February 07, 2008

Tax the fat?

[By Merry]

Talk about ‘no country for old men’ – it’s no country for old women either. Apparently some doctors in Britain don’t want to treat people who are old or obese. According to the BBC, "About one in 10 hospitals [in the U.K.] already deny some surgery to obese patients and smokers, with restrictions most common in hospitals battling debt."

And this is not an opinion limited to the British. A new bill in Mississippi would make it illegal for restaurants to serve obese customers. The legislation, introduced by three members of the state’s House of Representatives, would allow health inspectors to revoke the license of any restaurant that "repeatedly" feeds extremely overweight people. I get the feeling that a lot of people are, if you will excuse the pun, fed up with people who are overweight. (I do hope you will excuse the pun. I couldn't think of another way to phrase it.)

I can see doctors getting exasperated with people whose behavior made them unwell. But not treating people because they’re old? That’s not just saying Do Not Resuscitate, which is after all supposed to be decided by the patient. This is more like the insurance company that refused a liver transplant to that sick teenage girl. (They argued about it until she was too sick to have the operation performed anyway, basically Death by Red Tape.) Where do you draw the line on how much money to spend on a patient?

Even if the doctors are exasperated, what good will come from stopping treatment because the patient is morbidly obese? All it would do is cause more suffering. It won’t stop people from becoming obese. This article got me thinking about Worst Case Scenarios, the kind of measures the governments might take if we continue to gain weight at this rate. Taking things to a logical extreme, I came up to a few possible W.C. scenarios:

  • They could pass a law that those of us who have more than 30% body fat must go to a nutritional counselor or physical trainer. Like sending someone who has trouble driving to traffic school. Or sending an alcoholic to rehab. You can’t force someone to stop overeating or under-exercising, but you can make it clear what the consequences of this behavior are. Something along the lines of showing children pictures of a smoker’s lungs, showing pictures of untreated diabetes?

  • Or they might put a higher tax on junk food, as some states do with cigarettes, and use the money to fund nutritional education. Katharine at Editing My Body wrote about how expensive it is to eat well in America. Researchers found that the problem was worst in the rural South, which is a region where you could grow some kind of vegetable year ‘round. There’s a cultural bias against “Yankee” food, but it’s surely better to change a bias than to try to reverse diabetes or something like that.

  • If I were really paranoid, the most extreme solution I can see would be forcing people to have gastric bypass surgery. Okay, that’s an extremely extreme solution, but it is similar, in thought if not in scale, with forcing people to wear helmets (or seat belts) or risk being fined. (I do wear helmets or seat belts, but the idea of being forced to look after myself is still annoying.)

These solutions all sound draconian, but not nearly as much as refusing to treat people altogether. That sounds like the voice of exasperation pushed to the point of being totally pissed off. It’s like they want to punish people for being unhealthy.

I suppose the thought behind refusing to treat the obese is based on the feeling that if you're fat, it's your own fault. The relationship between obesity and illness is seen as cause and effect, in the same way that jumping into a tiger’s cage can result in permanent loss of limb or life. If you make a deliberate, conscious choice, you should be prepared for the possible consequences. Fair enough, but not everyone makes a deliberate choice to live off junk food or become a couch potato. I think a lot of people become obese because we didn’t make a conscious choice to be anything else, following the path of feast least resistance.

*********obligatory disclaimer****************
I know there are people who are morbidly obese due to factors beyond their control. Speaking for myself, my weight is my own fault. It would be easier to lose weight if my thyroid functioned like those lean greyhound-type people. (You know who I mean, the ones who can eat anything and remain thin.) But even as I am, I can lose weight if I work at it.
*********end of obligatory disclaimer****************

I still worry about the old people. I mean, who decides the definition of old? To me, old is a term applied to people who have been on this planet longer than I have. I’m not old, and I’ll thank all you young whippersnappers to remember that fact.

Some ancient tribes in the arctic supposedly would abandon their old people out on an ice floe when they got too old to work. Maybe that’s where we got the expression ‘go with the floe’ from. Okay, maybe not. I could see insurance companies wanting to return to that tradition. But it surprises me to find the same feeling is apparently so widespread among doctors. Am I being naive?


  1. Wow--I find this stuff appalling. And your hypotheticals, while shocking, actually sound less alarming than some of the proposals already out there.

    It's ironic, too, because there was a study that just came out (a helpful reader alerted me to it but I'm too lazy to write a whole post about it) that says that it's actually CHEAPER, in the long run, to provide medical care for obese patients and smokers, because they don't live as long.

    I do understand why doctors would get frustrated, but outright discrimination just seems wrong.

  2. Oh, I saw that study too! An engineer was reading it at work (on company time! horrors!). I didn't read the whole article, but the engineer (a heavy smoker, alas) said that the theory was that it costs a lot more to treat people at the end of their life than it would cost to prevent or alleviate the problems early. Maybe that's why these doctors don't want to treat old people, since there's no way to alleviate age? (Not in the long run, that is.)

  3. This is sad..I was also going to mention what you cited, crabby, about obese people are cheaper in the long run to provide care to.
    So many people for some reason equate being fat with being somehow less moral, or less of a person. That attitude has to change before anything else does.

