In what is perhaps the world’s most biased and blame based health policy, Britain’s NHS just banned patients with obesity or who smoke from receiving elective surgeries in a bid presumably to
inspire encourage help whip and prod people into losing weight (or quitting smoking – but I’m not going to touch on smoking in this piece, not because I agree with the policy, but rather because it’s not my area of expertise).
The policy’s two primary presumptions are ignorant and misguided.
The first has to do with the value of BMI as a clinical tool. While it’s true that the risks of medical complications and morbidities rise with weight, BMI is a measure of bigness, not health. Half of the NFL have been reported to have BMIs greater than 30, as did my friend and colleague Dr. Spencer Nadolsky pictured below in his wrestling days when he sported a BMI of 32.
The second presumption is that obesity is a disease of personal responsibility and choice. While no doubt weight can be dumbed down to eat less, move more, I still find it shocking that public health professionals and policy makers exist who believe that somehow people with obesity simply haven’t absorbed enough societal guilt, shame, and discrimination to finally lose weight.
Of course, even if you do want to embrace personal responsibility as the sole cause of obesity, medicine isn’t about blame. We patch up drunk drivers and folks who don’t wear seat belts. We treat people with asthma who don’t bother keeping up with their puffers, pneumonias exacerbated by the early discontinuation of antibiotics, and the psychotic breaks of folks who stop their antipsychotics.
Oh, you want surgical examples?
How about liver transplants in patients who once suffered with alcoholism; or how about one that doesn’t involve a so-called vice at all – heart bypasses on folks who simply didn’t bother to take their blood pressure, cholesterol or diabetes medications?
We operate on them all in a timely manner, and so we should, but yet here the NHS feels comfortable discriminating against people with obesity, because they apparently still feel justified discussing obesity on the basis of blame based causation.
But putting those two erroneous presumptions aside, the notion that blame based medicine is something that the UK wants to adopt is plainly repugnant. Medicine’s not about blaming and shaming. Life is complicated. And even if a person has the time and personal health to allow a run at intentional behavior change, how high on the list of priorities do you think healthy living lies for someone whose children struggle with substance abuse, or whose debts are staggering, or whose spouse is hobbled with post-traumatic stress disorder? Or someone with any of those same issues who is also unemployed?
Clinically useless truisms aside, obesity is complicated, and moreover we have yet to discover a non-surgical, reproducible, and uniformly effective plan for the management of obesity. And while there’s no argument about the fact that in a ideal world everyone would take it upon themselves to live the healthiest lives possible, there’s two problems with that argument. Firstly, not everyone is interested in changing their lifestyle, and secondly, statistically speaking, the majority of even those who are interested and successful with lifestyle change will ultimately regress. Meanwhile the burden of suffering that the elective surgery those with obesity are being denied may add to absenteeism, presenteeism, pain, depression, and more.
If someone from the NHS’ clinical commissioning groups (CCGs) in Hertfordshire (who thought up this loathsome, biased, and backwards policy) is reading this, I want to remind you of the NHS Constitutions first guiding principle:
“The NHS provides a comprehensive service, available to all
It is available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status.”
Either you’re going to have to reverse this idiotic policy, or amend that statement above to explicitly exclude those with obesity.
(In rushing this post through, I utilized paragraphs from a number of previous stories I’ve written about obesity, blame, and bias)