Fat Stigma and Public Health:A Theoretical Framework and Ethical Analysis
This paper proposes a theoretical framework for understanding fat stigma and its impact on people’s well-being. It argues that stigma should never be used as a tool to achieve public health ends. Drawing on Bruce Link and Jo Phelan’s 2001 conceptualization of stigma as well as the works of Hilde Lindemann, Paul Benson, and Margaret Urban Walker on identity, positionality, and agency, this paper clarifies the mechanisms by which stigmatizing, oppressive conceptions of overweight and obesity damage identities and diminish moral agency, arguing that the use of obesity-related stigma for public health ends violates the bioethics principles of nonmaleficence, autonomy, and justice.
According to the Centers for Disease Control and Prevention (2012), a drastic increase in the prevalence of overweight and obesity in the United States over the past 20 years constitutes an epidemic. The World Health Organization (2013) speaks of the global obesity epidemic, or “globesity,” as “taking over many parts of the world.” In the world of public health, obesity is understood to be a major health issue in need of immediate intervention.
In attempts to address the obesity epidemic, public health professionals, researchers, and health care providers have contributed to the stigmatization of overweight and obese people. For example, in July of 2012, the New York City Human Resources Administration (HRA) launched their “Cut the Junk” campaign, “a citywide effort to help New Yorkers make healthy food choices and cook nutritious meals on a limited income” (2012). Posters for this campaign feature a stigmatizing image: a silhouette of a morbidly obese man pouring a full-sized bag of potato chips into his mouth (see figure 1). What message was HRA trying to communicate by including this image in [End Page 247]
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their campaign? What widely held cultural beliefs were HRA counting on to evoke emotional responses in their viewers? Is it the place of a public health campaign to count on, or even produce, such cultural beliefs to change health behaviors? How does this image work to achieve the goal of the “Cut the Junk” campaign?1
In this paper, I propose a theoretical framework for understanding obesity-related stigma, also referred to as weight stigma or fat stigma, and its impact on people’s well-being. I argue that stigma should never be used as a tool to achieve public health ends. Drawing on Bruce Link and Jo Phelan’s conceptualization of stigma (2001), which is attentive to relationships between power, positionality, and health, as well as the works of Hilde Lindemann (2001a; 2001b; 2006), Paul Benson (1994), and Margaret Urban Walker (1998) on identity, positionality, and agency, I explore the mechanisms by which stigmatizing, oppressive conceptions of overweight and obesity damage identities and diminish moral agency. I use concepts outlined by Link and Phelan, Lindemann, Benson, and Walker to make sense of literature on the negative impact obesity-related stigma has on people’s lives and to argue that the use of stigma as a tool to achieve public health ends violates Beauchamp and Childress’s (2001) bioethics principles of nonmaleficence, autonomy, and justice.
WHAT IS OBESITY-RELATED STIGMA?
Since the publication of Erving Goffman’s Stigma: Notes on the Management of Spoiled Identity, social scientists have published countless works on stigma, its operation, and its impact on the lives of those stigmatized. However, the ways stigma are defined and operationalized are inconsistent in social science and public health research. Defining stigma in a way that is clear and precise is necessary for understanding its consequences. Bruce Link and Jo Phelan’s (2001) multi-level conceptualization of the term is comprehensive, clear, and appropriate for understanding the components of obesity-related stigma and their effects on people’s lives.
In their 2001 paper titled “Conceptualizing Stigma,” Link and Phelan define stigma as the result of five interacting components:
(1.) People distinguish and label human differences. . . . (2.) Dominant cultural beliefs link labeled persons to undesirable characteristics—to negative stereotypes. . . . (3.) Labeled persons are placed in distinct categories so as to accomplish some degree of separation of “us” from “them”. . . . (4.) Labeled persons experience status loss and discrimination that lead to [End Page 249] unequal outcomes. . . . (5.) Stigmatization is entirely contingent on access to social, economic, and political power that allows the identification of differentness, the construction of stereotypes, the separation of labeled persons into distinct categories, and the full execution of disapproval, ejection, exclusion, and discrimination.(367)
In order for stigma to occur, all five components must be present.
