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On Surprises, Stigma, Sports, Sprouts (or Kale)

On Surprises, Stigma, Sports, Sprouts (or Kale) Abstract Given the plethora of weight loss interventions, Devine and Barnhill rightly propose to also investigate unintended consequences. I agree. Some questions need to be raised: unintended consequences is a messy concept. How to distinguish between surprises and pseudo-unintended consequences? How to make sure that such research is not a box-ticking formality? And will results be implemented? Being a Burden ‘Or maybe this is someone else’s shame and I’m just being forced to carry it’. Roxanne Gay, Hunger. A memoir of (My) Body, Corsair, 2017 p. 212. ‘You are a fat, ugly slob and expensive for society’. Obese people may suffer not only from physical disadvantages and risks of obesity but also from nasty criticisms of their bodies, behavior and personality. There is a lot of blaming and shaming, stigmatizing and attributing culpability. I have often been surprised (even shocked) by the discriminatory ‘fattist’ views and matching zeal of the thin and the lean to judge and change the lifestyle of others, with little attention for the complex fabric of (epi-) genetic factors, socio-economic aspects and individual psychology; the intolerance toward obese people, and the lack of interest in how (the perception of) their weight has influenced their body image and identity (de Beaufort and van de Vathorst, 2012). Insults are added to injury. Of course the increasing number of people with obesity concerns health care professionals and governments. In the past decennia, we have seen a plethora of interventions targeting the individual, the workplace, cities and whole societies, initiatives fueled by serious concerns about individual and public health, and also by the societal costs of obesity. Interventions carried out because of a sense of urgency, sometimes bordering on panic: ‘We have to do something before it is too late’. Often there was little knowledge, let alone evidence, about effectiveness. This is a long way of stating that I agree with the authors. Measuring weight loss (or the lack thereof) is not enough and does not do justice to the complexity of weight, lifestyle and eating cultures. I want to raise three issues: the messiness of unintended consequences, the need for thorough research and the risk of results gathering dust in policymakers’ drawers. Unintended, Surprise, Pseudo-Unintended Unintended consequences are complex, even messy. What to look for, register or even measure? Can one sensibly foresee some or all? Or does one have to fish by casting a very wide net? This is ethically important and relevant for designing and doing research. I cannot go into the old but ongoing ethical debate on intended, and foreseen but unintended consequences; murdering your cousin or not doing something when he drowns in the bath; or just gently waving your axe around you or beheading someone (not necessarily a cousin again). Suffice a warning: qualifying a consequence as foreseen but unintended does not solve all moral qualms. It does not provide absolution nor automatically justify negative unintended consequences (‘but honestly we did not want them….’). It is useful to distinguish between expected/foreseen unintended consequences, positive, e.g. whole families embarking on healthier lifestyles, or negative, e.g. increasing stigmatization of obese persons; and surprise consequences. Then a distinction should be made between real surprise (and, therefore, obviously) unintended consequences and fake surprise consequences. There certainly is room for genuine surprises, but beware of the excuse of ‘We didn’t see that coming at all’. No indeed. If you don’t look in the right direction, you will not see it coming. It is easy to willfully disregard what you do not want to see (coming). Sometimes one need not be a genius to think of consequences that obviously will have an impact on the possible success of a measure, the DUH-factor: as a working mother of three, juggling work demands and different diets for different family members causes stress. Of course one may incidentally be pleasantly surprised: family cohesion may increase through solidarity and sharing a goal, even by bonding through sprouts. This raises the question: if there are positive unintended consequences, why not actually intend them? Maybe to escape blame for failing, if you intend them and they are not realized. Then there is what one might call pseudo-unintended consequences. Sometimes consequences are (secretly) hoped for but they are not considered to be politically or ethically correct, e.g. making people feel ashamed of their weight, thus, motivating them to lose weight; saying or admitting one intends such consequences is not an option. Thinking about these (and other) distinctions is relevant. Ideally one wants few fake surprises and pseudo-unintended consequences. An ethical analysis of a proposed measure beforehand along the framework we have developed that aims to look into possible ethical pitfalls can be helpful (Have et al., 2013). It stimulates the debate on which consequences are welcome and which are not? That is not always evident. (Is the contagious use of kale-ginger-smoothies good or bad? Are people ‘obesessed’?) Consequences qualified as unwanted can be prevented by, for example, changing a design, and the inevitable ones can be mitigated or contained, or accepted if outweighed by the positive consequences. In short, to unravel different (kinds of) possible unintended consequences, and sometimes changing their status from unintended to intended, is interesting and will improve research. It requires and stimulates critical reflection helped by imagination, fiction, autobiographical stories, pilot studies, focus groups and even the occasional ethical insight. One can learn from past research. Ticking Some Boxes? Such research will require finesse and a truly interdisciplinary approach combining anthropological, sociological, psychological, economics, medical methods, and by no means a simple endeavor (Vandamme et al., 2010). I worry about quick fixes. (‘Has someone ticked the unintended consequences boxes?’) It may be used as a lubricant to pave the way for a program to go ahead anyway (‘We will looked at the unintended consequences. So we’re all right.’) It will, as the authors also mention, cost money. Some may use that as an argument not to do it, or to do it scantly. With the authors, I think the investment will pay off in the end by truly improving strategies, not only result-wise but also ethically. Ceremonial Ritual? Some findings may be convincing in some cultures or socio-economic surroundings and not in others. One cannot do research in the USA and simply transpose the results to, for example, France because of the cultural, social and socio-economic differences. Within groups, one might find different results among individuals. The authors are aware of this. This complexity, if not already used against doing such research in the first place, may be used against implementing the results. The research may be used as a ceremonial ritual to let the results gather dust on desks. That should not happen. Comment on The Ethics and Public Health Importance of Unintended Consequences: The Case of Behavioral Weight Loss Interventions, Carol M. Devine and Anne Barnhill. References de Beaufort I. , van de Vathorst S. ( 2012 ). Obesity. In Chatwick R. , Holm S. (eds), Encyclopaedia of Applied Ethics (Second Edition). Elsevier, 265 – 273 . Have M. T. , van der Heide A. , Mackenbach J. P. , de Beaufort I. ( 2013 ). An Ethical Framework for the Prevention of Overweight and Obesity: A Tool for Thinking through a Programme’s Ethical Aspects . European Journal of Public Health , 23 , 299 – 305 . Google Scholar Crossref Search ADS PubMed Vandamme S. , van de Vathorst S. , de Beaufort I. (eds), ( 2010 ). Whose Weight Is It Anyway? Essays on Ethics and Eating . Acco Leuven . © The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

