As of early July 2020, Googling “coronavirus obesity” brings up about 178 million results. For perspective, that’s 64 million more than “coronavirus chronic kidney disease” (114 million) and 165 million more than “coronavirus sickle cell” (13.3 million). According to the official CDC website, people with all of the above conditions are “at increased risk of severe illness” from COVID-19, the disease caused by the novel coronavirus. Comorbid conditions like renal failure and sepsis are listed far more often in connection to COVID-19 deaths than obesity. And yet, interest in obesity and COVID-19 is higher than other conditions. There are several explanations: (1) the media is uniquely fascinated by the relationship between obesity and COVID-19, (2) there is genuine concern about the hospitalization rate of people who have underlying conditions such as obesity, and (3) most people, including doctors, think fat people are responsible for their fatness and the media loves shaming fat people. I think (1) – (3) are all explanatory with respect to the media’s interest in COVID-19 and obesity, but as we will see, (3) raises urgent bioethical questions.
In this post, I’ll argue that fat shaming is oppressive, particularly towards women. And in a pandemic, fatphobia can be deadly. Fatphobia, like other phobias, can be characterized as an aversion to fatness. We can recognize fatphobia in some expressions of concern, disgust, or even hatred (CW: slurs) for fat people. Fatphobia can also cause implicit and explicit bias. For example, fat kids are bullied more and are lonelier and more anxious than their peers. Parents pay more for cars and college when their kids are thin, even controlling for income and grades.
While fatphobia does affect both women and men, it targets women more perniciously. Women are subject to the strictest beauty and thinness norms, and when they violate those norms, they pay, literally: fat women earn less money over their lives than women of average weight, who themselves earn less than women who weigh less than the average weight. In an egregious example, the plaintiff in Meith v. Dothard won her Title VII sex discrimination case by showing that weight requirements for a job in a state prison excluded over 41 percent of the female population but only 1 percent of the male population. Violating the thinness norm results in financial, professional, and romantic punishment.
Even in non-pandemic times, doctors are fatphobic. A survey of physicians in 2003 found that over half of respondents viewed “obese” patients as “awkward, unattractive, ugly, and noncompliant.” These attitudes reduce the quality of care that physicians provide to fat people and can worsen their health outcomes. These effects are compounded by factors like racial identity. Black women, for example, are widely perceived by doctors are being “noncompliant” patients, and doctors tend to ignore pain more often or more severely when it is reported by Black women.
Now imagine there is a pandemic and you are a doctor in a crowded hospital with limited resources, and you have to make a decision about who gets a ventilator. You have two patients but only one ventilator left. One patient is fat and the other is thin. You have to make a decision and someone’s life depends on it. You have read that fat people have a higher chance of dying even after they receive treatments like mechanical breathing assistance via intubation and ventilation, ECMO, a technique for oxygenating the blood and returning it to the body, and proning, which a positioning technique to help patients breathe by making them lay on their fronts rather than their backs. So, to whom will you give the ventilator or ECMO? To whom will you assign your limited number of nurses for proning? A fat patient who might die anyway or a thin patient you think has a better chance of surviving?
In situations like these, bioethicists, hospitals, and doctors devise triage protocols. Triage protocols are sets of instructions that tell doctors how to make resource allocation decisions in situations where resources are scarce or stretched too thin. We usually think of doctors using triage protocols during wartime, but they can also be relevant during mass shootings, terrorist attacks, and pandemics, where health systems become overwhelmed (as happened in NYC, and is currently happening in new hotspots like Arizona, Texas, and California).
Triage protocols are good, useful tools, if they are designed justly. They reduce cognitive load on doctors and can help prevent them from burning out after making many individual decisions about who lives and who dies. Bioethicists have been worrying about how coronavirus triage decisions are made, though, and whether they unjustly sacrifice groups like disabled people or the elderly. I (and others) have the same worry about triage protocols and fat people.
Although triage policies are unlikely to discriminate against fat people explicitly, they might implicitly. According to a recent study which analyzed triage policies from 29 different hospitals in 18 states and the District of Columbia, the most commonly mentioned triage criterion is benefit (mentioned by 25 policies, or 96.2%). What is benefit in the context of a triage policy? Triage policies based on benefit evaluate who is least likely to benefit from mechanical ventilation and exclude them from receiving the treatment, or the policies evaluate who is most likely to benefit from ventilation as measured by increases in survival. In other words, a strategy of maximizing benefits aims to either save the most lives or save the most life-years (e.g., choosing to save one patient with an estimated five years of life remaining than four patients each with an estimated one year of life remaining). Benefit is usually determined using a scoring system like the Sequential Organ Failure System (or SOFA, which calculates risk of death based on organ performance), while some policies also restricted resource allocation based on specific diagnoses like cardiac arrest. Furthermore, the study does not mention that any policy reviewed excluded body size from factoring into resource allocation decisions.
If a triage decision policy uses a scoring system like SOFA, that policy may systematically mis-rate those with a higher BMI. SOFA scoring relies on measuring a deviation from baseline levels of biological factors like white blood cells, creatinine, and blood urea nitrogen. However, at least one study has shown that individuals with a higher BMI may have higher deviations from the baseline than individuals with a lower BMI, raising the possibility that SOFA may be an “inaccurate representation of actual severity of illness or organ dysfunction” among individuals with a higher BMI.
