2 Column Dept - Pediatric Nursing

Pediatric Ethics, Issues, & Commentary
Anita J. Catlin, DNSc, FNP, FAAN
Parents of Obese Children and Charges
Of Child Abuse: What Is Our Response?
The alarming rate of childhood obesity in the
United States is, unfortunately, no longer news.
Obese children are presenting as patients to hospitals
and clinics for a variety of reasons, most of
which were previously only seen in the adult population:
type 2 diabetes mellitus, high blood pressure, high cholesterol,
glucose intolerance, asthma, sleep apnea, menstrual
abnormalities, impaired balance, and orthopedic problems
(American Academy of Pediatrics [AAP], n.d.). Equally concerning
are the negative mental and social effects of obesity,
such as low self-esteem, depression, negative body
image, stigma, teasing, discrimination, and social marginalization
(AAP, n.d.). Evidence also demonstrates that childhood
obesity is associated with lower math and reading
scores (Mitgang, 2011). How should this growing problem
in our country be resolved? One drastic proposal that made
the headlines in the summer of 2011 was to consider
removing severely obese children from their parents’ custody
(Murtagh & Ludwig, 2011). Is this action what is best
for these children?
This article provides an overview of the reasons for and
against the prosecution of parents of obese children.
Additionally, alternative perspectives that re-examine social
policies that may contribute to childhood obesity will be
explored. Finally, pediatric nurses will be encouraged to
engage in policy discussions about childhood obesity.
Excluded from the discussion are cases of obesity due to
genetic conditions.
Reasons for Prosecution
Although the law recognizes that parents have the primary
responsibility for raising their children, the state may
intervene to protect a child from harm or abuse. One way
a state may intervene is through its child abuse laws.
Federal legislation identified the following minimum definition
for each state to adopt in their respective child abuse
statutes: “Any recent act or failure to act on the part of a
parent or caretaker which results in death, serious physical
or emotional harm, sexual abuse or exploitation; or an act
or failure to act which presents an imminent risk of serious
harm” (U.S. Department of Health and Human Services,
2008). While people recognize a role for the State in
addressing problems with children’s health, the extent to
Kellie R. Lang
which government should be involved in issues of childhood
obesity remains subject to debate (Tao & Glazer,
2005). The rationale for invoking child abuse laws for
severely obese children is that the child faces imminent
health risks and the parent has repeatedly failed to address
these medical problems, thus meeting the definition for
mandatory child abuse reporting (Murtagh & Ludwig,
2011). In an interview about Murtagh and Ludwig’s (2011)
article, Dr. Norman Fost, a pediatrician and ethicist,
explained that both morbid obesity and undernutrition are
forms of malnutrition and that parents of undernourished
children are routinely charged with abuse, so the same
standard can apply for parents of obese children (Ogilvie,
2011). In other words, if a parent who endangers a child’s
health by starving her or him can be charged with abuse,
why should a parent who endangers a child’s health by
over-feeding her or him not also be subject to these
charges?
Using the legal system as a resource for health professionals
to protect children from the health complications of
obesity is not a new or recent phenomenon. In fact, a number
of jurisdictions have recognized that morbid obesity is
a justification for state intervention (Mitgang, 2011). For
example, in 2002, a Texas court of appeals upheld the termination
of a mother’s parental rights based, at least in
part, on the child’s obesity. In this case, a five-year-old,
G.C., weighed 136 pounds, experienced difficulty breathing,
and had a mildly enlarged heart and mild congestive
heart failure (In re G.C., 2002).
It is important to note that those who support removing
an obese child from her or his home would do so only
when necessary to address a current risk of serious harm or
to prevent loss of life (Mitgang, 2011). However, determining
exactly “when” harm becomes imminent is one of the
challenges with this standard (Mitgang, 2011, p. 566-567).
Attempts have been made to articulate objective criteria
that establish a threshold for state intervention. Varness,
Allen, Carrel, and Fost (2009) justify removal from the
home when there is 1) a high likelihood of serious, imminent
harm; 2) a reasonable likelihood that coercive state
intervention will result in effective treatment; and 3) no
other alternative options are present to address the problem.
Varness et al. (2009) distinguished between four cate-
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Kellie R. Lang, JD, RN, is an Assistant Adjunct Professor of Bioethics
and Medical Humanities, Center for Bioethics and Medical Humanities,
Institute for Health and Society, Medical College of Wisconsin,
Milwaukee, WI.