On Surprises, Stigma, Sports, Sprouts (or Kale)

Public Health Ethics , Volume 11 (3) – Nov 1, 2018

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References (3)

Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
ISSN
1754-9973
eISSN
1754-9981
DOI
10.1093/phe/phy012
Publisher site
See Article on Publisher Site

Abstract

Abstract Given the plethora of weight loss interventions, Devine and Barnhill rightly propose to also investigate unintended consequences. I agree. Some questions need to be raised: unintended consequences is a messy concept. How to distinguish between surprises and pseudo-unintended consequences? How to make sure that such research is not a box-ticking formality? And will results be implemented? Being a Burden ‘Or maybe this is someone else’s shame and I’m just being forced to carry it’. Roxanne Gay, Hunger. A memoir of (My) Body, Corsair, 2017 p. 212. ‘You are a fat, ugly slob and expensive for society’. Obese people may suffer not only from physical disadvantages and risks of obesity but also from nasty criticisms of their bodies, behavior and personality. There is a lot of blaming and shaming, stigmatizing and attributing culpability. I have often been surprised (even shocked) by the discriminatory ‘fattist’ views and matching zeal of the thin and the lean to judge and change the lifestyle of others, with little attention for the complex fabric of (epi-) genetic factors, socio-economic aspects and individual psychology; the intolerance toward obese people, and the lack of interest in how (the perception of) their weight has influenced their body image and identity (de Beaufort and van de Vathorst, 2012). Insults are added to injury. Of course the increasing number of people with obesity concerns health care professionals and governments. In the past decennia, we have seen a plethora of interventions targeting the individual, the workplace, cities and whole societies, initiatives fueled by serious concerns about individual and public health, and also by the societal costs of obesity. Interventions carried out because of a sense of urgency, sometimes bordering on panic: ‘We have to do something before it is too late’. Often there was little knowledge, let alone evidence, about effectiveness. This is a long way of stating that I agree with the authors. Measuring weight loss (or the lack thereof) is not enough and does not do justice to the complexity of weight, lifestyle and eating cultures. I want to raise three issues: the messiness of unintended consequences, the need for thorough research and the risk of results gathering dust in policymakers’ drawers. Unintended, Surprise, Pseudo-Unintended Unintended consequences are complex, even messy. What to look for, register or even measure? Can one sensibly foresee some or all? Or does one have to fish by casting a very wide net? This is ethically important and relevant for designing and doing research. I cannot go into the old but ongoing ethical debate on intended, and foreseen but unintended consequences; murdering your cousin or not doing something when he drowns in the bath; or just gently waving your axe around you or beheading someone (not necessarily a cousin again). Suffice a warning: qualifying a consequence as foreseen but unintended does not solve all moral qualms. It does not provide absolution nor automatically justify negative unintended consequences (‘but honestly we did not want them….’). It is useful to distinguish between expected/foreseen unintended consequences, positive, e.g. whole families embarking on healthier lifestyles, or negative, e.g. increasing stigmatization of obese persons; and surprise consequences. Then a distinction should be made between real surprise (and, therefore, obviously) unintended consequences and fake surprise consequences. There certainly is room for genuine surprises, but beware of the excuse of ‘We didn’t see that coming at all’. No indeed. If you don’t look in the right direction, you will not see it coming. It is easy to willfully disregard what you do not want to see (coming). Sometimes one need not be a genius to think of consequences that obviously will have an impact on the possible success of a