Abstract

Introduction: It is important to be aware of the ethical pitfalls in programmes to prevent overweight and obesity, such as stigmatization, blaming the victim and reinforcement of health inequalities. In this article, we present an ethical framework for facilitating a structured analysis to the extent to which a programme prevents overweight or obesity is ethically acceptable. Methods: First, we made an inventory of ethical issues in programmes to prevent overweight and obesity. Secondly, we studied the available ethical frameworks that address the area of public health. Finally, we designed an ethical framework for the prevention of overweight and obesity, which was tested in two international workshops. Results: At the heart of the framework is a list of eight questions on the morally relevant features of a programme: its effects on physical health, psychosocial well-being, informed choice, cultural values, equality, privacy, responsibility and liberty. Answering these questions provides a map of the potential ethical pitfalls of a specific programme. This mapping should be followed by a structured discussion of the arguments and their importance, and the decision whether, and if so under what conditions, the programme should be implemented. Conclusion: Considering the ethical aspects of the programmes to prevent obesity or overweight is extremely important in the face of the urgent and extensive health problem of overweight and obesity. Our framework is a practical tool for systematic ethical evaluation. It is applicable to a broad range of programmes in different stages of development and implementation.

Introduction

According to the World Health Organization (WHO), overweight is among this century’s major health threats.1 The number of people with serious overweight or obesity is increasing steadily: in 1960–62, e.g. an estimated 31.6% of the US adults were overweight (Body Mass Index between 25 and 30) and 13.4% were obese (Body Mass Index >30).2 In 2007–08, 68.0% of the US adults were overweight, of whom 33.8% were obese.3 The prevalence of overweight and obesity in children has increased in parallel: in 2007–08 almost 17% of the school-aged children and adolescents were obese.3 The prevalence of overweight widely varies in different subgroups of the population: it is notoriously high among persons with a low educational level and a low income, and in non-Western migrant groups.3,4 Obesity is an important risk factor for diabetes, cardiovascular disease and diseases of the locomotor system. Overweight is also related to psychological problems.1

Thus, prevention of overweight and obesity is high on the political, public health and research agenda. However, programmes to prevent overweight and obesity are susceptible to various ethical pitfalls. For example, programmes may portray overweight persons as lazy, unattractive and unintelligent and thus be ‘stigmatizing’; programmes may attribute the responsibility for overweight solely to the overweight person and neglect the influence of the obesogenic environment, thus ‘blaming the victim’; and programmes may be ineffective among the groups where obesity rates are highest and thus ‘reinforce health inequalities’.5

It is important to be aware of these ethical pitfalls that threaten values highly important to many of us. If overweight prevention programmes have unintended harmful consequences, they may even threaten one of the basic ethical principles underlying health care, which holds: ‘first, do no harm’.6 Threatening ethical values is undesirable in itself and may also lead to societal objections and undermine the effectiveness of a programme.7 Awareness of the ethical issues in the prevention of overweight and obesity is necessary for those involved in designing, implementing and publicly justifying prevention programmes. It enables them to avoid or revise problematic elements and to make a deliberated decision about whether and under what conditions to implement or support a programme.

In this article, we present an ethical framework for making transparent what the potentially ethically problematic aspects of a programme are and for evaluating to what extent a programme to prevent overweight or obesity is acceptable from an ethical point of view. It does not provide clear-cut answers to ethical questions, because ethical issues are too complex to be solved in such a way. Instead, the framework is a tool for thinking through a programme’s ethical aspects and for facilitating a structured analysis and evaluation.

The framework presupposes certain values that are not universally endorsed. It presumes respect for autonomy, which is a liberal principle not equally endorsed by all. It also presumes the value of health, even though people make different trade-offs between health promotion and other values. We believe that it is undesirable for our framework to be completely neutral regarding conceptions of the good life. Such a framework would also be neutral regarding the health problems caused by overweight and obesity, whereas our starting point is that they must be tackled.