The first component of Link and Phelan’s conceptualization of stigma requires that people distinguish and label human differences. Labeled differences in the form of differences in health status and behaviors must exist in order to make any meaningful progress toward achieving the goals of medicine and public health. Those who work in medicine and public health must distinguish between healthy and unhealthy conditions and behaviors. One example of the ways differences are labeled is classification of people’s bodies by weight status. A body of normal weight has a body mass index (BMI) between 18.5 and 24.9, overweight a BMI greater than or equal to 25, and obese a BMI greater than or equal to 30. Further distinctions are made among obese bodies: class I obesity has a BMI 30 to 34.9, class II obesity a BMI 35 to 39.9, and class III obesity a BMI greater than or equal to 40.
The second component of stigma requires that labeled differences be linked with negative stereotypes. People link “fat” body types with negative stereotypes such as laziness, social ineptitude, lack of self-control, stupidity, worthlessness, and disgustingness (Teachman and Brownell 2001; Schwartz et al. 2003; Wang, Brownell, and Wadden 2004; Greenleaf et al. 2006; Schwartz et al. 2006; Vartanian 2010). This component of stigma, linking labeled differences with negative stereotypes, renders characteristics good and bad or better and worse than one another. It provides motive for the next component of stigma.
The third component of Link and Phelan’s conceptualization of stigma is that labeled persons are placed into distinct categories, separating “us” from “them.” For example, people are placed into categories based on the color of their skin. Some people with light-colored skin are categorized as white. People with dark-colored skin are Black. People are also placed into categories based on their weight status. People with fat body types are fat or, in the world of public health, they are overweight, obese, or morbidly obese. This is different from saying a person has cancer, a person has the flu, a person has brown eyes, blond hair, etc. Those placed into distinct categories are labeled as being a type of person, not as having characteristics. Based on this component of stigma, part of the process of [End Page 250] stigmatizing is making labels part of a person’s identity, part of who they and others understand them to be.
The fourth component of Link and Phelan’s conceptualization of stigma is that “labeled persons experience status loss and discrimination that lead to unequal outcomes” (2001, 367). For Link and Phelan, stigma requires that persons experience status loss and discrimination as individuals or as a group because they have been labeled different—a difference that is linked with negative stereotypes—and have been placed in a distinct category that works to separate “us,” the nonstigmatized, from “them,” the stigmatized. Further, stigma requires that persons who experience status loss and discrimination have unequal outcomes. Obese individuals experience unequal outcomes resulting from status loss and discrimination. Overweight and obese individuals are regularly the victims of employer discrimination, not getting hired for jobs, having employers assume laziness or physical disability because of their weight, receiving lower pay, and being wrongfully terminated (Roehling 1999; Baum and Ford 2004; Cawley 2004; Puhl, Andreyeva, and Brownell 2008; Puhl and Heuer 2009; Brown 2010). Overweight and obese individuals also experience health care provider prejudice and reduced access to quality health care (Teachman and Brownell 2001; Schwartz et al. 2003; Puhl and Heuer 2009; Brown 2010; Teixeira and Budd 2010). I will elaborate on this when I discuss how obesity-related stigma and oppression damage identities.
The fifth component of Link and Phelan’s conceptualization of stigma is that political, social, and economic power are necessary for the execution of the other components of stigma, especially for placing people into distinct categories and for influencing status loss and discrimination that lead to unequal, often inequitable outcomes. This power to stigmatize resides with those who have “better” characteristics. Those in power have the political, social, and economic capital necessary to influence what and who are understood and accepted as being “better” and “worse” or “good” and “bad.” Power is necessary for “us” to influence status loss, discrimination, and unequal, often inequitable outcomes experienced by “them.”