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Pediatric Ethics, Issues, & Commentary focuses on
exploring the interface between ethics and issues in clinical
practice. If you have suggested topics or cases for consideration
in the column, please contact Anita J. Catlin, DNSc,
FNP, FAAN, at acatlin@napanet.net
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Pediatric Ethics, Issues, & Commentary
gories of obese children, depending upon the presence of
co-morbidities that predict serious harm and whether these
are reversible in adulthood, or whether these constitute
imminent harm in childhood. State intervention would be
justified when the co-morbid conditions predict serious
harm and are not reversible in adulthood, as well as when
the co-morbid conditions constitute serious harm in childhood
(Varness et al., 2009).
Citing concerns for bias and conjecture in reaching a
decision about obesity as child abuse, Mitgang (2011)
underscored the importance of objective, physical evidence
in an abuse analysis. She would justify state intervention
when necessary to prevent loss of life or to address a current
risk of serious harm and only after home-interventions had
failed (Mitgang, 2011). Mitgang (2011) identified four factors
that should be used by a court in determining whether
actual medical harm caused by the child’s obesity warrants
state intervention:
• The severity of child’s illness associated with obesity.
• The degree in which medical treatment can mitigate
the resulting health effects.
• The child’s complete physical and mental health picture.
• When the just answer is unclear, the child’s risk of
remaining obese as an adult.
Response to Murtagh and Ludwig
As one would expect, Murtagh and Ludwig’s (2011)
article was met with a strong response from the medical
and legal communities. Each of these three letters to the
editor, including Ludwig and Murtagh’s response, will be
discussed in turn.
Ms. Carol Erskine, a justice in a Massachusetts county
juvenile court, wrote to underscore that in these cases, state
intervention may occur only under clearly defined legal
parameters (Erskine, 2011). The state has to meet the burden
of proof required to disrupt the privacy rights of the
family; the mere suggestion of state intervention does not
change the state’s actual burden (Erskine, 2011). Ludwig
and Murtagh (2011) agreed with Ms. Erskine in their
response to her letter and indicated their intent was to work
within the existing legal structure, not to change it.
Robert Siegel (staff physician for the Northern
Kentucky Children’s Advocacy Center) and Thomas Inge
(director of the Surgical Weight Loss Program for Teens &
Center for Bariatric Research) took issue with Murtagh and
Ludwig’s (2011) suggestion, stating that it might be unethical
for an obese child to undergo bariatric surgery without
first considering foster care (Siegel & Inge, 2011). For these
physicians, weight-loss surgery and social service intervention
are mutually exclusive (Siegel & Inge, 2011). Suitable
candidates for this surgery would not be appropriate candidates
for state intervention, and children under consideration
for social service referral would not be appropriate candidates
for surgery (Siegel & Inge, 2011). They explained
that any family that met the Varness et al. (2009) criteria for
state intervention would not meet the best-practice criteria
for weight-loss surgery (Siegel & Inge, 2011). They also cited
evidence that foster care may, in fact, be an obesogenic
environment (Siegel & Inge, 2011). Ludwig and Murtagh
(2011) responded to this criticism by noting that there are
children who fall in between these categories, where they
experience inadequate parenting that does not meet the
legal definition of neglect.
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Finally, Drs. Susan Yanovski, Jack Yanovski, and Mary
Horlick (2011) noted that Murtagh and Ludwig’s (2011)
article held two false assumptions: 1) severe childhood obesity
necessarily resulted from poor parenting rather than
genetics, and 2) type 2 diabetes requires removal from the
home, and foster care is beneficial to obesity treatment.
These authors argued that there is no evidence that foster
families control the weight of obese children better than
the children’s families of origin, and that greater social
resources should be provided to parents of obese children
so that medical complications can be prevented or treated
within their own homes (Yanovski, Yanovski, & Horlick,
2011). Ludwig and Murtagh (2011) responded that they
recognized genes affect weight and that foster care would
not be appropriate for most severely obese children, noting
that the primary treatment for type 2 diabetes is lifestyle
modifications and weight loss. While they agreed the foster
care program should receive greater scrutiny, they also
noted one case where a young teenager died while waiting
for custody hearing (Ludwig & Murtagh, 2011). Finally,
Ludwig and Murtagh (2011) agreed that greater resources
should be provided but raised the practical question of who
would actually provide those resources. They conclude that
in the interim, existing resources that would preclude the
need for foster care or bariatric surgery should be used
(Ludwig & Murtagh, 2011).