Methods

Our goal was to design a framework that is practically useful for evaluating the ethical aspects of programmes to prevent overweight and/or obesity. Supplementary Box 1 provides an overview of what we assume to be the characteristics of such a framework.

We designed the framework in three steps. The first step involved making an inventory of ethical issues in programmes to prevent overweight and obesity. This inventory was discussed in two expert meetings with preventive health-care professionals, researchers, ethicists and policymakers. We found that current programmes or policies to prevent overweight or obesity may (alongside the benefits they strive for) include eight potentially problematic aspects.5

The second step consisted in studying available ethical frameworks that address the area of public health and that might be used to evaluate overweight prevention programmes. We assessed the area on which the available ethical frameworks focus, their aim, the users they target at and the type of policy or programme they propose to address. Further, we looked at their structure and content, that is, tools for guiding the analytic process, the main ethical principles or values, possible criteria for dealing with ethical conflicts and the concrete policy issues they are applied to. We found that the available public health ethical frameworks address many issues that are important in the prevention of obesity and overweight, but that they lack practical guidance for this specific area.8 The studies in step one and two form the basis for our ethical framework and have been published elsewhere. Supplementary Box 2 provides an overview of the key messages and findings of these studies.

Finally, based on the first two steps, we designed a draft ethical framework for the prevention of overweight and obesity, including a set of procedural recommendations. We tested the feasibility and usefulness of this draft framework in an international workshop9 that was attended by 29 experts from a wide range of sectors (national parliament, national and local governments, insurance companies, commercial companies, preventive health-care services, research). During three parallel sessions, the experts were asked to use the framework to evaluate several programmes and to formulate an advice on whether and under what conditions these should be implemented. On the basis of our observations of these workshops, discussion in a plenary session and individual comments, we further improved the draft ethical framework. The revised version of the framework was tested in a workshop during an international conference of the International Society for Behavioral Nutrition and Physical Activity (ISBNPA).10 The workshop was attended by 40 professionals working in the area of the prevention of overweight and obesity. The adjustments we made based on these final comments have resulted in the current version of the framework.

Results

The framework

At the heart of the framework is a list of eight questions that helps in making a complete inventory of the morally relevant features of a programme (Box 1). Some questions concern ethical values that underlie the aim of programmes. Other questions concern ethical values that are not related to the aim of programmes, but that can be affected nevertheless. Each question is equally important, since each ethical pitfall requires equal attention. The ‘ethical pitfalls’ to which these questions refer are shortly clarified in the next sections (for more detailed information, we recommend reading other literature about ethical issues in overweight prevention, for instance our inventory of ethical issues on which the clarification of ethical pitfalls was based and the literature references in the table).5 By ethical pitfalls, we mean aspects that are potentially problematic from an ethical perspective. The mere presence of ethical pitfalls does not imply that prevention of overweight is ethically wrong.

Box 1 Questionnaire regarding ethical pitfalls

  • How does the programme affect physical health?

  • How does the programme affect psychosocial well-being?

  • How does the programme affect equality?

  • How does the programme affect informed choice?

  • How does the programme affect social and cultural values?

  • How does the programme affect privacy?

  • How does the programme affect the attribution of responsibilities?

  • How does the programme affect liberty?