Again, in order for stigma to occur, all five of its components must be present. However, they may be present in varying degrees. Stigma, therefore, occurs in varying degrees. Stigma and its impact vary from person to person, even among those who are stigmatized for the same labeled characteristic. A woman may experience stigma that comes with being obese different from a man. A person living in poverty may experience stigma that comes with being obese different from a wealthy [End Page 251] individual. Further, one person can experience more than one form of stigma simultaneously, say for being obese and Black or for being obese and a woman. Stigma related to overweight and obesity, its workings, and its consequences are complex. We must keep this in mind as we consider its use as a tool to achieve public health ends and the impact this use may have on the lives of those stigmatized, on identity and agency.
THE USE OF STIGMA IN PUBLIC HEALTH
Understandings of the goals and scope of public health vary depending on person, discipline, place, time, etc. Some understand public health to be the responsibility of government to reduce and prevent morbidities and premature mortality at a population level (Rothstein 2002). Others understand public health more broadly as protecting and promoting physical, mental, and spiritual well-being of populations and individuals (2014). It is my understanding that regardless of how broad or narrow one understands the goals and scope of public health to be, there is general consensus that public health work ought to be conducted in a way that is ethically sound, in a way that is transparent, just, and respectful of persons (Rothstein 2002; 2002; 2011; 2014).
The work done to achieve the goals of public health takes many forms, including policy, scholarship, education, advocacy, etc. Public health work can take the form of health-related information dispersed to a target population. It can take the form of a policy that bans the production, sale, and use of certain products that have a negative impact on health. Regardless of its form, public health work always aims to directly or indirectly see through the goals of public health, in their narrowest or broadest sense. Education or information campaigns provide target populations with information that public health professionals hope will inform health behaviors and improve individual and population health over time. Ad campaigns evoke emotional responses that public health professionals hope will persuade certain health behaviors and improve health outcomes. And policies require, restrict, or ban health behaviors in certain contexts or geographic areas.
Stigma is one tool that is used to achieve the goals of public health. Based on the five-component definition of stigma, if some of the components are already present, public health work can use stigma by fueling the nonexisting components. Labeled differences—the first component of stigma, in the form of differences in health status and behaviors—must exist in order to make any meaningful progress toward achieving the [End Page 252] goals of public health. Those who do public health work must distinguish between healthy and unhealthy conditions and behaviors. The next two components—linking labeled differences with negative stereotypes and placing people into distinct categories based on labeled differences—do not need to exist in order to do public health work but may be counted on or produced in order to evoke emotional responses meant to persuade people to behave in ways that will be good for their health.
Public health professionals can contribute to the production of components of stigma or count on existing stigma to do its work through the use of campaigns, programs, and policies that denormalize or invoke negative emotions, such as shame, disgust, anger, fear, etc., associated with labeled differences, including behaviors.2 Based on literature published on stigmatization of smokers in the United States, it could be said that public health work has contributed to the stigmatization of a previously nonstigmatized group (Markle and Troyer 1979; Kim and Shanahan 2003; Bayer and Stuber 2006; Bayer 2008). The NYC Human Resources Administration campaign discussed previously is an example of counting on existing stigma to evoke emotional responses in hopes of changing health behaviors. In a 2013 paper, Daniel Callahan makes the case for invoking stigma in this way, “stigmatization lite” (2013, 39), in order to provoke changes in eating and exercise behaviors and address the obesity epidemic. Responses to Callahan’s paper go to show that many believe this approach would not only be ineffective, but would also be unethical (Goldberg and Puhl 2013; Gostin 2013; Schmidt 2013; Tomiyama and Mann 2013; Walter and Barnhill 2013). Contributions to the components of obesity-related stigma for the sake of public health are ethically problematic for reasons I will now discuss.
