DebraSY

On Science and Ethics

In Weight-Loss Maintenance on December 1, 2010 at 11:59 am

Note to casual readers – if you aren’t reading the comments, you are missing the best of this blog – the commenters are superb.  Now, in response to a brilliant observation on my last post from Debby, I found a worthy observation falling from my own fingertips:   

“My mission statement, as a blogger, and I probably ought to post it somewhere, is “tell a truth; advance compassion.” I can do that, since I’m not a scientist — I just observe them.  A scientist’s mission statement can only be “tell a truth; advance more research.” When they unwittingly adopt an agenda, such as “advance weight control for all,” then they betray their mission as scientists.”

Other people, say, public policy makers, rely on scientists to provide unbiased information so that they may make decisions about what to advance.  Biased information, by definition, is incomplete, and that will compromise decisions.  

I recently ran across an interesting scientific overview of ethics as they might apply to public policy and obesity.  Forgive the grammatical eccentricities.  I think it’s been translated from Dutch.

The scientists looked at various ethical frameworks that public policy makers might use to frame decision making with regard to obesity.  As I was reading, however, I couldn’t help but notice that the overview itself has been affected by bias.  I was stopped short at the background section, for example, where they give three sample ethical questions that public policy makers might ask when creating policy: 

“Is a campaign that stresses the importance of a healthy weight acceptable when it stigmatizes overweight persons? At what point does encouraging physical activity in the workplace become too intrusive in the personal life sphere? Is policy to inform people about health risks of obesity ethically sound when it does not reach people from ethnic minorities?” 

Each of these questions could merit a blog post, but I would like to highlight the third today, because it blatantly states the most dangerous false assumption that underlies much of current public policy:  the “health risks of obesity.” 

Huh? 

Let’s be clear:  causation has never been proved.  It would be fair to say “the health risks associated with obesity,” but public policy that assumes that obesity itself is the cause of compromised health is wrong, and may lead to bad decision-making, both by public policy makers and the people they serve.  Moreover, it contributes to the stigmatizing of fat people, something they clearly recognize as a problem in sample question one. 

It is fine for public policy makers to think in terms of health risks associated with obesity, because those health risks are also associated with other conditions we recognize as life threatening:  heart disease, diabetes, etc.  It is fine for policy to encourage healthy habits, but to state that obesity itself is a health risk does NOT encourage healthy habits.  Quite the opposite.  Average people try to rid themselves of their dreaded obesity through all kinds of unhealthy measures – fad dieting, disordered behavior, unnecessary surgeries, untested dietary supplements, reliance on amphetamines, etc.  Actually, ethically, public policy should be debunking that phrase “health risks of obesity.”   Public policy should counter the diet culture presented in silly women’s magazines, not justify it.

Obesity may be a symptom of disease (especially when it is located in the abdomen and it is engulfing organs), and its rise in our developed world may be a harbinger of something that should catch our attention.  However, demonizing obesity and calling it a health risk in its own right is unproductive, even dangerous.

Now, since I have summarily determined that our public policy makers and many of our scientists are working from false assumptions, what, my friends, do WE think they should be asking, with regard to obesity and public policy?  As you contemplate this, you may wish to work backward from an ethical framework.   Let’s choose the Public Health Leadership Society, which governs the thinking of the American Public Health Association.  I have copied it here from Table 4 of the study at hand.  Ask yourself, what assumptions might lead to good policy under the following framework: 

  1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.
  2. Public health should achieve community health in a way that respects the rights of individuals in the community.
  3. Public health policies, programs and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.
  4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that that the basic resources and conditions necessary for health are accessible to all.

Number one begs the question:  is obesity a disease?  I, obviously, would argue it is not, and that should be one basic assumption that guides policy.  The question that follows from that is whether controlling obesity itself is one of the “requirements for health, aiming to prevent adverse health outcomes?”   Hmmmm.

Number three assumes (rightly or wrongly) that the community has good information to participate in the discussion.  It makes me scratch my head:  Is Michelle Obama’s “Let’s Move” campaign supplying good information? 

There is much to think about here.  I hardly know where to begin, so I throw it to you!

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  1. The sacred cultural myth that says people have free agency to choose their behaviors (actions) runs so wide and deep in many cultures that trying to deconstruct this single false premise (upon which a host of crazy-making arguments are constructed and consumed unquestioned as fact) requires a grasp of philosophical, psychological and theoretical concepts so far beyond the level of education provided in most schools it is akin to successfully explaining foreign policy to a three month old.

    Exhibit A: one Sarah P., who by virtue of her profound PRIDE concerning her lack of knowledge of geography, history, literature, economics, etc, has nestled snugly into a media empire that strokes the ego every ignorant person who aspires to ANY goal, no matter how ridiculous, while reassuring them: YES, ANYONE CAN DO ANYTHING IF THEY SIMPLY PUT THEIR MIND TO IT!

