PoPulationand Public HealtH etHics

Case
A Body Mass Index (BMI) surveillance programme (heights/weights) will be
implemented by public health nurses in a representative sample of elementary
schools (children aged 4–11 years). Passive (‘opt out’) consent (with forms
mailed to children’s homes) will provide robust and representative populationlevel
statistics and contribute to the development of evidence-based public
health programs and policy.
It can be argued that surveillance is justified because obesity is a highly
prevalent, serious health issue with an acceptable measure (BMI) and an excellent
opportunity for data collection. Schools are a logical measurement site
because they reach virtually all children. To do nothing might be thought to
be analogous to causing harm. However, ethical issues could raise objections
to the program. These include whether:
1 possible stigmatization of obese children may pose risks to their
health;
2 screening rather than surveillance should be introduced so children
identified as “at risk” can be followed up;
3 active consent should be sought because of the risk of harm to children
within the program, and;
4 the use of BMI measurements may lead to confusing messages by
increasing the legitimacy of using weigh scales at the same time as
public health messages are telling people to ‘put away the scale, adopt
healthy behaviours that will improve overall health.’
These objections can each be addressed:
1 Stigmatization will be minimized by ensuring confidentiality through
use of a privacy screen, careful control of records (e.g, codes, locked
forms), training and strict adherence to protocols. Care will be taken
to ensure children do not see results (e.g. having them stand on the
scale backwards). Children (or parents) who request results will be
referred to their doctors. An important justification for not providing
the data to the child or parents, as would be required if this were a
screening process, is the risk to confidentiality if information is given
to the children to transmit to parents.
Obesity Surveillance in School Children
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