OBESITY-RELATED STIGMA AND OPPRESSION: THE VIOLATION OF NONMALEFICENCE
The use of stigma to achieve public health ends violates the principle of nonmaleficence, which is to say that it does harm. In her essay “Identity and Free Agency,” Hilde Lindemann (2001b) discusses how systems of power and oppression create oppressive identities necessary for these systems to operate. Based on Lindemann’s description of “oppressive identities,” I have illustrated the relationship between stigma and oppression (see figure 2). All oppressed persons are stigmatized, as oppressed persons must also be labeled different, a difference that is linked with negative stereotypes; placed into distinct categories that work to separate “us,” the [End Page 253] oppressor, from “them,” the oppressed; and must experience status loss, discrimination, and unequal outcomes. What distinguishes oppression from stigma is that use of the term “oppression” requires a normative judgment; to use the term “oppression” requires one to deem different outcomes unfair.3
In “Identity and Free Agency,” Lindemann (2001b) explains why those who experience status loss because of the ways their differences are labeled are discriminated against and have inequitable outcomes: damaged identities. She describes two types of damage to identity, both of which affect how individuals perceive and exercise their moral agency: deprivation of opportunity and infiltrated consciousness. Any degree of stigma damages identities in both of these ways. Stigma results in or perpetuates status loss, discrimination, and inequitable outcomes.
The Impact of Obesity-Related Stigma on Identities
In Damaged Identities, Narrative Repair, Lindemann defines identity as “the interaction of [a] person’s self-conception with how others conceive her: identities are the understandings we have of ourselves and others” [End Page 254] (2001a, 6). In An Invitation to Feminist Ethics, Lindemann explains identity more thoroughly:
Your identity is a complicated interplay of how you see yourself and how others see you, and both senses of who you are take some of their shape from culturally authorized, shared understandings of what sorts of lives there are and who may (or must) live them.(2006, 43)
Our identities, including our individual identities, social identities, political identities, national identities, racial identities, gender identities, sexual identities, etc., are shaped by historically, politically, and geographically located conceptions of skin color, sexuality, gender, class, geographic location, political affiliation, religious belief, etc. They are shaped by specific personal experiences and the experiences of others, by widely accepted cultural narratives, by stigma, and by stories of resistance. One person has many identities, which are relational and may conflict with or seem to contradict one another, e.g., Catholic and Queer.
Our bodies and health status contribute to the understandings that we have of ourselves and others. The color of our skin, hair, and eyes, our features, our body shape, our health behaviors, and our health status tell others, accurately or inaccurately, where we’re from, our history, and our habits. Weight classification, which is understood as one indication of health status, contributes to our understandings of ourselves and others (and others’ understandings of us) as healthy and beautiful. It contributes to our perception of our own and others’ abilities to exercise self-control and self-discipline, to be virtuous, morally upright people (Loomis 2001; Schwartz et al. 2003; Wang, Brownell, and Wadden 2004; Danielsdottir, O’Brien, and Ciao 2010; Puhl and Heuer 2010; Vartanian 2010).
Identities damaged via deprivation of opportunity
One form of damaged identity—deprivation of opportunity—occurs when the dominant group’s negative perception of the stigmatized group leads to systematic deprivation of opportunities to “[exercise] their capacities or [gain] access to material goods” (Lindemann Nelson 2001b, 61) or meaningful relationships. Negative perceptions of the stigmatized group (component 2 of stigma), no matter how irrational, allow the dominant group to justify or be comfortable with systematic deprivation of opportunities for certain groups of people. Deprivation of opportunity is perhaps synonymous with the fourth and fifth components of stigma: [End Page 255]
status loss and discrimination that lead to unequal outcomes . . . contingent on access to social, economic, and political power that allows the identification of differentness, the construction of stereotypes, the separation of labeled persons into distinct categories, and the full execution of disapproval, ejection, exclusion, and discrimination.
Deprivation of opportunity occurs through policy, such as segregation by law or not allowing certain groups to vote in political elections, as well as through practices that aren’t, at first glance, obviously inequitable, such as the incarceration of nonwhites in the United States.
