitioner who is giving this advice should accept the responsibility of attaining and maintaining a personal BMI of between 22 and 25.
Not only physicians should accept the practical ethics and moral responsibility of attaining an optimum BMI. I also think that others in our community in positions of responsibility and from whom leadership is to be expected should accept that their example is primary. Politicians, clergy, police and moral philosophers must lead the way in physical fitness if we are to expect to reap the benefits of a lean society.
Aristotle listed charm, wit and a good sense of humour as virtues, which they certainly are in the practice of medicine. The gradual introduction of the subject of ethics into the consulting room need not be dissociated from these virtues. Aristotle's "doctrine of the mean" -- that virtue consists in avoiding extremes, in attaining the right and proper mean between excess and deficiency -- might not only help in establishing attitudes that counter the tendency to become overweight, but also the opposite tendency to become underweight resulting from the pressures of the fashion industry upon young women. Let us propose a BMI of 22 to 25 as a "virtuous mean" to which we should all aspire.
References
Authors' details
PO Box 7177, Hutt Street, Adelaide, SA 5000.
John N Burry, FRCP(E), BA(Hons), Dermatologist.
No reprints will be available from the author.
Correspondence: Dr J N Burry.
burryATdove.net.au
This guy leads off with a lot of things that I have little or no argument with. And then he zaps us with his brilliant insight.
For those of you who don't want to wade through the whole thing, I have denoted the absurd parts in blue.Comments, anyone? (I'm still speechless.)
---------------------------------------------
The Weight DebateObesity and virtue. Is staying lean a matter of ethics?
Self-control of one's own weight might be described as a form of bioethics
John N Burry
MJA 1999; 171: 609-610
An estimated 97 million adults in the United States are overweight or obese, a condition that substantially raises their risk of morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and endometrial, breast, prostate, and colon cancers. Higher body weights are also associated with increases in all-cause mortality. Obese individuals may also suffer from social stigmatization and discrimination. As a major contributor to preventive death in the United States today, overweight and obesity pose a major public health challenge.
-- Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults.1
In 1992, 30% of the female and 44% of the male population of Australia were overweight or obese.2 More recent studies indicate that the prevalence has risen to 34% and 48% and is continuing to rise.3,4 Overweight is defined as a body mass index (BMI; kg/m2) greater than 25 and obese as a BMI of 30 or greater.
In a 15-year cohort study of middle-aged men, the BMI associated with the lowest morbidity and mortality was 22.5 The relationship of BMI to blood lipids, blood cholesterol, blood pressure and blood sugar confirms the worth of scientific measurement and of knowing one's optimum BMI. A BMI of 22 is not optimal in all individuals, because
. . . not all types of obesity are hazardous. Individuals with peripheral obesity -- ie, fat distributed subcutaneously around the gluteofemoral region and in the lower part of the abdomen -- are at little or no risk of the common medical complications of overweight.6
Nonetheless, most individuals with a BMI over 25 are entering into the zone of increased health risks. Among these people, the life-threatening diseases associated with being overweight regress if weight is lost. Loss of weight will reduce blood pressure and heart size and negate the need for drug control.7 Excess prepregnancy weight may adversely affect the child8 and obesity is more likely in offspring if parents are obese.9 The burden of illness and the need, demand and costs for medical services would be reduced if fewer people were overweight.10,11
Yet the trend is all the other way, and many authors have suggested that orthodox medicine does not have a solution to the problem:
Most doctors feel that the treatment of obesity is unsatisfactory . . . It is not at all surprising that people who live long enough and who have unlimited access to palatable food (especially fatty food) are very likely to become obese.12
Currently the long term results of most weight loss programs are poor, no matter which approach is taken.2
. . . the modification of diet and exercise patterns . . . is . . . either impossible, impractical or not achievable for a great many individuals . . .13
. . . for both the patient and the physician, the treatment of obesity remains a frustrating and usually unsuccessful endeavour, with a failure rate of up to 95% at 5 years.14
The treatment of fatness does not work. Indeed if all doctors practised evidence-based medicine, half the dieticians in any one country would be out of a job. Diets don't work, commercial clinics have rarely published unselected results, psychological therapies either do not work or are in their infancy, surgery has an appreciable mortality and in any case has been reserved for the morbidly obese and 5HT-release and uptake inhibitors have been withdrawn because of the risk of cardiac fibrosis.15
