Should obese people pay more for medical treatment

Obesity is an incredibly expensive disease, both for the patients and the hospitals. Aside from being a disease which is associated with many further complications and problems, which themselves lead to an increased cost, this disease also requires costly medication and specialised equipment for diagnosis and treatment. This results in a condition which has proven extremely costly to nearly all parties involved. It has been reported that £47 million was spent purely on anti-obesity drugs in the fiscal year of ’06 to ‘07.1 This figure, coupled with the fact that the prevalence of adult obesity in the U.K. is above 20 per cent and set to rise10, signifies the incredible cost associated with this disease and, in turn, highlights the growing problem of obesity on a social and economic scale. It’s a problem that can’t be ignored, and throughout the course of this paper I will attempt to weigh and evaluate both sides of the argument; Should obese people pay more for medical treatment?, in order to find a resolution.

First, before jumping in to the crux of the question, it is imperative to establish the importance of the NHS as well as its core principles, in order to allow a fully in-depth analysis of the question at hand. The NHS, which is the primary healthcare provider in Great Britain, was set up in 1948 with one of its key principles being; “the health service will be available to all and financed entirely from taxation, which means that people pay into it according to their means.”2 It is important to stress the word all in the sentence. This word refers to the nation as a whole, regardless of their medical condition. The importance of the NHS clearly can’t be stated enough, a nationwide health service which aims to treat all without directly taking money from the patients, is vital to maintaining the infrastructure of the country. It would seem then that the very nature of this question would oppose the core principles established in the set-up of the NHS, however in the recent light of the current economic situation and even proposed budget cuts3, the question raised could one day become a reality.

It is important to first define and explain obesity ahead of tackling the ethical dilemma which is the title of this paper. One definition would simply be “too much body fat on an individual”, while this is somewhat accurate, it is also incredibly basic and not at all scientific. The BMI (body mass index) measurement is one of the most straightforward and useful techniques to establish the condition of obesity. The BMI is calculated by correlating a relationship between the height and weight of an individual, it is used by many organisations around the world such as WHO and NHS. The formula for calculating the BMI is:

The results gained from the BMI can be classified in table 1 in order to specify the particular weight class of an individual.

Classification

BMI (kg/m2)

Principal cut-off points

Additional cut-off points

Underweight

<18.50

<18.50

Severe thinness

<16.00

<16.00

Moderate thinness

16.00 – 16.99

16.00 – 16.99

Mild thinness

17.00 – 18.49

17.00 – 18.49

Normal range

18.50 – 24.99

18.50 – 22.99

23.00 – 24.99

Overweight

≥25.00

≥25.00

Pre-obese

25.00 – 29.99

25.00 – 27.49

27.50 – 29.99

Obese

≥30.00

≥30.00

Obese class I

30.00 – 34.99

30.00 – 32.49

32.50 – 34.99

Obese class II

35.00 – 39.99

35.00 – 37.49

37.50 – 39.99

Obese class III

≥40.00

≥40.00

Table 1. adapted from WHO

While the use of the body mass index to calculate a person’s weight class is used worldwide it has a fair number of shortcomings and flaws. For instance, this table of classification for BMI is not gender specific, so it is applied the same for both males and females equally, as well as this, it also doesn’t account for weight distribution in individuals nor is it possible to consider bone or muscle mass, both of which are heavier than fat. These problems will hold more significance later in this essay while discussing how obesity should be defined.

Obesity is caused by a variety of different factors. These include genetic susceptibility, socio-environmental factors, malfunctioning appetite regulation or may also be a cause of other diseases, such as Cushing’s syndrome.7 While it was previously thought that obesity was caused by a lack of willpower or a lifestyle choice, more recent studies have discovered that obesity is a chronic disease, involving a number of different biochemical and metabolic processes compared to individuals who aren’t obese.8

As stated previously, obesity is linked to many more serious health conditions and illnesses. Examples of these include diabetes mellitus, increased cholesterol, coronary heart disease and hypertension amongst many others.7 It is important to discuss the seriousness of these resulting conditions in order to fully comprehend the fatality of obesity. Diabetes mellitus (otherwise known as type II diabetes) is a serious condition which occurs when the body either does not produce enough insulin or the cells do not properly react to the insulin produced. This condition is said to affect approximately 2 million people across England and Wales, supposedly with a further 750, 000 unaware that they have this condition.4 Type II diabetes can also lead to kidney disease, nerve damage or even strokes. Coronary heart disease is another serious condition which can be caused because of obesity, which affects almost 300, 000 people a year in the U.K.11

There are multiple actions that can be taken in an attempt to treat or cure obesity. These include dietary therapy in order to regulate the number of calories taken in by an individual, and to maintain that over a long-term period. Other methods which may be used in conjunction with this may be increased exercise, to burn off calories, weight loss surgery, such as gastric band surgery or possibly drug therapy, which is often used as a last resort. It should be noted that not one of these methods are able to fully treat obesity alone, instead they must be used in unison depending on the severity of the disease and also the individuals diagnosed with them.

It apparent that obesity is an incredibly complicated disease in terms of the causes, secondary factors and treatments, all of which contribute towards a confusion regarding the nature of obesity in the minds of the public as well as upping the cost due it’s many treatment techniques, none of which can be considered 100 per cent effective. This encompasses all of the aspects of the disease, which is often described as an epidemic, as it’s a growing concern, and the economic burden attached is sure to evoke strong opinions regarding the question of this paper.

Now that the importance of the health care system has been established and the medical significance of obesity has been recognised, the essay question itself can be discussed. The initial views on this topic are polarising, with some instantly believing that the obese should pay more for the disease that they’ve inflicted upon themselves, believing that it is unfair that the rest of the nation should pay the cost. Others believe that they shouldn’t pay the financial cost, stating that the NHS was set up to help all, despite whether or not their condition is self caused. The argument can even be pushed further, extrapolating that smokers, drinkers and even athletes would also have to pay for the medical costs for their diseases or injuries, because, by that same logic, these conditions are also self inflicted. Although there are certainly some truths to be had in these two contrasting opinions, the two sides of the argument will be investigated and examined on the grounds of ethicality, societal and fairness in an attempt to bring about some form of a resolve on this controversial topic.

One of the primary factors for the argument for obese people having to finance the treatment of their medical condition is that the disease they are burdened with is self inflicted, which is to say that they literally brought it on themselves, so should therefore have to deal with the consequences. While there is some validity in this argument, it isn’t quite as black and white as it may initially sound, with many further complexities set to arise. Those that oppose this argument, are likely to call discrimination, as this ideology that separates a certain type of people from the rest and forces them pay more, which is highly unjust. Also, by this same reasoning, and in the issue of fairness, other patients with self inflicted disease should also have to pay more for conditions and illnesses which they have brought upon themselves. Such conditions would include lung cancer for smokers, liver disease for those who drink as well as injuries to sports players and athletes, as these are all, to some degree, self inflicted.

A counter point to this counter point would be that smokers and drinkers already pay more through an increased tax for the drugs (i.e. cigarettes and alcohol) which lead to the individual diseases, so an alternative, or possibly in addition, to forcing obesity patients to have to pay for medical treatments would be to raise the tax on foods with an increased calorie count. This may also be used to deter away from choosing these unhealthy foods as well as generate income from those who cost the NHS so much money in its treatment for obesity. However, this would result that members in the public that fall in to the “normal” weight range would also have to pay the increased tax for these same foods, if they choose to occasionally indulge. This, at first glance, seems like a fair compromise, as smokers who don’t cost the NHS with treatment for smoking related disease still have to pay the tax on cigarettes, however, the idea comes full circle that people who aren’t obese are still having to pay lifestyles of the obese, indirect as it may be, which is one of the main points evoking the question at hand.

There is evidence to suggest that those who are obese are also more likely to be in lower paid jobs, and as such, have less expendable income. This may be because those with lower income are more likely to live in poorer areas and where healthier, more nutritious foods aren’t as readily available or outside of their budget. This may also be due to a discrimination present against people who are obese and overweight. Employers may be more likely to hire those who aren’t overweight as they see their ability to resist overeating or staying in shape as a good quality in what Acs, Lyles and Stanton (2007) describe as a “willingness to delay gratification.” Whatever the reason may be for the correlation between being overweight and having lower income, the fact remains that the lack of capital possessed by the obese population would prove to be incredibly troublesome if obese people were to finance their medical treatment in this manner. The case for increasing the tax of unhealthy foods may be less applicable as it may push both healthy foods and unhealthy foods out of reach for poorer and obese population financially. To overcome this, healthier foods have to be made cheaper and more widespread, which may again be difficult given the nature to produce healthier and organic foods are likely to cost more. Even so, it would seem any loss made would surely help the NHS spend less on obesity, which, in the 2007, was estimated at £4.2 billion.6

The basis for this particular argument is on essentially boils down to the thought that “obese people are obese solely because of their own doings”, which many people believe to be an accurate portrayal of reality. However, this statement by no means holds true to the complete population of obese people. There is a genetic link associated with obesity, with the inheritable risk of obesity thought to be approximately 30%.7 Many genes have been found that code for weight control hormones, and a defect in these genes may be passed on the offspring, thereby increasing the chance of obesity in that child.5 This would bring about many more questions and dilemmas concerning the topic at hand. For instance, what if the cause for obesity was mainly genetic as opposed to being environmental? Should the patient still pay more even though, by definition, this type of obesity isn’t necessarily “self-inflicted”? Some may answer this question by stating that those with genetic factors shouldn’t pay, however, what if both social and biological factors play an equal role in the cause of an individuals’ obesity? Or, further expanding on the idea that those found to have the genetic link shouldn’t pay, how would the “obesity genes” be examined in the patient? Genetic testing may be carried out, but performing these tests on the entire to obese population in order to determine who should pay these costs would itself be costly, therefore being counter-productive where one of the primary aims of the question raised is to cut back on money being spent.