    Ahem. Ad hominid attack withdrawn. Sorry.

    Still.

    If we think that science, research, social policy, medicine, psychiatry, history, and so forth, are systematically constructed and maintained by neutral or objective beliefs or by people without massively conflicted interests (see the *power of rational choice*) then we are simply a culture in mass denial. About virtually everything.

    In nursing school and in clinical settings I tried to argue that *successful* weight loss and long term maintenance is simply beyond most people’s ability to control, through no fault of the individuals. I tried to show that correlation does not prove causality.

    As a fat woman, I had no credibility.

    Didn’t matter what studies I provided to support sound evidence based practice. Didn’t matter that the other team members could find virtually NO evidence to support their (doomed) patient outcome strategies for long term weight loss. The other team members were given credibility, based on the holy idea that humans have the power of choice about how much they eat and whether they move *enough*. You know, god given free agency. (Umm, regardless of having few or no options from which to choose…regardless of whether it was even an appropriate choice…)

    One group project *proved* that weight loss dieting and exercise was effective for improving health outcomes in cardiac patients. Oh lord. I was assigned to that group.

    The group found no long term data to support that health outcome. Shocking.

    Nope, instead, the whole project outcome was based on findings from one little study, from a European country that has vastly different health practices and health care services than in the US, such that patients had unlimited access to modern exercise facilities (free), nutrition support (free), as needed counseling with nutritionists (free), exercise physiologists (free), and psychiatric nurse therapists (free), for as long as needed by the patients. The follow up was for one year. Patient outcomes did improve. Modestly.

    However, in the US version, which the team implemented, a patient brochure was designed which outlined the basics of healthy eating and exercise. Colorful USDA pyramid etc. included. The nurse would show pretty pictures then ask leading questions to see if patient understood contents. Ta da! (That is what passes as patient education or, even worse, health promotion.)

    I could not convince the team that there were any ethical dilemmas connected to their patient care plan, which looked simply *beautiful* in their poignant powerpoint presentation. Actully, it looked magnificent. BEST. USE. OF. TECHNOLOGY. EVER!

    Appearances. Yep. Remember: all that matters is appearance management (we use to call it “running a con” when I was nine).

    Obviously, I was often viewed as an irrational trouble maker (and my fatness of course helped to confirm that.)

    And, hence, I am RNegade. Unemployed, almost on the verge of homelessness, eating burgers at McDs (no buns), and still working to enlighten just one additional mind.

    And yet dreaming of that future (theoretical) critical mass…

    • Grrr! at your comrades in nursing school. Doesn’t surprise me. Wonder if they saw you now whether they’d assume you’d changed your mind, since, after all, you appear to have seen the light and lost weight. I do hope you get a job soon, in nursing, and partially for selfish reasons. Of course, I’d love you to have a good job for your well being, but I’d also love for you to be in a position to talk truth to power, as it were, in your current reduced body. (Prayer thrown in for good health insurance too.)

  2. To start off on a bit of a tangent:
    A scientist’s mission statement can only be “tell a truth; advance more research.” When they unwittingly adopt an agenda, such as “advance weight control for all,” then they betray their mission as scientists.”

    While this sounds nice and all, it’s not quite true. First off, we scientists are human, too, and by nature we approach any study with preconceived notions and biases. The best that we can do is try to control for these biases through our selection of hypotheses and experimental design.

    But furthermore, I don’t believe it necessarily *should* be true. Yes, the hypothesis-selection and experimental design phases of research should be approached with as few biases as possible. But I do not believe that our end goal should always and ever be only “more research”. Yes, that keeps us in jobs and all – but that’s not the reason we go into science in the first place, except for perhaps those conducting the purest of pure research. The rest of us enter science to make discoveries and/or fine truths which are then put to use. For example, look at research into effects of global climate change and forest fragmentation. When study after study after study shows the same thing – that climate change and fragmentation are driving rapid environmental collapse and extinction – it’s foolish to insist that all scientists can do is advocate for more research. Yes, one should not design a study of fragmentation effects with the end goal of showing the negative effects, but after one has conducted the millionth study showing the same thing, it is appropriate – even necessary – to advocate an end to rapid forest loss. Scientists tend to be an insular bunch, speaking only to one another, and it’s necessary for someone to communicate our results to those who can act upon it (politicians, policy workers, educators, etc.)