The problem generalizes to other scoring systems. QALYs are quality-adjusted life years, a measure combining the expected length and quality of life gained from a medical intervention. Multiple studies cite obesity as a factor reducing the QALYs gained from medical interventions. However, since “obesity” is defined using BMI, these studies don’t account for variations at the individual level in terms of comorbid conditions and metabolic fitness. Regular exercise or physical activity is associated with both greater tidal lung volume and less chronic inflammation and cytokine response. Based on what we currently know about how COVID-19 kills people, all of these factors are likely to help COVID-19 patients survive, even if they’re fat. If COVID-19 causes worse health outcomes in people who are fat, it’s not merely because they are fat. So, using fatness as a metric by which to calculate treatment benefits in triage scenarios is a bad practice.
The central problem with the distinction between obesity and thinness is that obesity is not a good indicator of whether someone is healthy. Anti-fat bias is often couched in language of concern for a fat person’s health. According to the widely-held set of beliefs called “healthism,” weight and health are causally related, and both are an individual’s personal responsibility. But healthism is wrong on both counts.
First, although weight and measures of health such as the frequency of comorbid conditions, or average lifespan are correlated, so are “social determinants of health” like race or whether someone is transgender. So, one might say “being Black is bad for your health” to make a rhetorical point, but in truth, being Black is only “bad for your health” in the sense that if you are Black, you are more likely to be discriminated against in emergency rooms and doctors’ offices, lack health insurance, and have preexisting conditions related to the high stress of living with discrimination, all of which exacerbate things like disease and chronic health conditions. Fatness is similar. Although popular media and medical institutions and even the U.S. government would lead you to believe otherwise, fatness does not cause illness. They are merely correlated. What does cause illness and poor health outcomes are things like malnutrition and a lack of exercise or physical movement. In fact, when “obese” people are “metabolically fit” – that is, active and physically well – their risk of heart disease and cancer are no greater than non-obese people. Just look at athletes like fat ultramarathoner Mirna Valerio and fat yogi Jessamyn Stanley. Fat people can lead metabolically fit lives.
The metric often used to determine whether someone is “obese”, body-mass index (BMI), is not even a scientifically coherent type of measurement. It was developed by a mathematician in the 1800s who explicitly said the measurement should not be applied to individuals. Obesity is a medical fiction. Who counts as obese seems arbitrary; the definition has changed several times, such that on separate occasions in the 20th century, millions of people suddenly became “obese” overnight. According to the current definition of obesity, Dwayne ‘The Rock’ Johnson is obese, despite being a paradigm of masculinity and fitness. That’s because BMI, the metric used to determine obesity, doesn’t distinguish among muscular people, sedentary fat people, tall skinny people, or shorter people. It is merely a height to weight ratio, which, it turns out, is pretty uninformative when it comes to metabolic fitness.
Second, healthism obscures systemic factors that contribute to malnutrition and body shape. A billion-dollar diet and fitness industry would have you believe that your weight is determined by your self-control and willpower. But that’s false. In Nickle and Dimed, Barbara Ehrenreich talks about her experiences trying to make ends meet working minimum-wage jobs in the late 1990s. She describes renting out a room with only a microwave and no oven, and how people in similar positions eat only frozen food and hot dogs. These processed foods are often cheaper than fresh foods that we associate with nutritionally robust diets, so they are more affordable for low-wage workers. Additionally, many workers have unpredictable schedules and sometimes work multiple jobs to make ends meet, so they have little time to prepare fresh food. And of course, these issues are intersectional (in that systematic discrimination varies according to the social identities occupied); you’re far more likely to be in a vulnerable, low-paying job trying to provide for a family if you are, for example, an undocumented migrant woman than a white man. And thus, more likely to be considered obese.
What does this tell us about obesity, women, and the pandemic? Although men are dying at a higher rate than women due to COVID-19, women may be more vulnerable in how they are treated by doctors, and by triage policies that use obesity as a metric, as more women than men are considered considered “severely” obese. We can expect this to be true if triage policies are left to a doctor’s subjective judgment, as well, because of anti-fat bias and a smaller range of acceptable body types for women. As I have argued here, “obesity” is not a disease, but rather a medical classification based on a height and weight ratio. Individuals who are classified as “obese” are more likely to have conditions like diabetes or heart disease. But that’s not a necessary connection, nor a causal one. It’s merely a correlation. Obesity doesn’t cause heart disease, and obesity doesn’t cause COVID-19 deaths. COVID-19 is a disease that affects vascular systems in the body, so there is a causal connection between having heart disease, getting COVID-19, and then dying. The correlation between obesity and COVID-19 deaths is not a medically helpful correlation, so we should make sure it’s not one we use to create triage policies.
Since COVID-19 is disproportionately killing Black, brown, and indigenous people, we need to be especially cognizant in recognizing and combating anti-fat bias among these groups. This means doing things like designing triage protocols alongside fat people, and especially fat people of color. Coronavirus is going to be with us for a long time. Let’s protect vulnerable groups and prevent them from suffering unjustly.
An earlier version of this essay appeared at the International Journal of Feminist Approaches to Bioethics.
The Women in Philosophy series publishes posts on women in the history of philosophy, posts on issues of concern to women in the field of philosophy, and posts that put philosophy to work to address issues of concern to women in the wider world. If you are interested in writing for the series, please contact the Series Editor Adriel M. Trott or Associate Editor Julinna Oxley.
Madeline Ward
Madeline Ward is a PhD candidate in philosophy at Georgetown University and works on topics in feminist epistemology, bioethics, and social justice. You can read more of her work at www.madelineward.com.