Physical health

Various effective programmes are being implemented to reduce overweight. However, the (cost-) effectiveness of programmes to prevent overweight is often unknown, unfavourable or hard to prove. Further, programmes to prevent overweight may have unintended negative health effects. Negative health effects may occur in the case of surgery or weight loss drugs. Furthermore, concern exists that programmes to prevent overweight may increase the risk of eating disorders. Further research is necessary to examine this.11,12 Negative health effects may also occur indirectly due to the negative and problem-based focus of prevention programmes on overweight, which may discourage overweight people to visit health services or to be physically active, or encourage unhealthy weight loss methods.6 Programmes that are merely implemented for the sake of appearances (to give the impression that the issue is being addressed or to boost the image of the initiator) may be ineffective. If such programmes are in fact targeted at increasing the turnover of overweight-inducing products, they could even lead to unfavourable effects on physical health. The World Health Organization calls for a controlling of the promotion of dangerous and deliberately deceptive approaches to weight loss or control, such as special weight loss aids, ‘miracle-cures’ and certain drugs and treatments often offered through unlicensed weight loss centres.1 The implementation of ineffective programmes or programmes with an unfavourable cost-effectiveness profile is at odds with the value of ‘well-being’.

Psychosocial well-being

Programmes to prevent overweight generally aim to support people in improving their health and well-being. However, they may have various (unintended) negative psychosocial consequences. They may create uncertainty, fear and worries about the health risks of overweight and obesity.13 They may create feelings of powerlessness among people who want to lose weight but do not succeed. People may lose sight of the distinction between the health consequences of occasionally vs. continuously snacking and between limited overweight vs. severe obesity. Furthermore, programmes may blame and discriminate overweight persons and may contribute to the already existing stigmatization of overweight. Stigmatization is a known risk of health promotion programmes.7,14 It is plausible that this holds specifically for programmes to prevent overweight, since overweight and obesity are already pervasively stigmatized in Western culture.15,16 Overweight prevention programmes may reinforce the already existing stigmatization of overweight by focusing on the negative consequences of overweight and by claiming that overweight is to be avoided. Furthermore, if negative stereotypes that exist in society penetrate into policy and programmes, programmes may present overweight persons as being unattractive and associate them with negative character traits such as laziness and stupidity.1618 Finally, stigmatization may sometimes be used on purpose with the assumption that it may convince people to lose weight. Stigmatizing and blaming messages undermine ‘well-being’ and show a lack of ‘respect’.

Equality

Enabling people to live healthier lives is a valuable goal of preventive health-care interventions. However, some efforts to achieve this goal are at odds with the value of equality. Ironically and sadly enough, programmes are often least effective among the groups who need them most. In Western societies, a lower educational level and being a member of an ethnic minority are associated with a higher risk of overweight and obesity.19 Programmes to prevent overweight are generally less effective among those groups and may thereby increase already existing health inequalities. If a campaign contains information that is hard to grasp for lower educated people or people from ethnic minorities, and therefore does not succeed, it may increase already existing health inequalities.13 Furthermore, programmes that affect financial distribution are likely to hit harder among people with low income. Although it is not a requirement for any single programme to actively pursue the aim of reducing health inequalities, it is generally considered to be a positive duty of public health to diminish existing health inequalities.7,20 Equality may also be infringed upon by programmes that involve unjust discrimination. Programmes targeted at overweight persons use criteria such as BMI to ‘discriminate’ and treat them differently from non-overweight persons, for instance, at the workplace, in schools and regarding insurances. Treating overweight persons differently is ethically sensitive because it may contribute to the stigmatization of overweight persons. Discussion is needed on the question when differential treatment crosses the line to unjust discrimination and leads to unequal outcomes. The presence or aggravation of health inequalities and unjust discrimination conflicts with the principles of ‘justice’ and ‘equality’.

Informed choice

Providing information and raising consciousness about healthy choices is a valuable aim of programmes to prevent overweight and obesity. However, programmes may not always succeed in promoting informed choice regarding diet and physical activity. Sometimes, they involve inadequate information and provide unclear, overstated, oversimplified, subjective, incomplete or even false messages. This may be due to the rush ‘to do something’ about the problem or to the translation of epidemiological information to individual cases without reserve. Evidence, for example, that the population-wide adoption of a healthy diet can prevent 25% of all deaths from cardiovascular disease, does not indicate that adopting a healthy diet reduces each individual person’s risk by 25%. Programmes that suggest that personal choices to eating healthily or engage in physical activity are the solution to all problems neglect other health determinants and fail to acknowledge that obesity is a condition that in some cases requires long-term medical treatment. Inadequate information may also occur in programmes or products stemming from corporations with their own agenda, for instance, when they promote products ‘without fat’ that contain a lot of sugar and when they suggest that ‘quick’ fixes for overconsumption are available in the form of slimming products that ‘demotivate’ people to practise a healthy lifestyle. Inadequate information is ethically sensitive since it is at odds with the value of ‘truthfulness’ and ‘transparency’.21 It hampers the exercise of freedom of choice and ‘autonomy’ and may have negative consequences on health.