Negative perceptions of overweight and obese people lead to systematic deprivation of opportunities to “[exercise] their capacities or [gain] access to material goods” (Lindemann Nelson 2001b, 61) or meaningful relationships. Perceptions of overweight and obese individuals as morally incompetent, lazy, less rational, having less self-control and self-discipline have a real impact on overweight and obese individuals, as does work in medicine and public health that draws on or perpetuates these perceptions. As mentioned previously, overweight and obese individuals are regularly the victims of employer discrimination, not getting hired for jobs, having employers assume laziness or physical disability because of their weight, receiving lower pay, and being wrongfully terminated (Roehling 1999; Baum and Ford 2004; Cawley 2004; Sartore and Cunningham 2007; Puhl, Andreyeva, and Brownell 2008; Van Dusen 2008; Wang 2008; Puhl and Heuer 2009; Brown 2010). According to a 2008 Forbes article on the effects of weight on one’s career, “weight-based discrimination consistently affects every aspect of employment, from hiring to firing, promotions, pay allocation, career counseling and discipline. . . . The bias appears to be most prominent during the hiring process, when an employer knows a potential employee the least and therefore is most likely to be influenced by stereotypes (such as fat people are lazy)” (Van Dusen 2008). According to a 2007 study by Sartore and Cunningham, qualified job applicants who are perceived as overweight are less likely to receive a hiring recommendation than unqualified applicants who are perceived as thin. Stigma associated with being “fat” has a material impact on those stigmatized.
Overweight and obese individuals also experience reduced access to quality health care. According to the Council on Size and Weight Discrimination, “large people are systematically denied health insurance and life insurance, or they are forced to pay higher premiums than those of average weight” (2014). Further, anti-fat bias among health care providers, who are not immune from widely held cultural beliefs, [End Page 256] serves as a disincentive and a barrier to overweight and obese people seeking medical care as they may experience discrimination and receive lower quality health care (Teachman and Brownell 2001; Schwartz et al. 2003; Wang 2008; Puhl and Heuer 2009; Brown 2010; Teixeira and Budd 2010). “Not only does societal discrimination punish fat people with fewer opportunities, it also subjugates fat people by refusing them the medical and financial support that would help them to improve their weight management” (Wang 2008, 1913–14).
Overweight and obese people systematically experience employer discrimination and reduced access to health insurance and quality health care. Such discrimination and reduced access to health care are then examples of systematic deprivation of opportunities to “[exercise] capacities or [gain] access to material goods” (Lindemann Nelson 2001b, 61). They serve as evidence that obesity-related stigma damages identities through deprivation of opportunity.
Identities damaged via infiltrated consciousness
Infiltrated consciousness occurs when marginalized individuals or groups accept negative, oppressive understandings of their group. According to Lindemann, “a person’s identity is damaged when she endorses, as part of her self concept, a dominant group’s dismissive or exploitative understanding of her group, and loses or fails to acquire a sense of herself as worthy of full moral respect” (2001a, xii). Lindemann draws on Paul Benson’s (1994) hypothetical Gas Light remake to illustrate what she means by infiltrated consciousness. The leading man of Benson’s remake, a Victorian-era physician, pathologizes his wife’s behavior, that is her excitability, active imagination, strong passions, and emotional outbursts, based on sexist, oppressive notions of psychological health. Because the physician’s wife trusts his judgment “on the basis of reasons that are accepted by a scientific establishment which is socially validated and which she trusts” (Benson 1994, 657), she accepts oppressive understandings of herself and women like her. It is in this way that her identity is damaged through infiltrated consciousness.
Stigma damages identities through infiltrated consciousness. It does this when stigmatized people accept negative understandings of themselves as being less worthy of respect, having less self-control and self-discipline, or being less capable of responsibly exercising agency. Obesity-related stigma is known to have a negative impact on the self-esteem of people in higher weight classes (Myers and Rosen 1999; Carr and Friedman 2005; [End Page 257] Friedman et al. 2005; Puhl and Brownell 2006; Puhl and Heuer 2009; Schmalz 2010). Not only does obesity-related stigma have an impact on their self esteems, studies by Wang et al. (2004) and Schwartz et al. (2006) found that overweight and obese people exhibit anti-fat attitudes, regardless of their own weight status, that fat people are lazier, dumber, and worth less than thin people. A 2008 study by Laura Durso and Janet Latner found that overweight and obese people exhibit weight bias internalization, internalizing negative messages about themselves as overweight and obese individuals. Durso and Latner found that weight bias internalization is correlated with negative body image, self-esteem, and mood. Anti-fat attitudes held by overweight and obese people and internalization of weight bias serve as evidence that stigma damages identities through infiltrated consciousness.