"Darwinian medicine"16,17 regards obesity as a prime example of an abnormality arising from the evolutionary history of Homo sapiens. In this perspective, human beings become fat because they are ill-adapted to the circumstances of perpetual plenty and physical leisure in modern society, which are very different from the more strenuous circumstances prevailing during tens of thousands of years of adaptation:
Human motivations and metabolism are programmed to store fat reserves in times of plenty for later times of shortage. A tendency to minimize physical activity may also be adaptive for minimizing expenditure of such reserves. The variability in these processes may be great, with some individuals, who have thrifty genotypes, now especially vulnerable to obesity. They store calories more efficiently than others, but never benefit from the episodes of famine to which they are especially adapted. Attempts to restrict food intake voluntarily may be interpreted by the regulatory mechanism as uncertain food availability; in such situations, binges of eating would be adaptive.16
Thus, regarding the evolutionary perspective and the clinical evidence, we can agree with Proietta that, "barring famine, obesity is with us to stay".2 Nor are cure-all drugs likely to be found for obesity. Leptin, a genetic product associated with weight regulation, has been identified, but its complex functions within the body suggest that the use of analogues to control weight would be fraught with dangers of side effects.18 The diet drugs fenfluramine and dexfenfluramine were recently withdrawn because of a relationship to heart valve abnormalities.19 We must hope that the recently introduced Sisyphean drug orlistat20 (reminiscent of that "legendary diet drug which was nothing but a live tapeworm"21) might be of good and lasting value, but, on the grounds of probabilities, it is likely to suffer the same fate. In any event, drug therapies intended for the extremes of obesity cannot be seen as a solution for the 30%-40% of the population who are overweight.
Instead, the remedy would appear to be to eat less and exercise more, but this apparent simplicity begs the question of how to change the eating habits of populations. Control of weight, no matter that some have a genetically determined potential to acquire and retain more weight in comparison with others,22 remains a matter of self-control and personal responsibility.
This responsibility is related to personal health and the health of offspring, and to the health costs and the healthy functioning of the general community. The responsibility is fulfilled by maintaining a BMI of somewhere between 22 and 25. In a liberal society, fulfilling this responsibility must be a matter of voluntary behaviour, as "personal autonomy, the right to choose one's own way of life for oneself, is the supreme value."23
Self-control of one's own weight might be described as a form of bioethics.
However, obesity is often associated with a low standard of living.24 Exercising personal responsibility involves a minimum social, economic, political and educational understanding if the socially disadvantaged are to afford and to choose those foods necessary to maintain an optimum weight. I do not wish to deny that there are social elements to the problem, but we need a motivating framework for those who have practical autonomy yet cannot control their weight.
Aristotle's Nicomachean ethics, which is addressed to students who are presumed to have an adequate education and a solid foundation of good habits, is one of the classics of moral philosophy. The Ethics is directed to the formation of character and discusses those admirable human qualities that fit a man for life in an organised civic community and make him a good citizen:
Perhaps the truest way of conceiving Aristotle's meaning is to regard a moral virtue as a form of obedience to a maxim or rule of conduct accepted by the agent as valid for a class of recurrent situations in life. Such obedience requires knowledge of the rule and acceptance of it, as the rule of the agent's own actions.25
Thus, attaining an optimum weight can be seen as flowing from the acceptance of the maxim that one "should" have a BMI between 22 and 25. In medical practice, on these principles, it would be immoral not to advise overweight patients to lose weight26 -- but, more importantly, the medical practitioner who is giving this advice should accept the responsibility of attaining and maintaining a personal BMI of between 22 and 25.
Not only physicians should accept the practical ethics and moral responsibility of attaining an optimum BMI. I also think that others in our community in positions of responsibility and from whom leadership is to be expected should accept that their example is primary. Politicians, clergy, police and moral philosophers must lead the way in physical fitness if we are to expect to reap the benefits of a lean society.