Additional Reasons Against Prosecution
Other reasons to oppose the removal of obese children
from their homes stem from a broad range of concerns.
These include 1) severe emotional or psychological harm to
the child, especially in light of the lack of evidence that foster
care for these children is effective “treatment;” 2) inconsistencies
in the legal process that might lead to unfair outcomes;
and 3) a social and political landscape that arguably
has a net effect of promoting childhood obesity.
Lack of Evidence about Foster Care
And Potential for Harm
A more compelling argument against prosecution of
parents is the most glaring: the lack of evidence regarding
the effectiveness of protective custody or foster care
(Diekema, 2011; Siegel & Inge, 2011; Yanovski et al., 2011).
Diekema (2011), a pediatrician and ethicist, argued that
without any evidence of its effectiveness, removing a child
from her or his home should not be a mechanism used to
treat childhood obesity. As a correlating factor, Diekema
(2011) called attention to the significant psychological
harm experienced by a child when removed from the
home, and noted that this must be considered in any protective
custody decision. This is compounded by a concern
that some foster homes may not offer a nurturing environment.
It is interesting to note that even those who support
state intervention have cited concerns about the quality of
foster care (Murtagh & Ludwig, 2011). Without evidence
that the potential benefit of removing an obese child from
her or his home outweighs the harm of doing so, the disruption
of a family relationship cannot be justified
(Diekema, 2011).
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Potential for Unfair/Disparate Impact
Another concern is the very real possibility that the
interpretation of criteria to remove children from families
may vary between different communities and jurisdictions

that result in, albeit unintended, negative social consequence.
For example, a New York trial court agreed with the
Department of Social Services and found that parents of an
obese girl were unwilling to comply with a court order to
ensure that the child attended school, gym, and other
activities. However, the parents appealed this decision, and
the appeals court found there was a lack of evidence that
the parents had not complied with the court order (In re
Brittany, 2008). It is disturbing to consider the injustice of
what might have happened had the parents not appealed
the initial decision. Compounded to these questions of fairness
is the concern that state action may result in a disproportionate
impact on minority families because minority
children in the United States are disproportionately represented
in overweight/obese statistics (Mitgang, 2011).
The Role of Society in Childhood Obesity
A final reason for opposing prosecution of parents is
that it is unfair to place the blame solely on parents when
society has also played a role in the obesity epidemic. Our
modern environment encourages a sedentary lifestyle
through limited outdoor and unstructured activity opportunities;
an increased reliance on automobiles for transportation;
increased use of television, video, and other
technology as entertainment; and less meals prepared with
fresh foods at home (Brody, 2011). Although parents are
responsible for their children, they do not have control
over their child’s behavior inside or outside the home
(Diekema, 2011). Parents do not raise their children in a
vacuum; our environment in tandem with social policies,
especially regarding marketing and school lunches, can
have a powerful influence on family health. In looking at
childhood obesity then, a wider lens must be incorporated
that includes an examination of the social and political
landscape that so strongly influences our culture. To illustrate
this landscape and demonstrate the general public’s
concern about childhood obesity, this author will include
citations from general public, or non-medical, resources.
In the summer of 2011, there were two national initiatives
targeted toward addressing the country’s obesity epidemic.
First Lady Michelle Obama brought the issue of obesity
to national attention with the “Let’s Move” campaign
(Let’s Move, 2011). Second, the United States Department
of Agriculture launched its new food icon MyPlate (Vilsack,
2011) that replaced the food pyramid with the goal of helping
consumers choose healthier food options. These recent
public education initiatives are helpful, but unfortunately,
cannot counter the effects, past and present, of the food
marketing industry.
Food and beverage marketing is very effective among
children and is associated with increasing obesity rates
(Brody, 2011). Food advertisements on television watched
by children promote products high in fat, sugar, or sodium
(Harris & Graff, 2011). Research has revealed that food marketing
affects children’s brand and specific food preferences,
and has demonstrated an association between soft
drink advertising, specifically, and consumption of sugarsweetened
drinks (Harris & Graff, 2011). The obesity crisis
cannot be solved without significant changes to the marketing
environment that surrounds children (Harris &
Graff, 2011). Although the food industry has taken some
self-regulatory steps to address advertising concerns, the
fine-print reveals that these steps are fraught with exclusions
and limitations that will not improve existing marketing
practices (Harris & Graff, 2011).
