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Tuesday, May 27, 2008

Paternalism and Ethical Obesity Policies

Yesterday I attended a talk by Angus Dawson, Senior Lecturer and founding Director of the Centre for Professional Ethics, Keele University, UK, who is currently a Visiting Professor, Centre for Ethics, University of Toronto.

His presentation with the title: "Ethical Obesity Policy: Paternalism, Preference Change and the Good Life" was part of the University of Alberta Health Law Institute Research Seminar series.

Dawson's basic thesis was that when it comes to preventing obesity simply providing information does not work, some form or "paternalism" (not to use the term coercion) will be required to help people change behaviours.

This is in contrast to what is happening where most policy makers (and some public health workers) still treat obesity as a matter of individual choice and focus their prevention efforts at individuals rather than addressing this issue at the more complex system level.

This is unfortunate because there is little evidence that a key contributer to the obesity epidemic is indeed epistemic or lack of knowledge - therefore trying to remedy obesity by providing knowledge does not address the root cause of the problem.

In fact, Dawson argues, there is no evidence that people today are less knowledgeable about healthy behaviours than previous generations, nor are they weaker willed or more prone to obesity by "choice".

Rather, the obesity epidemic is a consequence of systemic factors such as removing physical activity from the workplace, less time to spend at home with the family, less physical demands on commute and travel and industrialisation of our food supply.

Thus, obesity is not a result of people making poor choices but rather the result of societal changes that leave most individuals with little choice (but to become obese or fight weight gain by swimming against the stream).

This raises the issue of collective action: individuals are limited in their choice by the choices that the majority makes. For e.g. if you live in a neighbourhood where people prefer to eat at fast food restaurants and drive cars then you may have no choice but to also eat fast food and drive a car unless you are prepared to leave your neighbouhood to find a healthier restaurant and are willing to risk being run over on your bike.

Getting the majority to change their behaviour is unlikely to happen without some form of paternalism, which raises the ethical dilemma of how much individual "freedom" society as a whole is willing to sacrifice for the common good.

Examples that were cited included laws requiring the use of seat belts or helmets - issues that are surprisingly still contended by some who reserve "the right to be foolish".

Overall, not much that I have not heard before but certainly a nice summary of how complex some of the issues around obesity prevention actually are.

When it comes to obesity prevention - don't hold your breath!

Edmonton, Alberta


Yoni Freedhoff said...

I have to disagree with Dr. Dawson's hypothesis.

Do a straw poll or a well designed study that asks the following three questions:

1) How many calories does your body burn daily?
2) How many calories are in (insert food item here)?
3) How many calories do you burn doing (insert activity here)?

Given that calories are in fact the currency of weight, that the vast, vast majority of folks have no clue how many they need or eat or burn and the fact that these 3 areas are easily translatable into knowledge provision and I therefore would argue that individuals, while perhaps knowledgable about the fact that obesity is relatable to energy balance, have not a clue as to how to manage energy/calories.

If you want to add a fourth question to the above it'd be,

4) Can you describe an eating pattern that would minimize hunger and cravings?

Again, the answer will likely be "No", despite the fact that regularly spaced meals and snacks containing a minimum amount of calories and protein do in fact minimize hunger and cravings and therefore consumption.

Sounds to me like Dr. Dawson has done what many do and that is assume that the only thing you need to know to lose weight is, "Eat less exercise more" which clearly is a useless piece of information that even if "known" doesn't lend a helping hand.

That doesn't mean I don't like the notion of paternalism, but rather that I don't think that knowledge provision can be ruled out as a tool to help with prevention since helpful knowledge has yet to be universally provided.

The changes Dr. Dawson refers to are indeed environmental. Unfortunately individuals are simply not knowledgable about how those changes affect their caloric balance.

Let's see mandatory calories on menu boards, appropriate education in schools on energy expenditure and intake and public health campaigns encouraging the benefits of frequent meals, snacks and protein and when nothing happens then we can have a discussion about whether knowledge provision works or not.

Hanafy M. Hanafy, MD said...

Knowledge has different levels of detail and applicability. For example, knowing that moving to a certain location is better, in and by itself is not enough to initiate an action. The know-how about the steps that lead to that moving is central. After being comfortable with the fine steps, one is more likely to perform the task. Paternalism will hopefully offer the above sort of guidance, along with encouragement, motivation and some sort of external pressure. I think Yoni and Dr. Dawson are both right, but are commenting on different levels of knowledge and information.