Aristotle listed charm, wit and a good sense of humour as virtues, which they certainly are in the practice of medicine. The gradual introduction of the subject of ethics into the consulting room need not be dissociated from these virtues. Aristotle's "doctrine of the mean" -- that virtue consists in avoiding extremes, in attaining the right and proper mean between excess and deficiency -- might not only help in establishing attitudes that counter the tendency to become overweight, but also the opposite tendency to become underweight resulting from the pressures of the fashion industry upon young women. Let us propose a BMI of 22 to 25 as a "virtuous mean" to which we should all aspire.
References
- Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. Arch Intern Med 1998; 158: 1855-1867.
- Proietta J. Prospects for the treatment of obesity [editorial]. Med J Aust 1992; 157: 363-364.
- Tonkin AM, Bennett S. Cardiovascular disease at the turn of the century: Multifaceted approaches are needed to reduce the burden on the Australian community [editorial]. Med J Aust 1999; 170: 408-409.
- National Health and Medical Research Council. Acting on Australia's weight: a strategic plan for the prevention of overweight and obesity. Canberra: NHMRC, 1997.
- Shaper AG, Wannamethee SG, Walker M. Body weight: implications for the prevention of coronary heart disease, stroke, and diabetes mellitus in a cohort study of middle aged men. BMJ 1997; 314: 1311-1317.
- Arner P. Not all fat is alike [commentary]. Lancet 1998; 351: 1301-1302.
- Karason K, Wallentin I, Larsson B, et al. Effects of obesity and weight loss on left ventricular mass and relative wall thickness: survey and intervention study. BMJ 1997; 315: 912-916.
- Cnattingius S, Bergstroem R, Lipworth L, et al. Prepregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med 1998; 338: 147-152.
- Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997; 337: 869-873.
- Fries JF, Koop CE, Beadle CE, et al. Reducing health care costs by reducing the need and demand for medical services. N Engl J Med 1993; 329: 321-325.
- Birmingham CL, Muller JL, Palepu, et al. The cost of obesity in Canada. Can Med Assoc J 1999; 160: 483-488.
- Garrow JS. Treatment of Obesity. Lancet 1992; 340: 409-413.
- Prins JB, O'Rahilly S. Regulation of adipose cell number in man. Clin Sci 1997; 92: 3-11.
- Boisaubin EV. Questions and answers: treatment for obesity. JAMA 1996; 276: 445.
- Jeffcoate, W. Essay. Obesity is a disease: food for thought. Lancet 1998; 351: 903-904.
- Williams GC, Nesse RM. The dawn of Darwinian medicine. Q Rev of Biol 1991; 66: 1-22.
- Nesse R. What is Darwinian medicine? <http://157.242.64.83/hbes/medicine.htm> Accessed 23 June 1999.
- Auwerx J, Staels B. Leptin [review article]. Lancet 1998; 351: 737-742.
- Moore TJ, Psaty BM, Furberg CD. Time to act on drug safety [commentary]. JAMA 1998; 279: 1571-1573.
- Sjoestroem L, Rissanen A, Anderson T, et al. Randomised placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients. Lancet 1998; 352: 167-172.
- Schwartz H. Never satisfied: a cultural history of diets, fantasies and fat. New York: Macmillan, 1986: 326.
- Born to be fat? [editorial]. Lancet 1992; 340: 881-882.
- Charlesworth M. Bioethics in a liberal society. Cambridge: Cambridge University Press, 1993: 1.
- Carpenter L, Bartley M. Fat, female and poor. Lancet 1994; 344: 1715-1716.
- Smith JA. In the introduction to: Aristotle. Nicomachean ethics. New York: Dover Publications, 1998: ix.
Field AE. The obesity problem [letter]. N Engl J Med 1998; 338: 1156.
Authors' details
PO Box 7177, Hutt Street, Adelaide, SA 5000.
John N Burry, FRCP(E), BA(Hons), Dermatologist.
No reprints will be available from the author.
Correspondence: Dr J N Burry.
burryATdove.net.au