Additionally, national social programs contribute to
unhealthy diet in school children. The National School
Lunch Program, originally intended to provide healthy
meals to children regardless of income, was also designed to
subsidize agribusiness, such as beef and dairy (Yeoman,
2003). As a result, critics of the program argue school lunches
contain too much fat, additives, and preservatives and
not enough vegetables (Parker-Pope, 2009; Yeoman, 2003).
In fact, a group of retired generals, called “Mission:
Readiness,” has even advocated for healthier school lunches
and described the current program as a national security
issue, citing obesity as the leading medical disqualifier for
military service (Mission: Readiness, 2011). In spite of the
growing national concern for childhood obesity, Congress'
initial reaction to regulatory changes, which would have
made school lunches healthier, was a refusal to accept these
changes (Nixon, 2011).
Despite the national attention to the public health
concern of childhood obesity, the public does not seem to
have reached a consensus as to whether our elected officials
should control the conditions of the sale of some foods,
restrict advertising of certain foods, subsidize healthier
alternatives, and restrict or ban certain ingredients (Kersh,
Stroup, & Taylor, 2011). The American Nurses Association
has taken note of this as well. “While the effects of previous
policies that have contributed to decreased physical activity
and increased intake of ‘empty calories’ are beginning to
be acknowledged in public policy debates, current policy
initiatives are more likely to focus on individual choices
than sweeping economic and social changes” (Tao &
Glazer, 2005).
The social policy contributions to obesity may seem
daunting, but several first-steps have been proposed. The
Robert Wood Johnson Foundation has funded evidencebased
interventions and made efforts at community, state,
and federal levels to advance the following policy priorities:
1) ensure all food/beverages served and sold in schools
meet or exceed the Dietary Guidelines for Americans; 2)
increase access to affordable foods through new or
improved grocery and corner stores that sell more healthful
foods; 3) increase time, intensity, and duration of children’s
physical activity at and out of school; 4) use pricing strategies
(incentives and disincentives) to promote the purchase
of healthier foods; and 5) reduce exposure to marketing of
unhealthy foods through regulation, policy, and effective
industry self-regulation (Govea, 2011; Kersh et al., 2011).
Other suggested interventions include controlling the conditions
of sale, subsidizing healthy foods that are frequently
more expensive, and restricting certain ingredients
(Kersh et al., 2011).
When industry practices render a significant negative
effect on the health of a country’s citizens, especially their
most vulnerable, and when these industries do not voluntarily
make changes; then all levels of government are obligated
to intervene where they are able (Harris & Graff,
2011). It is disheartening to note on one hand, the apparent
willingness of our society to prosecute individual parents
for childhood obesity and accept those social costs,
monetary and otherwise; and yet, on the other hand, be
unwilling to take steps that would help to prevent childhood
obesity in the first place. Diekema (2011) notes the
irony of a country that allows removing obese children
from their homes but that does not support healthier children
through controlled advertising, legislating a living
wage, or making healthy foods affordable. A responsibility
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Pediatric Ethics, Issues, & Commentary
of government is to promote public health, especially for
children (Harris & Graff, 2011). If the state is allowed to
remove an obese child from her or his home, it should also
be required to advance sound, consistent health policies
that promote the health of children.
Role of Pediatric Nurses
Nurses are privileged to hold the public’s trust (Jones,
2010), and as such, it is important for them to thoughtfully
and critically think about the social conditions and public
policies that have profound effects on health. The
Nurses Code of Ethics mandates that nurses promote and
advocate and work to protect the health and rights of
patients, collaborate with others to promote efforts to meet
health needs, and shape social policy (American Nurses
Association, 2001). Because pediatric nurses care for children
who live within a broad range of family and social situations,
they must be comprehensive in their approach to
addressing the problem of childhood obesity. Does the
adversarial process of removing obese children from their
homes benefit children in the short or long term? Does the
practice (or threat of) removing obese children from their
homes serve as a deterrent to other parents who may raise
obese children? Do clinics and hospitals, in practice, support
healthy food choices for their patients? Do health care
providers and organizations actively encourage laws that
will protect or ensure children’s health? Do we elect representatives
that introduce or support these laws? As public
health professionals, patient advocates (Tao & Glazer,
2005), and participants in a democracy, nurses can influence
public discussion and initiate solutions that benefit
the whole child.
References
American Academy of Pediatrics (AAP). (n.d.). About childhood obesity.