OBESITY-RELATED STIGMA DIMINISHES MORAL AGENCY: THE VIOLATION OF AUTONOMY
Traditionally, agency has been understood as the capacity of individuals that allows them to act freely. Free exercise of agency is then dependent on the agent’s ability “to govern one’s conduct willfully and . . . capacity to regulate one’s will reflectively” (Lindemann Nelson 2001b, 51). But this understanding of agency doesn’t capture the whole picture. Free exercise of agency is not just dependent on the capacities of moral agents; it also has a social component (Benson 1994; Walker 1998; Lindemann Nelson 2001b). Hilde Lindemann (2001b) echoes the work of Paul Benson (1994) when she writes about “normative self-disclosure,” or “the ability to reveal through his actions who he is, morally speaking” (Lindemann Nelson 2001b, 52), as one of the capacities of a moral agent: “normative self-disclosure . . . embraces not only the agent’s ability to appreciate the moral construction that others will place on one’s actions but also recognition, on part of those others, that the actions are those of a morally developed person” (Lindemann Nelson 2001b, 54). The works of Benson (1994), Lindemann (2001b), and Margaret Urban Walker (1998) speak to the social component of the free exercise of agency. That is, free exercise of agency is in part dependent on agents’ relationships and the ways agents’ actions are taken up by others.
How is identity related to free agency? Again, our identities depend on the understandings we have of ourselves and others (Lindemann Nelson 2001a). These understandings impact the way our actions are taken up by others. Our identities impact the way we’re seen as morally responsible, morally reprehensible, and worthy of moral respect; they impact how [End Page 258] we’re viewed as moral agents. Lindemann writes about how identity relates to agency:
The connection between identity and agency is an internal one, for my actions disclose not only who I am but who I am taken—or take myself—to be, which directly affects how freely I may act. . . . If others’ conception of who I am keeps them from seeing my actions as those of a morally responsible person, they will treat me as a moral incompetent. This is the harm of deprivation of opportunity. If my own conception of who I am keeps me from trusting my own moral judgments, I will treat myself as a moral incompetent. This is the harm of infiltrated consciousness.
The understandings we have of ourselves and others affect free exercise of agency. Damages to identity, both deprivation of opportunity and infiltrated consciousness, diminish free exercise of agency.
As I discussed previously, stigma contributes to understandings we and others have of ourselves. Obesity-related stigma contributes to our perception of our own and others’ abilities to exercise self-control and self-discipline, to be virtuous, morally upright people (Loomis 2001; Schwartz et al. 2003; Wang, Brownell, and Wadden 2004; Danielsdottir, O’Brien, and Ciao 2010; Puhl and Heuer 2010; Vartanian 2010). Perceptions of stigmatized identities based on health status, health behaviors, gender, race, and class interact to influence how people are seen by themselves and others as moral agents and as worthy of moral respect. It is in this way that obesity-related stigma not only damages identities, but also diminishes agency.