Social and cultural values

Programmes to prevent overweight often aim to raise awareness of the impact of eating habits on health. However, by focusing on health effects and lifestyle changes, designers of programmes may overlook that food and eating habits are more than just a biological need. They are also related to cultural and social values. Food is for instance consumed to celebrate, to show hospitality or as a part of cultural traditions.22 Some measures aimed at changing people’s personal lifestyles interfere with the social and cultural value of food. Take for instance programmes that suggest to moderate participation in a Christmas dinner or in festivities after the Ramadan or to turn down a colleague’s birthday cake. Such behavioural changes may lower calorie intake, but may at the same time diminish positive feelings of community. Disregarding the cultural and social value of food may pose a threat to ‘cultural’ and ‘social values’ and to ‘well-being’.

Privacy

In the focus on helping people to lead healthier lives, programme designers may unintentionally lose sight of the fact that information about weight and lifestyle habits is very personal. Programmes that ask for the provision of personal information or that insufficiently warrant that personal information does not become accessible to others, intervene in the personal life sphere and may thereby be sensitive to ‘privacy’ issues. Personal information for instance includes body weight, eating habits or styles of rearing children. Certain ways of gathering the information are sensitive to threats against privacy, such as physical contact, pressure or a lack of consent. It also makes a difference whether the party who collects the information (government, general practitioner, insurance company or employer) has a legitimate reason to do so.

Responsibility

Programmes often urge various actors to make efforts to make healthy choices possible, which is the only way to tackle the worldwide increase of overweight and obesity. Every preventive programme expresses ideas about who must take action to prevent overweight or obesity: individual citizens, parents, schools, the government, the industry or a combination of these. However, a programme is ethically problematic if it goes against a ‘just division of responsibilities’ or the ‘balance between individual and collective responsibility’. Suggesting that the responsibility for the overweight epidemic should be attributed to one single party disregards the fact that overweight is the result of a complex web of causal factors.23 An emphasis on people’s personal responsibility may disregard the influence of the social and physical environment, socio-economic status and genetic characteristics.24

Liberty

Programmes to prevent overweight often aim to enable people to make healthy choices. The solution to the obesity epidemic is frequently sought in programmes that influence choices by regulations or laws, by changing the physical environment, by providing financial incentives for healthy behaviour or a healthy weight and by using psychological motivation or social influence. While many of such programmes may be unproblematic, it is sometimes overlooked that there is a thin line between enabling healthy choices and unwelcome intrusion. Influencing choices may be sensitive to issues of ‘liberty’, ‘autonomy’ and ‘freedom of choice’ regarding lifestyle choices by individuals, employees, parents and policy choices by commercial actors, schools and other organizations. Attempting to limit someone’s actions or to require actions by someone for his or her own good is called ‘paternalism’.25 Paternalistic programmes evoke moral objections because not all people consider health to be the only or the most important valuable thing in life.

Application of the framework

The supplement to the questionnaire provides alerts and possible answers (Box 2). Alerts indicated with a positive sign (+) point to a potential ethical strength of the programme. Alerts indicated with a warning sign (Δ) point to a potential ethical pitfall. The function of the alerts is to call for extra attention when answering the questions. They are not exhaustive: only a watchful attitude when answering the questions can help to detect all potential ethical pitfalls for a programme.

Box 2 Supplement to the questionnaire regarding ethical pitfalls
Question: How does the programme affect physical health? 
Values at stake: 
Well-being 
Answers Alerts 
+ Positive health effects are likely 
  • + Scientific evidence is available

  • + Experts expect positive health effects

 
− Positive health effects are doubtful or unlikely 
  • Δ No scientific evidence is available

  • Δ Programme is implemented for the sake of appearances

 
− Negative side effects are possible 
  • Δ Surgery or medication may have side effects

  • Δ Programme may encourage unhealthy weight loss methods

  • Δ Negative or problem-based focus on overweight may discourage people from visiting doctor or engaging in physical activity

  • Δ Programme is actually aimed at the promotion of overweight-inducing products

 
Example: The British government recommends stomach surgery and medication for exceptional cases of childhood obesity. Based on expert opinions, this programme is likely to have positive health effects. Negative effects are possible because surgery or medication may have side effects. 
Question: How does the programme affect psychosocial well-being? 
Values at stake: 
Well-being 
Respect 
Answers Alerts 
+ Positive psychosocial consequences are likely 
  • + Programme focuses on health and lifestyle instead of weight

  • + Programme is likely to contribute to empowerment

  • + Programme presents overweight persons respectfully

  • + Programme presents the causes of overweight in a nuanced way

  • + Programme includes efforts to prevent stigmata

 
0 Psychosocial consequences are unlikely  
− Negative psychosocial consequences are possible 
  • Δ Programme focuses on health risks and may create fear and worries

  • Δ Programme involves stigmatization by presenting overweight persons as unattractive or with negative character traits

  • Δ Programme blames overweight persons for their overweight

 
 
  • Δ Programme discriminates between overweight and non-overweight people

  • Δ Programme involves pressure on social relations

  • Δ Programme focuses on body weight

 
Example: Pupils are put on a weighing scale in front of their classmates. 
This programme may have negative psychosocial consequences because it focuses on body weight. 
Question: How does the programme affect equality? 
Values at stake: 
Justice 
Equality 
Answers Alerts 
+ Increased equality is likely 
  • + Programme is targeted on low-educated people or ethnic minorities

  • + Information provided has been tested for its comprehensibility and accessibility

 
0 Effect on equality is not likely  
− Decreased equality is likely 
  • Δ Programme may be less effective among low socio-economic groups and ethnic minorities, for instance because information provided is difficult to understand and inaccessible

  • Δ Financial triggers are likely to disfavour low socio-economic groups

  • Δ Programme involves unjust discrimination between overweight and non-overweight persons, for instance by treating overweight persons differently at the workplace, in schools and regarding insurances

 
Example: A university refuses to hand out diplomas to obese students. 
This programme is likely to lead to decreased equality, because it involves unjust discrimination between overweight and non-overweight persons. 
Question: How does the programme affect informed choice? 
Values at stake: 
Autonomy 
Transparency and truthfulness 
Answers Alerts 
+ Promotion of informed choice is likely + Information provided is adequate, understandable and accessible 
0 Influence on informed choice is unlikely  
− Negative effects on informed choice are possible 
  • Δ Information is unclear

  • Δ Information is overstated or oversimplified

  • Δ Information is one-sided, subjective or incomplete

  • Δ Information is incorrect

 
Example: A mass-media campaign claims that epidemiological information that is collected at an aggregate level, applies directly and without reserve to individual cases. 
This programme possibly leads to negative effects on informed choice because the information is oversimplified. 
Question: How does the programme affect social and cultural values? 
Values at stake: 
Respect for social and cultural values 
Well-being 
Answers Alerts 
+ Respect for social and cultural values is likely + Programme takes into account that food and eating habits mean more to people than fulfilling a biological need 
0 Effect on social and cultural values is unlikely  
− Interference with social and cultural values is likely Δ Programme hampers participation in social and cultural practices and events such as traditional festivities and gestures of hospitality 
Example: A ban on the tradition of birthday cakes from American schools. 
This programme is likely to interfere with social and cultural values because it hampers participation in traditional festivities. 
Question: How does the programme affect privacy? 
Values at stake: 
Privacy 
Answers Alerts 
+ Respect for privacy is likely Δ Programme includes explicit safeguards against interference with privacy 
0 Effect on privacy is unlikely  
− Interference with privacy is likely 
  • Δ Programme entails collecting sensitive personal information, such as weight, lifestyle and child rearing

  • Δ Programme entails sensitive way of collecting information, such as physical contact, pressure, lack of consent and lack of justification

  • Δ Programme has insufficient safeguards against access to the information collected by third parties, such as health insurance companies or employers

 
Example: Screening of employees on overweight. 
This programme is likely to interfere with privacy, because it entails collecting sensitive personal information and because the setting of the work sphere may involve pressure or insufficient safeguards against access to the information by employers. 
Question: How does the programme affect the attribution of responsibilities? 
Values at stake: 
Balance between personal and collective responsibility 
Just division of responsibilities 
Answers Alerts 
+ Acknowledgement of responsibilities of various parties is likely 
  • + A nuanced view is provided of the complex causal factors for obesity

  • + Complexity of responsibilities is explicitly acknowledged

  • + Responsibilities are freely adopted

 
0 Attributing responsibilities is unlikely  
− Unbalanced attribution of responsibility is likely 
  • Δ Responsibility for the causes of overweight is attributed to one single party

  • Δ Responsibility for tackling overweight is forced upon individuals, parents, schools, municipalities, social health-care services or commercial organizations

 
Example: A website claims that only parents are to blame for the overweight of their children. 
This programme is likely to involve an unbalanced attribution of responsibility, because responsibility for the cause of overweight is attributed to one single party. 
Question: How does the programme affect liberty? 
Values at stake: 
Liberty 
Autonomy 
Answers Alerts 
+ Promotion of autonomy and freedom of choice is likely 
  • + Education promotes autonomy

  • + Environmental changes enable free choices

 
0 Affecting autonomy and freedom of choice is unlikely  
− Interference with autonomy and freedom of choice of individuals, parents, employers, commercial factors, schools or other organizers is likely 
  • Δ Programme involves regulation and legislation

  • Δ Programme involves financial incentives

  • Δ Programme involves environmental changes

  • Δ Programme involves social influence such as peer pressure

  • Δ Programme involves psychological motivation by providing normative information and influencing personal preferences

  • Δ Programme is implemented in the working sphere

 
Example: A so called ‘fat tax’ is levied on fattening products. 
This programme is likely to interfere with freedom of choice of individuals, because it involves financial incentives. 
Question: How does the programme affect physical health? 
Values at stake: 
Well-being 
Answers Alerts 
+ Positive health effects are likely 
  • + Scientific evidence is available

  • + Experts expect positive health effects

 
− Positive health effects are doubtful or unlikely 
  • Δ No scientific evidence is available

  • Δ Programme is implemented for the sake of appearances

 
− Negative side effects are possible 
  • Δ Surgery or medication may have side effects

  • Δ Programme may encourage unhealthy weight loss methods

  • Δ Negative or problem-based focus on overweight may discourage people from visiting doctor or engaging in physical activity

  • Δ Programme is actually aimed at the promotion of overweight-inducing products

 
Example: The British government recommends stomach surgery and medication for exceptional cases of childhood obesity. Based on expert opinions, this programme is likely to have positive health effects. Negative effects are possible because surgery or medication may have side effects. 
Question: How does the programme affect psychosocial well-being? 
Values at stake: 
Well-being 
Respect 
Answers Alerts 
+ Positive psychosocial consequences are likely 
  • + Programme focuses on health and lifestyle instead of weight