Retrieved from http://www.aap.org/obesity/about.html
American Nurses Association (ANA). (2001). Code of ethics for nurses
with interpretative statements. Retrieved from http://nursingworld.org/codeofethics
Brody, J. (2011, September 12). Attacking the obesity epidemic by first
figuring out its cause. The New York Times. Retrieved from
http://www.nytimes.com/2011/09/13/health/13brody.html?pagewanted=all
Diekema, D. (2011). Reasons to think twice before calling CPS about
morbid obesity. AAP Grand Rounds, 26, 48.
Erskine, C. (2011). Letter to the editor. Journal of the American Medical
Association, 306(6), 1762-1763.
Govea, J. (2011). Ethical concerns regarding interventions to prevent
and control childhood obesity. Preventing Chronic Disease, 8(5),
A91. Retrieved from http://www.cdc.gov/ped/issues/2011/sep/10_
0288.htm
Harris, J.L., & Graff, S.K. (2011). Protecting children from harmful food
marketing: options for local government to make a difference.
Preventing Chronic Disease, 8(5), A92. Retrieved from
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In re Brittany T. (2008). 48 A.D. 3d 995. (Appellate Division of Supreme
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In re G.C., 66 SW3d. (2002). (Court of Appeals, Texas). 66 SW. 3d 517
(Tax App. 2002).
Jalonick, M.J. (2011). Congress fights Obama administration attempts
to make school lunches healthier. Retrieved from http://www.snawi.org/legislative-information/school-nutrition-bill-could-berevived-in-congress
Jones, J.M. (2010, December 3). Nurses top honesty and ethics list for
11th year. Gallup Economy. Retrieved from http://www.gallup.
com/poll/145043/nurses-top-honesty-ethics-list-11-year.aspx
Kersh, R., Stroup, D.F., & Taylor, W.C. (2011). Childhood obesity: A
framework for policy approaches and ethical considerations.
Preventing Chronic Disease, 8(5), A93. Retrieved from
http://www.cdc.gov/ped/issues/2011/sep/10_0273.htm
Let’s Move. (2011). About Let’s Move. Retrieved from http://www.lets
move.gov/about
Ludwig, D., & Murtagh, L. (2011). Letters to the editor, in reply. Journal
of the American Medical Association, 306(16), 1764.
Mission: Readiness. (2011). Too fat to fight: Retired military leaders
want junk food out of America’s schools. Retrieved from
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Mitgang, M. (2011). Childhood obesity and state intervention: An examination
of the health risks of pediatric obesity and when they justify
state involvement. Columbia Journal of Law & Social
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Murtagh, L., & Ludwig, D. (2011). State intervention in life-threatening
childhood obesity. Journal of the American Medical Association,
306(2), 206-207.
Nixon, R. (2011, November 15). Congress blocks new rules on school
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nytimes.com/2011/11/16/us/politics/congress-blocks-new-ruleson-school-lunches.html
Ogilvie, J.P. (2011, August 29). Pro/con: Does obesity qualify as child
abuse? Los Angeles Times. Retrieved from http://articles.latimes.
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Parker-Pope, T. (2009, January 29). Obama’s new chef skewers school
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Siegel, R.M., & Inge, T.H. (2011). Letter to the editor. Journal of the
American Medical Association, 306(6), 1763.
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abuse and neglect? Retrieved from www.childwelfare.gov/
pubs/factsheets/whatiscan.cfm
Varness, T., Allen, D.B., Carrel, A.L., & Fost, N. (2009). Childhood obesity
and medical neglect. Pediatrics, 123(1), 399-406.
Vilsack, T. (2011). USDA unveils new, simple tips to stay healthy, active
and fit. Retrieved from http://www.whitehouse.gov/blog/2011/
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Yanovski, S.Z., Yanovski, J.A., & Horlick, M. (2011). Letter to the editor.
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Yeoman, B. (2003). Unhappy meals. Retrieved from http://motherjones.com/politics/2003/01/unhappy-meals
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Additional Reading
Bonné, J. (2005). A call for limits on children’s food ads. Retrieved from
http://www.msnbc.msn.com/id/6795715/ns/business-us_
business/t/ call-limits-childrens-food-ads/
Harris, D., & Conley, M. (2011). Childhood obesity: A call for parents to
lose custody. Retrieved from http://abcnews.go.com/Health/childhood-obesity-call-parents-lose-custody/story?id=14068280
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