Studies show that obesity-related stigma has a negative impact on eating behaviors, including disordered eating and binge eating (Haines et al. 2006; Puhl and Brownell 2006; Puhl, Moss-Racusin, and Schwartz 2007; Major et al. 2014), and exercise behaviors (Schmalz 2010; Lewis et al. 2011). According to a 2011 study conducted by Lenny Vartanian and Sarah Novak, adults who have more experience with weight stigma, especially those who endorse stereotypes, avoid exercise and exercise-related situations. They report feeling embarrassed or uncomfortable going to the gym and avoid strenuous physical activity. According to Vartanian and Novak, “these findings add to a growing body of literature indicating that experiencing weight stigma can have negative consequences for health-related behaviors, including motivation to exercise, motivation to diet, and disordered eating behavior” (2011, 760). These findings serve as evidence that obesity-related stigma diminishes agency; obesity-related stigma can diminish the will to act in a way that’s best for one’s health. [End Page 259]
OBESITY-RELATED STIGMA AND THE VIOLATION OF JUSTICE
At this point, it should be fairly clear why the use of stigma to achieve public health ends violates justice, where justice is understood as synonymous with equity, as fair distribution of resources, treatment, benefits, and burdens (Beauchamp and Childress 2001). To re-cap, the fourth component of stigma is that stigmatized people experience status loss and unequal outcomes and the fifth is that social, political, and economic power are necessary for execution of the other components of stigma (Link and Phelan 2001). Stigma must operate within existing systems of power in order to effectively link labeled differences with negative stereotypes, place people into distinct categories so as to separate “us” from “them,” and strip status, discriminate, and influence unequal outcomes in the lives of those stigmatized. It is common public health knowledge that most epidemics have the greatest impact on those positioned lowest in social hierarchies. Diabetes, heart disease, smoking, HIV, and overweight and obesity all disproportionately affect socially disadvantaged populations (Parker and Aggleton 2003; Bayer 2008; Puhl and Heuer 2009). The use of stigma to attempt to reduce morbidity and mortality associated with any of these public health issues, including overweight and obesity, disproportionately affects the employment, health care, health behaviors, and life outcomes of those already stigmatized. The use of stigma perpetuates and produces injustice and is therefore unethical.
In this paper, I have proposed a theoretical framework for understanding obesity-related stigma and have argued that this stigma should never be used as a tool to achieve public health ends. Obesity-related stigma deprives people with overweight and obesity of opportunities for employment, fair pay, and fair evaluation of job performance and reduces their access to affordable health insurance and quality, nondiscriminatory health care. Obesity-related stigma does harm. Obesity-related stigma diminishes moral agency, negatively impacting health behaviors such as eating and exercise. It is unjust as it disproportionately affects those positioned lowest in social hierarchies. Obesity-related stigma should therefore never be used as a tool to achieve public health ends.
Although it is beyond the scope of this paper, there are questions I’ve alluded to that must be revisited. What is the relationship between shame and stigma, and between denormalization and stigma? Is there a moral difference between the use of shame, denormalization, and [End Page 260] stigma to achieve public health ends? Is there any way to use shame or denormalization and be sure you won’t produce or perpetuate stigma, which I have argued is ethically problematic? Continued discussion of these issues is critical to sustained commitments to effective, ethically and politically sound biomedical research, medicine, and public health.
Desiree Abu-Odeh, MA, is an MPH candidate and doctoral student in the Department of Sociomedical Sciences at Columbia University’s Mailman School of Public Health. Before attending Mailman, Desiree earned an MA in bioethics from the University of Minnesota. There she studied public health ethics, focusing on the impact body ideals and obesity have on people’s identities.
I would like to thank Ron Bayer for his patience, guidance, and support through all stages of this project. I would also like to thank Joan Liaschenko and Debra DeBruin for teaching me a great deal about the importance of feminist perspectives in bioethics and mentoring me as I grappled with how to apply these perspectives to my own work on overweight and obesity. Thank you to Jo Phelan and Gloria Vidal for their advice and comments on a later draft of this paper and to Grace Lee for her help putting together figures. Finally, I thank the anonymous reviewers whose feedback was crucial to my improving the quality of this paper.
1. Research shows that stigmatizing images of obesity, such as that in the “Cut the Junk” poster, are viewed negatively and do not work as well as empowering images to motivate positive health behaviors (Puhl, Peterson, and Luedicke 2013). While these findings make an important contribution to the body of literature that suggests using stigma to achieve public health ends does not “work,” this paper will argue that regardless of whether or not it “works,” the use of stigma is unethical.
2. This is not to say that all use of shaming and denormalization relies on or contributes to stigma. It is to say that such tactics, intentionally or unintentionally, lend themselves to building and/or perpetuating an association between labeled characteristics and negative stereotypes. They lend themselves to placing people into distinct categories in order to distinguish between “us” and “them.”
3. This raises the question: is stigma ever fair? Although this question is important, addressing it is beyond the scope of my work.