The requirement to respect autonomy - The Royal New Zealand ...

ethicsentails health risks, children will not necessarilyknow this, and messages of this kind may be confusingor difficult to interpret for children whosedomestic and social experiences deliver conflictingfood-related messages. Should adults be heldresponsible for failures to rid themselves offood-related attitudes and behaviours entrenchedin childhood?Claim 6 ties up the preceding claims with a normativebow, telling us that not only is successfulregulation of weight possible, it is also morallyrequired. In ethics, it is very often claimed that‘ought implies can’; that is, that one can onlybe obliged to do what it is possible to do. Theargument as cast above asserts that it is possiblefor individuals to avoid obesity through attentiveregulation of energy intake and output. Clearly,at one level, this is true, but this account glazesover many of the forces that act upon individualsin ways which load the bases in favour of, oragainst, successful regulation of energy consumptionand expenditure.There is by now a great deal of evidence to suggestthat obesity is not just a problem that societyfaces, but also a problem that society causes. 4The availability, pricing, and marketing of food,along with a slew of other factors (obeso-genicenvironments, changes in the nature of activitiesundertaken for work and recreation, geneticand familial predisposers; transport trends andimportant socioeconomic factors) combine forcesin a way that encourages, or even produces, obesity.13,14 Some people are more exposed to thesefactors than others, or are less able to avoid theirobesity-inducing effects. This means that obesityand the health problems associated with it occurunevenly across the population, in many casesconsolidating and extending pre-existing healthand other social inequalities.Whilst it may be possible for most people toavoid obesity, some face many more obstaclesto achieving this than others, many of whichare not the result of personal choices. If weas a society accept certain social arrangementsthat increase the difficulty of avoiding obesity,it would seem unfair to then deny accessto treatment for obesity on the basis that theobese have been morally irresponsible. In fact, itmay be that the obese have a harm-based claimagainst society, or some parts of it, for the harmto which obeso-genic policies and arrangementshave exposed them.These comments reveal the difficulty, in the contextof obesity at least, in establishing with certaintyprecisely what harms have occurred, whois responsible for them and what the appropriateresponse to them might be. If responsibility forharm is potentially disparate, it would be undulyharsh to distribute the full force of responsibilityto identifiable individuals.That is essentially what would happen if obeseindividuals were denied access to publicly-fundedtreatments like bariatric surgery on the groundsthat to provide access would be to facilitate harmto others. The harms involved in obesity and theobligations that they produce are too debatable,and responsibility for the production of harm istoo diffuse, to warrant refusal of public funding,at least on the grounds set out here.References1. Mill JS. On liberty. London: Penguin; 1974.2. Garrard E, Wilkinson S. Selecting disability and the welfare ofthe child. The Monist. 2006;89(4):482–504.3. Coddington D. Funding stapling is a kick in the guts for taxpayers.New Zealand Herald On Sunday. 2010 Feb 14.4. Swinburn BA. Obesity prevention: The role of policies, lawsand regulations. Aust New Zealand Health Policy. 2008;5(12).5. Christakis NA, Fowler JH. The spread of obesity in a large socialnetwork over 32 years. N Engl J Med. 2007;357:370–379.6. Mulvaney-Day N, Womack CA. Obesity, identity and community:leveraging social networks for behavior change in publichealth. Public Health Ethics. 2009;2(3):250–260.7. Epiphaniou E, Ogden J. Successful weight loss maintenanceand a shift in identity. J Health Psychol. 2010:10.8. Moore S, Daniel M, Pacquet C, Dube L, Gauvin L. Associationof individual network social capital with individual adiposity,overweight and obesity. J Public Health 2009;31(1):175–183.9. Mokhtar N, Elati J, Chabir R, et al. Diet culture and obesity inNorthern Africa. J Nutr. 2001;131(Supplement):887s–892s.10. Ebbeling CB, Pawlak D, Ludwig DS. Childhood obesity: publichealth crisis, common sense cure. Lancet. 2002;302:473–482.11. Kaufman L, Karpati A. Understanding the sociocultural rootsof childhood obesity: food practices among Latino families ofBushwick, Brooklyn. Soc Sci Med. 2007;64:2177–2188.12. Gibson LY, Byrne SM, Davis EA, Blair E, Jacoby P, Zubrick SR.The role of family and maternal factors in childhood obesity.Med J Aust. 2007;186(591–595):591.13. Butland B, Jebb S, Kopelman P, et al. Foresight. Tackling obesities:future choices—project report. 2nd ed. London (UK):Government Office for Science; 2007.14. Sobal J, Stunkard AJ. Socioeconomic status and obesity: areview of the literature. Psychol Bull. 1989;105(2):260–275.346 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE