Blaming the Patient

“Discrimination against heavy people, by the general public and medical professionals, might be a greater health and social problem than any extra pounds they may be carrying” argues UCLA Professor Abigal Saguy, PhD, in a provocative essay in the Washington Post.  “Despite the fact that body weight is largely determined by an individual’s biology, genetics and social environment, medical providers often blame patients for their weight and blame their weight for any health problems they have” she writes, comparing such “size profiling” to “racial profiling.” 

“Both types of profiling” she continues “lead to false positives (people wrongfully accused or medically overtreated) and false negatives (people who get away or are medically undertreated).”

I think comparing “size profiling” to the horrible continued legacy of racism is a stretch, but Dr. Saguy has a point–some clinicians seem quick to blame their patients for being overweight.  And also for smoking, for abusing drugs and alcohol, for eating unhealthful diets, for not exercising enough, for not taking their prescribed medications and for not following their physician’s advice.  I have heard some internists rail against patients who are “not taking responsibility” for their own health, demanding to know what the ACP is doing to make people accept more responsibility.

I can sympathize with physicians who are doing everything they can to help their patients improve their health, only to encounter patients who continue to do bad things to their health.  Especially, if the physician is subjected to performance measures that penalize them when their patients don’t have the desired outcomes.  No one wants to be blamed for things outside of their own control!

But this is true of patients as well.

 The “blame the patient” attitude assumes that how much we weigh or how sick or well we are is mostly a matter of will power. Sure, there are things that each of us can do (and don’t do) that can help make us less or more healthy.  But many of these things–eating better, exercising more, not smoking, not drinking to excess–may be very difficult or even impossible for some people to achieve because of genetics (family history of alcoholism and other substance abuse), culture and community (the diet your grew up with, the food choices available to you in your community, exposure to crime and violence), stress, literacy, physical and emotional abuse, how you were raised by your parents, the quality of your schools–the list goes on and on.  And even if you do everything right, it may not work–eating well and exercising does not guarantee that someone won’t be overweight.  And being overweight doesn’t guarantee you will get sick.

The “blame the patient” philosophy also shows up in public policy proposals: high deductible health plans that by definition mean that the sick will pay more out-of-pocket (because they need and use more health services) than the well (because they need and use fewer health care services); higher co-payments for receiving non-emergency care in emergency rooms (which disproportionately affect poor people in poor health who may not have good access to community-based primary care); and proposed regulations that allow employers to charge higher health insurance premiums or impose other rewards and penalties to employees based on how well they achieve improvements in their own health status. 

Yesterday, House Democrats sent a letter to the Obama administration, objecting to a proposed rule that allows employers to establish “health-contingent wellness programs” that “allow differential rewards based on health status factors, including a person’s cholesterol, blood pressure, weight or body mass index.”   The lawmakers argued that such programs would undermine the ACA’s prohibition on discrimination against persons with pre-existing conditions, and would disproportionately harm “certain population groups, including racial and ethnic minorities, such as  Hispanics, African-Americans, and some Asian groups [with] a higher proportion of known genetic predisposition for certain illnesses that are screened through biometric measurement such as cholesterol or blood sugar levels.”  

ACP, in a comment letter on the same proposed rule, similarly stated “that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals.” 

And ACP’s ethics policy, developed by its Committee on Ethics, Professionalism and Human Rights, states that “Incentives to promote behavior change should be designed to allocate health care resources fairly without discriminating against a class or category of people. The incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control. Incentives to encourage healthy behaviors should be appropriate for the target population. The American College of Physicians supports the use of positive incentives for patients such as programs and services that effectively and justly promote physical and mental health and well-being.”

Objecting to stigmatizing and punishing patients because of their body weight, health status, genetics, and personal choices is not the same as arguing that patients shouldn’t be engaged in, and responsible for, making contributions to their own health.  Physicians can and should engage patients in shared decision-making about their health.  They should engage patients in helping them understand their risk factors and how they might help reduce their risks.  They should help them succeed and also support them if they fail. 

Physicians can also advocate for public policies to engage and empower patients in healthcare decision-making–such as for reimbursement changes to allow physicians to spend the time required for effective shared decision-making and creating positive incentives to help people access effective weight-loss or other wellness programs. While advocating against policies to stigmatize and punish people for their health status.

As my mother might say, no one likes a scold.  Let’s stop scolding people for supposedly not doing enough to stay healthy.  And instead, lets start helping them be as healthy as they can and make sure they are cared for when they are sick, no matter what they did or didn’t do when it comes to taking care of their own health or the genes they inherited from their parents.

Today’s questions:  Do you agree with Dr. Saguy that many in the medical profession stigmatize patients for being overweight and other aspects of their health?  How do you feel about programs that would penalize people for not achieving measurable improvements in their health?