  4. Is this perhaps just part and parcel of the whole attitude of society toward anyone who doesn't fit the category of "young, slim, and beautiful"? Only the young, fit, and beautiful (and the rich, by default!) are valued in society anymore. The rest of us fall into the category of expendable. No-one considers the contributions to society that those of us in less-than-perfect shape make. To say nothing about the tax dollars that smokers contribute!!:)

    Seriously, though, the prevailing attitude nowadays seems to be that if you are overweight, you are stupid, and sloppy, and, in the long, run; worthless.

    Oh, and the elderly make absolutely no contribution at all - hell, why not have mandatory executions instead of retirement?!
    **Over 65? The line for the ovens is over there...**
    F*ckin' Nazi doctors...

    Oh my goodness, you got the Bag Lady all worked up this morning!! (Is it obvious that she is an old, fat smoker?)

  5. Prevention is cheaper, but no one cares enough to do it.
    Let me specify. Take junk food off the market. Serve only healthy food in restaurants.
    Remove tobacco from the market except for Natives for traditional use.
    Stop putting crap in the food supply and stop killing the soil.
    If doctors have to go to outlandish lengths to bring health problems to our attention, it may already be too late.
    Oh, and generally speaking, insurance is only for those who don't need it.

  6. "Insurance is only for those who don't need it"

    This bears repeating.

  7. I think that's why this tendency (of not wanting to treat) is so prevalent in Britain, since they have a National Health system as well as private health insurance.

  8. Whatever happened to "First, do no harm?" And when did taking care of people stop being a calling and start being strictly a money-making venture?
    If people want to halt obesity, then we need to call out the diet industry. How many diets have we been on, only to gain all the weight back, plus more? Instead of going after the overweight, why don't they go after the makers of Slim Fast and diet pills, and all the so-called experts who give us advice on how to lose the weight and never be hungry. Sorry, hunger is a natural state; it's what tells us to eat, just as thirst tells us to drink, or fatigue tells us to sleep. If we stopped listening to those "experts" and started listening to our own hunger and fullness cues again, maybe wouldn't be overweight.

  9. Let me just add that I am one of the ones who is struggling.

  10. "you are only as strong as your weakest link"

    and this goes to show that developed countries are leaving even more people to fend for themselves. Heartbreaking.

  11. "Logan's Run!" That is where we are headed. For those that are too young, it is a movie where the society killed off anyone over 30 (I think - it's been a very long time).

    "Or they might put a higher tax on junk food, as some states do with cigarettes, and use the money to fund nutritional education." That will never happen - how much of the cigarette tax money do you suppose they spend on anti-smoking education? I don't think it is nearly as much as they pull in.

    Illegal to serve obese customers? Yeah, that will work as well as prohibition did. People don't get fat from eating out in restaurants, they get fat from a myriad of other things.

    ARRrgh - okay, I'll quit now.

  12. It is crazy to me how little junk food costs compared to produce and other healthy items. Faced with a very limited budget, most families would feel forced to choose the less healthy option because it goes further. There are many many reasons for being overweight, but one important thing to consider is socio-economic status. Of course, according to these docs, we probably shouldn't be treating poor people either.

  13. One word...Kaiser...
    My grandfather passed last year, and his doctors at Kaiser did nothing to make him comfortable or help my grandmother in her greif or transition...They do not help you when you are sick...When I was a baby we had Kaiser, and I almost died because they kept telling my parents that there was nothing wrong with me, I just stopped breathing sometimes...They only want to help when you are well or have a very obvious health issue...On the other hand, they are very on top of the ball when you are healthy and just going in for regular things like eyes or girly stuff or check-ups. But God forbid you have an actual sickness...UGH!!!

    Wait...I can't go to restaurants anymore because I'm overweight?? Whatever douchebags, I like to cook anyway, and I guess you won't get my money, but shame on you and your little dog too...

    While we're on the topic of discriminating overweight people, why is it that in the Hidden Valley Ranch commercials (the ones where the kids eat all their veggies) all the kids are skinny and impecably quafed? Fat kids like veggies too, not me, but there are many fat kids who like veggies...WTF America??

    Meh...I'm done, all worked up...Gonna go have some Valentine's candy to calm myself down...

  14. I haven't read the whole article, but I have opinions (like Crabby) anyway.
    As as doctor, I think that pressures should be applied to people with behaviors that make them very poor risks for treatment. Smokers do not heal well. I would refuse elective surgery on a smoker if I felt that the chances of a successful outcome are minimal. Obesity increases the chance of death during general anesthesia. Unless the procedure is urgent or an emergency, I fully understand the doctor refusing treatment.
    Dr. J

  15. Why don't they tax the junk food and use the money to provide free health care? Problem solved.

  16. Ifeel that if obesity was such a concern there wouldn't be 2 isles of snack food in every grogery store. I was amazed when we got groceries the other day in our newly opened and expanded grocery store, which has 2 full aisles of snack food (not counting cookies), along with a whole bunch of ready made meals and a coffee shop and a deli sandwich counter. That is a little wierd...a collection instant gratification of food activities.They've started banning unhealthy food from schools and hospitals...but everywhere else is still fair game.

