The Bioethics of Surgery and the Moral Panic Against Fatness
TW: fatphobia and transphobia
In 2002, the Senate Committee on Health, Education, Labor, and Pensions (HELP) supported President George W. Bush’s nomination of Richard Carmona as Surgeon General of the United States. In explaining its support, HELP stated that obesity was an epidemic—a pressing issue on par with bioterrorism threats. Three years later, a confirmed Carmona echoed this sentiment, saying “obesity is the terror within.”
Fatness wasn’t always considered an epidemic or national security threat, but since the early 2000s, the Centers for Disease Control and Prevention and the World Health Organization have made a concerted effort to treat it as such. Falling in step, medical institutions across the world started adopting this language. “Obesity epidemic” became a common buzz phrase everywhere, from insurance providers to fitness classes. Fueled by sustained campaigns, the “obesity epidemic” has been informing medical practices ever since—with disastrous repercussions for fat people.
Media and popular culture also shaped perceptions of obesity. In their analysis of 332 articles from the New York Times between 1995 and 2005, sociologists Abigail C. Saguy and Kjerstin Gruys note a sharp distinction between depictions of obesity and those of anorexia. While the newspaper’s writers and reporters rightly pointed out the social factors of anorexia and mapped out the scientific context in which it occurs, most articles dealing with obesity overwhelmingly tried to blame it on the patient or their family’s ineptitude. Media’s framing of fatness as an outcome of moral ineptitude—combined with the medical community’s framing of obesity as an epidemic—created a narrative that fat people are lazy and destroying the healthcare system with their preventable “illness.”
This has had repercussions for fat people seeking medical care. In 2012, a survey of National Health Service doctors in the U.K. found that many of them supported denying non-emergency treatment to fat patients. It’s unsurprising, then, that four years later the Royal College of Surgeons of England published a report mapping out an increase in rationing out surgeries based on individuals’ weight and smoking status. Among 209 healthcare providers examined, 43 percent enforced a BMI (body mass index) threshold for cosmetic surgeries, with 31 percent doing so for routine surgical procedures.
The U.S. has put similar limitations on healthcare for fat people. In a 2010 analysis of Medicaid and state insurance laws in Public Health Reports, Jennifer S. Lee and other researchers found that 35 states allowed companies to change insurance premiums according to a patient’s BMI status. Insurance companies often adjust premiums through “carrot” and “stick” policies. While “carrot” policies reward “healthy-weight” people with a reduced premium, “stick” policies penalize fat people with higher premiums—even though both plans are essentially the same. These policies are meant to keep costs low for insurance companies by incentivizing “healthy living.” Whether “carrots” or “sticks,” such policies provide grounds for medical institutions and companies to engage in what are effectively discriminatory practices that punish fat people.
Aubrey Gordon, author of “What We Don’t Talk About When We Talk About Fat,” has written extensively on fat politics and the history of BMI. BMI, touted as a reliable indicator of fatness, measures body fat based on the height and weight of an individual. But, as Gordon shows in her essay, The Bizarre and Racist History of the BMI, BMI has been used as a social and medical tool, noting that it was intended as a statistical measure for populations—not for individual cases. The inventor of the tool, 19th century statistician and sociologist Adolphe Quetelet, used the tool to craft a racist model of the so-called “normal man.
BMI was rediscovered as a statistical tool in the 1970s after a landmark study by physiologist Ancel Keys. The large-scale study examined men from predominantly-white countries along with Japan and South Africa in order to create a calibrated index of weight relative to height and body fatness. Keys insisted BMI was the preferable index to apply across populations, yet the study had caveats; as pointed out in the original paper, BMI was unable to accurately measure the health status of the Bantu men. Not only did Keys’s metric fail to remotely measure one of the only two nonwhite groups included in the study: it didn’t even include any women. Decades after Keys’s study, BMI remains incredibly faulty.
Despite its well-documented shortcomings, BMI remains a key tool for healthcare providers and insurers to push policies that deny fat people procedures under the guise of rationing costs. Whether such restrictions are justified is a scientifically contentious topic. A systemic study of over 6000 cases did note an increased risk of myocardial infarctions, urinary tract infections, nerve damage, and wound infections in obese patients post-surgery. This increased risks aside, obese patients presented similar rates of cardiac arrest and death as non-obese patients after surgery.
This resistance to treating fat patients includes procedures that would clearly improve quality of life. Several knee implant manufacturers advise against implants for patients over a certain BMI, yet evidence from post-operative patients doesn’t support their claims. Recent studies have shown significant improvement in the quality of life for fat people who undergo these surgeries for a mobility aid. Researchers have also noted that rehabilitative spinal surgery for chronic pain has equal rates of complications for obese and non-obese people beyond a short time frame. While the complications are comparable, obese people gain more functional benefits from these surgeries.
BMI restrictions and biases also serve to deny trans people life-saving gender-affirmative care. Seen as cosmetic, non-emergency procedures, gender-affirmative surgery is denied to a significant proportion of fat trans people above a certain BMI.
Framing obesity as an epidemic is what allows medical providers to continue denying care to fat people. As Saguy and Gruys’s work reaffirms, the narrative around this so-called epidemic has been framed on moral terms rather than social and structural ones. Fatness, then, is depicted as personal moral failing. Popular culture has helped shape and perpetuate fatness panic, too. Fat people have been objectified and commodified as cringe content for mass consumption. Quite notably, the USA series The Biggest Loser uses fatness as dramatic narrative, consistently frames fat people as the cause of a moral crisis, and creates increasingly unhealthy environments for contestants and, by extension, the audience.
My 600-lb. Life, a TLC series which documents the lives of fat people as they attempt to lose weight, showcases these media themes in its episodes on the “1000-pound sisters,” Amy and Tammy. The show consistently poses Tammy as the villain of the two because she doesn’t lose enough weight to undergo weight-loss surgery. YouTubers over the years have in turn made a mockery of Tammy’s story by pitting her against her sister.
Exclusion lies at the heart of creating the moral panic about fatness. While there has been an increased medicalization of fat people by framing fatness as an epidemic, fat discrimination and weight stigma increasingly and disproportionately disincentivizes fat women from seeking treatment. Fat women are increasingly at the forefront of being discriminated against by doctors and using BMI as a metric to determine obesity often singles out women of color, particularly Black women, for discrimination.
Two contrasting narratives sit at the center of this moral panic. Doctors portray the “obesity epidemic” as underdiagnosed and undertreated, while scholars depict the issue as a moral panic and not a medical one. Yet, even without supporting fat politics, doctors have often said that the denial of healthcare to fat patients is a moral failure.
“Obese” has become a medical boogeyman, bringing with it complicated threads of bioethics and a concerted effort to deny surgery to fat people since the turn of the century. As pop culture narratives and moral panics continue to hold center stage in conversations about medicine, it’s necessary to examine the biases that have created this circumstance. Fat women and people of color are repeatedly singled out in these cases and denied healthcare, all while being made to pay higher premiums for insurance. The medical hegemony supposed to help create “better lives” for fat people is the same thing that kills them. In creating a moral crisis that would supposedly “aid” fat people by changing their bodies, the medical industry has taken away a functional and happier life from them.
Image credit: Weight of the Weightless by mrd00dman, 2008 (Flickr | CC BY-NC 2.0)