measure, the DUH-factor: as a working mother of three, juggling work demands and different diets for different family members causes stress. Of course one may incidentally be pleasantly surprised: family cohesion may increase through solidarity and sharing a goal, even by bonding through sprouts. This raises the question: if there are positive unintended consequences, why not actually intend them? Maybe to escape blame for failing, if you intend them and they are not realized. Then there is what one might call pseudo-unintended consequences. Sometimes consequences are (secretly) hoped for but they are not considered to be politically or ethically correct, e.g. making people feel ashamed of their weight, thus, motivating them to lose weight; saying or admitting one intends such consequences is not an option. Thinking about these (and other) distinctions is relevant. Ideally one wants few fake surprises and pseudo-unintended consequences. An ethical analysis of a proposed measure beforehand along the framework we have developed that aims to look into possible ethical pitfalls can be helpful (Have et al., 2013). It stimulates the debate on which consequences are welcome and which are not? That is not always evident. (Is the contagious use of kale-ginger-smoothies good or bad? Are people ‘obesessed’?) Consequences qualified as unwanted can be prevented by, for example, changing a design, and the inevitable ones can be mitigated or contained, or accepted if outweighed by the positive consequences. In short, to unravel different (kinds of) possible unintended consequences, and sometimes changing their status from unintended to intended, is interesting and will improve research. It requires and stimulates critical reflection helped by imagination, fiction, autobiographical stories, pilot studies, focus groups and even the occasional ethical insight. One can learn from past research. Ticking Some Boxes? Such research will require finesse and a truly interdisciplinary approach combining anthropological, sociological, psychological, economics, medical methods, and by no means a simple endeavor (Vandamme et al., 2010). I worry about quick fixes. (‘Has someone ticked the unintended consequences boxes?’) It may be used as a lubricant to pave the way for a program to go ahead anyway (‘We will looked at the unintended consequences. So we’re all right.’) It will, as the authors also mention, cost money. Some may use that as an argument not to do it, or to do it scantly. With the authors, I think the investment will pay off in the end by truly improving strategies, not only result-wise but also ethically. Ceremonial Ritual? Some findings may be convincing in some cultures or socio-economic surroundings and not in others. One cannot do research in the USA and simply transpose the results to, for example, France because of the cultural, social and socio-economic differences. Within groups, one might find different results among individuals. The authors are aware of this. This complexity, if not already used against doing such research in the first place, may be used against implementing the results. The research may be used as a ceremonial ritual to let the results gather dust on desks. That should not happen. Comment on The Ethics and Public Health Importance of Unintended Consequences: The Case of Behavioral Weight Loss Interventions, Carol M. Devine and Anne Barnhill. References de Beaufort I. , van de Vathorst S. ( 2012 ). Obesity. In Chatwick R. , Holm S. (eds), Encyclopaedia of Applied Ethics (Second Edition). Elsevier, 265 – 273 . Have M. T. , van der Heide A. , Mackenbach J. P. , de Beaufort I. ( 2013 ). An Ethical Framework for the Prevention of Overweight and Obesity: A Tool for Thinking through a Programme’s Ethical Aspects . European Journal of Public Health , 23 , 299 – 305 . Google Scholar Crossref Search ADS PubMed Vandamme S. , van de Vathorst S. , de Beaufort I. (eds), ( 2010 ). Whose Weight Is It Anyway? Essays on Ethics and Eating . Acco Leuven . © The Author(s) 2018. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Public Health EthicsOxford University Press

Published: Nov 1, 2018

There are no references for this article.