    Similarly, if – and that’s a *big* ‘IF’ – obesity had been shown time and time again (and not just in studies funded by pharmaceutical companies and the diet industry) to have direct, causative, negative impacts on health outcomes, I would feel it’s appropriate for scientists to say so upon conclusion of their studies. But that’s just not true. While some studies show non-directional correlation between obesity and negative health outcomes, others actually show correlation between overweight and/or obesity and *positive* health outcomes. Yet every single lay-person summary I have read of such a study either completely twists the results, or presents them accurately but still ends with a conclusion that “regardless, people should not take this as an excuse to be lazy and eat whatever they want, and weight loss dieting is still recommended.” The breakdown, as I see it, comes as often from the interpretation of the science as from the science itself.

    As a HAES advocate, I would support public policy aimed at promoting improved health through those means that we know work – increasing activity (where/as possible), decreasing consumption of HFCS and highly sugary or fatty foods, and improving availability and affordability of fresh fruits and vegetables in all communities, particularly poorer and inner-city communities. But the end goal should be health itself, not obesity which – as you’ve already shown above – is a poor indicator of health.

  3. With regard to your tangent, I think scientists are in a similar position to journalists, but in journalism there are (supposedly) clear distinctions between commentators and straight reporters. The straight reporters understand their obligatin to subsume their preconceived notions and biases toward a goal of objectivity. The best ones get pretty close (even though they’re only human). And when they blow it, a commentator is likely to jump in and call them on it.

    In science there are practitioners who are more objective than others, but it’s a big secret to the general population who is who. Many of the obesity think tanks, presumed to be unbiased, are associated with hospital weight loss programs, and that’s not acknowledged as a biasing factor. It should be.

    As for advocacy, I still think it needs to be set apart from the actual science itself somehow, and your field hasn’t seemed to do that. Maybe we shall agree to disagree. I’ll keep scratching my head. You keep scratching yours. Maybe we’ll solve the dilemmas of the world.

    I agree with you that the science on global warming is exasperating. Legit science is smacked down with junk science. It becomes a confusing war of words in the marketplace of ideas because the public doesn’t know who the players are: who is legit and who is junk.

    That’s an argument for this ethical framework and public policy model, where outsiders apply ethics to decide policy based on the best, most rigorous science. But then, the assumptions undergirding that rigor have to right to start with, and (back to the topic at hand) with obesity those assumptions are wrong.

    (She grabs her head and runs screaming from the room!)

    Then she pops her head back in — I do agree that policy ultimately should be about health and should OMIT the word “obesity” from the equation.

  4. It’s important to not confuse scientific results with “truth”. Scientists gather data. That data constitutes facts. From that point, those facts are interpreted in various ways. Interpretation is always influenced by the interpreters personal bias. It isn’t “the truth”, but rather the truth they would prefer to believe to advance an agenda. That doesn’t mean they are self-serving. In many cases, people want to help and do what is best, but there is no such thing as an objective truth. There are simply facts, and they can be seen in various ways.

    This applies to everything, not just weight. The main issue with weight is that the bias being applied tends to be greatly heavier because it is laden with emotional considerations (both on the part of anti-fat people and fat advocates). I think that any effort to talk about “truth” or to use science in any way other than it is intended (that is, to advance an agenda rather than to gather data), is flawed from the start.

    The question of whether or not “obesity is a disease” is an irrelevant one. It’s the wrong question. Obesity, like all other physical manifestations, is a symptom of something. The question is whether or not it is a symptom of something benign or dangerous for a particular individual (much as a mole may be safe or cancerous). But the issue is so laden with increasing social and now political judgment that people care little about what the language they use conveys or where it makes us look.

    • Wait a sec, though. It’s hypotheses that inform scientists’ choice of data, and experiments are designed to either support or fail to support the hypotheses. If a hypothesis is well supported, it becomes a theory.

      Now, there are all kinds of ways that biases can affect this process, but it doesn’t make any sense to collect data completely out of context. What purpose would that serve? The choice of which data to collect is impossible to make without having some objectives in mind.

  5. Greetings for yor site and for the post that helps people, readings and reading… We suggest our Ethics, Deontologia in Italy and Italian Good reading and work… Link to NotitiAE
    http://notitiae.wordpress.com/2010/10/22/manuale-fotografia/

  6. Hmmmm. Some of you regular bloggers, is Notitiae a real person for whom English is a second language, or an example of the Spam I’m supposed to watch out for? My apologies, Notitiae, to talk about you in the third person in front of you, if you are real, but I’m just not sure. Are all WordPress.com sites safe? I haven’t clicked for fear of what I’ll see.

  7. Ever the curious linguist, I checked out the “Notitiae” site. It seems to be a bona fide Italian-language website that deals mostly with cultural events. “Notizie” is the modern Italian word for “announcements”. I have a feeling that some well-meaning Italian found your site, didn’t really understand its focus and decided that you might like to visit their site. I don’t think you’re dealing with trolls here, just lost souls who speak just enough English to find their way onto sites that have nothing to do with their interests.

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