There are also further complications regarding this wide held belief that obesity is self-inflicted. Are cases where individuals are driven to high calorie, comfort foods because of bullying or depression, be considered self-inflicted? Also, who should pay the cost for cases of childhood obesity? While some may point the fingers at the parents, one would have to ask if that is at all fair. For instance, parents aren’t sentenced for the crimes that their children commit. Evidence exists which associates an addiction to eating (as well as other addictions) with mental illnesses.9 Should these cases also have to pay for medical treatment themselves? By this same merit should schizophrenics and patients with other mental conditions have to finance their treatment?

There are a host of other problems and issues which are presented if this question is to be seriously considered. The question of affordability and practicality surely arises when applying the theoretical question to a real-world scenario. If obese patients were to pay directly for their medication, surgery or weight-loss programs then how much should be charged? It would surely have to be a fairly significant amount as the cost of obesity itself is already at an extremely costly figure.6 Having to pay for medical treatment may create a divide between patients who can and can’t afford the costs, possibly adding another level of discrimination. And what if patients are unable to meet the expense of these bills? Should they be denied treatment? Anything beyond entertaining this idea would bring about huge moral dilemma’s, as the hospitals would essentially be playing God, deciding who lives and dies, based purely on their financial background.

Also, the practicality of such a situation is likely to bring up further complications, with one question being; how should it be charged? The NHS wasn’t set up to accept payments in this particular manner, so how could this be accomplished? Would the patients need to pay before their medication or surgery? If so, and the patient does not pay, it will again bring up the concept of denying treatment to patients. There is also the possibility that patients would pay post-surgery. But if they refuse to pay or can’t afford it, then some form of policing body would need to be enforced to ensure these payments are made. While this will cost more money, again a problem given the nature of the question is to decrease the money spent, it also sends out an image of the NHS reminiscent of some sort of mobster loan shark.

Another issue when considering this subject is the concept of defining obesity. Earlier I have stated the use of the BMI system to define obesity the world over, as well as outlining its fundamental flaws. A concern with defining obesity with the use of the BMI scale is that the differences between being classified as overweight or obese may literally be a few inches in height or a few kilograms in weight. This may very well create scenarios where a person may be a few inches shorter than another who is the same weight having to pay more for treatment. This could possibly be countered by measuring obesity by more methods than simply BMI alone, which is currently in place to diagnose obesity by the NHS. Other methodologies may also have to be in place in order to diagnose or differentiate between different classes of obesity. These could possibly include calculating the waist-to-hip ratio (WHR), Waist circumference (WCR) and Skinfold thickness.7 together these allows for a more accurate representation of a patients’ physical status, allowing to charge for medical treatment accordingly, if that path were to be taken.

It is clear that any attempt to find a solution to this question brings up series of arguments and counter points which negate and nullify each other, and instead of establishing a concrete plan of action, it would seem that the wisest and safest bet would be to sit on the fence. My personal opinion on the matter would be to increase the tax of unhealthy foods and make healthier foods readily available and at an affordable price as well as pushing for a more active lifestyle, something akin to the change4life scheme recently set up by the government. Though this isn’t without flaws, it certainly seems to reach a form of middle ground in term of ethics and equality. One of the main aims of the NHS was to treat all patients who pay tax, so forcing a section of people to pay more, regardless of whether or not the condition is self inflicted, opposes its key ideologies as well as being highly discriminatory. My proposed plan of action is certainly more subdued and the benefits of which would only be realised after a longer period of time, however, it strikes a fair balance between staying true to the NHS philosophy, equality for all an attempt to treat obesity and healthy lifestyle.

The report should be similar in overall style to the topic discussed in Nelson’s

Issue II (Human Organ Transplantation) above. Another example for style could

be a Scientific American article (e.g. How breast milk protects newborn

(December, 1995) by J. Newman, pp58-61).

The essay should cover the basic science, including recent developments and

ongoing research, but should focus on examination of the ethical, social and legal

issues related to the topic.

1.”More than a million anti-obesity prescriptions were issued in England in the last financial year at a cost of £47million. It means about 88,000 people could be on a course of treatment.”

http://www.thisislondon.co.uk/news/article-23406735-pills-not-the-answer-to-obesity-says-top-doctor.do

2. http://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/NHShistory1948.aspx

3. http://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/NHShistory1948.aspx

http://news.bbc.co.uk/1/hi/health/8012588.stm

4. http://www.nhs.uk/conditions/diabetes-type2/Pages/Introduction.aspx

5. Bouchard 1994

6. http://www.healthcarerepublic.com/news/934442/Cost-obesity-NHS-England-rise-62-billion/

Acs : 9781845425005 , obesity, business and public policy.

7. Tomlinson

8. brock

9. truth mental illness: 9780757301070

10. http://www.who.int/infobase/report.aspx?rid=118&iso=GBR&Def_Code=cd.0701&Survey_Year_End=2005&genGraphButton=Generate+Graph

11. http://www.nhs.uk/Conditions/Coronary-heart-disease/Pages/Introduction.aspx?url=Pages/What-is-it.aspx

red: expand

blue: unsure