    People aren't being taught what is appropriate to eat anymore I think. I feel I can get through a grocery trip without coffee or a sandwich. Add to that the fact that many people aren't learning how to cook, because their lives aree so busy they aren't taught, and so they go for the unhealthy but more convenient choices.

    Me? I am an emotional eater who once verged on being a binge eater. I deal with it in part by limiting crappy snacky food from my life to not tempt me. It would be harder if those in my life had this stuff around me. Luckily my husband is trying to be healthy too.

    This whole obesity and health link is a real sticky point with me...as I have a close relative who is quite obese and complains about it, yet cannot seem to beat it. She does have some thyroid problems, but there are so many serious health problems related to her weight (including severe sleep apnea) that she *needs* to lose weight or I am very sure she will not make it to 50. Already she is exhausted at the end of the day, simply from just walking around. And simply learning to eat better and WHY she should eat better would change a lot.

    All I know is whenever I feel lousy about myself I go to a store and pick up a 10Lb bag of flour...and remind myself I used to carry 4 times that with me everywhere I went. A friend showed me that when I was big and it was one of the serious kickers to get me healthier. I agree with the idea of anyone who is obese going to a nutritional counselor or physical trainer...people need to know why the weight is bad FOR them and how to live better...not that *they* are bad.

    Hmmm...I'll be quiet now. I'm ranting again...:)

  17. Dr. J, I understand what you're saying, but shouldn't that ultimately, be the patient's decision? Do we stop giving treatment to addicts who repeatedly backslide, or do we keep reaching out, in the hope that they can one day stay clean?
    I have a friend who was repeatedly refused knee surgery because of her weight. Well, it turns out the condition wasn't actually caused by her weight, but was neurological. By that time they found that out, however, she'd already had a weight loss surgery she didn't want just so she could have the knee surgery.
    I'm just saying that denying people medical help seems inhumane.

  18. I think the thing people miss about being denied treatment/surgery for being fat is that it is *dangerous* for obese people to go under anesthesia, and the increased risk of other chronic health conditions make you heal poorly, or more slowly. Your chances of recovery and healing from a surgery are much better if you lose weight first...regardless of wherther the weight is the cause of the condition or not.
    I suppose an individual could risk death if they so chose, but I think doctors are sticking to the "do no harm" pledge by telling overweight patients this.
    It *is* mean, but it is something the patient can do, like quitting smoking, that will increase the odds of them surviving a treatment.
    Ethically, would you all give someone who might die/reject an organ an organ? You can't get a transplant if you have had cancer treatment in the past few years (time varies from place to place) so why not expand that to include weight. I don't like it either...but it *is* like treating an addict. You have to address the root cause of the problem *while* you try and treat the physical problem...
    Oops. I'm off again. Sorry.

  19. But I need to state that I think denying anyone treatment they need *is* wrong...
    *stuff sock in mouth and runs off*

  20. "Why don't we tax the junk food?"

    I believe where I live, our sales tax is much higher for junk food including soda, chips, cookies, etc. I'm so glad that I'm doing something about it.

  21. Wow, these are all great comments! I think this subject raises a lot of issues with people, self included.

    Dr. J., thank you for speaking up from a doctor's POV. The article emphasized the monetary aspect of refusing treatment, but it makes more sense if the treatment is higher risk for obese patients. Did you have an opinion about refusing treatment for older people? I can see that at some point you'd have to say "all we can do is make them comfortable," but how do you decide when that point has been reached?

    I still think a lot could be achieved with taxes (not that I love taxes) and education. The NY Times ran an article last week about plastic bags, which of course clutter up the landfills and don't readily degrade. In Ireland the government added a tax on plastic bags, I think it was 33 cents, on each plastic bag. The usage dropped something like 94%. It became "uncool" to use store-supplied plastic bags, and people started bringing their own reusable bags to the store with them.

    Maybe taxing junk food isn't such a crazy idea after all. It just might work...

  22. Great post. I was reading a similar topic on thedailyskinny.com that went into how to lose belly fat first and why certain types of foods and exercise aren't really as effective as most people would like to believe. Thanks again for the info

  23. "Did you have an opinion about refusing treatment for older people?"

    I can't imagine refusing treatment to an "older person," unless it was significantly life threatening. Maybe some cosmetic procedure, or a really expensive elective surgery if their family members asked me not to do it.
    The decision to "let" a person die is really in the hands of the legal profession, not something we, as doctors, can decide.
    Dr. J

  24. wow, i honestly cannot form a coherent opinion on this, try as i may. i mean, i'm not one to endorse "fat acceptance" because i believe being "fat" and being "me" are not the same thing, and people should be more worried about being healthy than being "accepted", but i would never say fat people don't deserve the same medical treatment as the rest of us. that seriously boggles my mind. and the restaurant thing is interesting... i wonder how that will go over. it's like serving alcohol to a drunk, which makes sense, but people are much more sensitive about being overweight than they are about being drunk. huh.

  25. So does that mean we should "force feed Anorexic's"? Hey why strap "Bulimis's into straight jacket's so they can't stick something down their throat and vomit.


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