  • + Programme is likely to contribute to empowerment

  • + Programme presents overweight persons respectfully

  • + Programme presents the causes of overweight in a nuanced way

  • + Programme includes efforts to prevent stigmata

 
0 Psychosocial consequences are unlikely  
− Negative psychosocial consequences are possible 
  • Δ Programme focuses on health risks and may create fear and worries

  • Δ Programme involves stigmatization by presenting overweight persons as unattractive or with negative character traits

  • Δ Programme blames overweight persons for their overweight

 
 
  • Δ Programme discriminates between overweight and non-overweight people

  • Δ Programme involves pressure on social relations

  • Δ Programme focuses on body weight

 
Example: Pupils are put on a weighing scale in front of their classmates. 
This programme may have negative psychosocial consequences because it focuses on body weight. 
Question: How does the programme affect equality? 
Values at stake: 
Justice 
Equality 
Answers Alerts 
+ Increased equality is likely 
  • + Programme is targeted on low-educated people or ethnic minorities

  • + Information provided has been tested for its comprehensibility and accessibility

 
0 Effect on equality is not likely  
− Decreased equality is likely 
  • Δ Programme may be less effective among low socio-economic groups and ethnic minorities, for instance because information provided is difficult to understand and inaccessible

  • Δ Financial triggers are likely to disfavour low socio-economic groups

  • Δ Programme involves unjust discrimination between overweight and non-overweight persons, for instance by treating overweight persons differently at the workplace, in schools and regarding insurances

 
Example: A university refuses to hand out diplomas to obese students. 
This programme is likely to lead to decreased equality, because it involves unjust discrimination between overweight and non-overweight persons. 
Question: How does the programme affect informed choice? 
Values at stake: 
Autonomy 
Transparency and truthfulness 
Answers Alerts 
+ Promotion of informed choice is likely + Information provided is adequate, understandable and accessible 
0 Influence on informed choice is unlikely  
− Negative effects on informed choice are possible 
  • Δ Information is unclear

  • Δ Information is overstated or oversimplified

  • Δ Information is one-sided, subjective or incomplete

  • Δ Information is incorrect

 
Example: A mass-media campaign claims that epidemiological information that is collected at an aggregate level, applies directly and without reserve to individual cases. 
This programme possibly leads to negative effects on informed choice because the information is oversimplified. 
Question: How does the programme affect social and cultural values? 
Values at stake: 
Respect for social and cultural values 
Well-being 
Answers Alerts 
+ Respect for social and cultural values is likely + Programme takes into account that food and eating habits mean more to people than fulfilling a biological need 
0 Effect on social and cultural values is unlikely  
− Interference with social and cultural values is likely Δ Programme hampers participation in social and cultural practices and events such as traditional festivities and gestures of hospitality 
Example: A ban on the tradition of birthday cakes from American schools. 
This programme is likely to interfere with social and cultural values because it hampers participation in traditional festivities. 
Question: How does the programme affect privacy? 
Values at stake: 
Privacy 
Answers Alerts 
+ Respect for privacy is likely Δ Programme includes explicit safeguards against interference with privacy 
0 Effect on privacy is unlikely  
− Interference with privacy is likely 
  • Δ Programme entails collecting sensitive personal information, such as weight, lifestyle and child rearing

  • Δ Programme entails sensitive way of collecting information, such as physical contact, pressure, lack of consent and lack of justification

  • Δ Programme has insufficient safeguards against access to the information collected by third parties, such as health insurance companies or employers

 
Example: Screening of employees on overweight. 
This programme is likely to interfere with privacy, because it entails collecting sensitive personal information and because the setting of the work sphere may involve pressure or insufficient safeguards against access to the information by employers. 
Question: How does the programme affect the attribution of responsibilities? 
Values at stake: 
Balance between personal and collective responsibility 
Just division of responsibilities 
Answers Alerts 
+ Acknowledgement of responsibilities of various parties is likely 
  • + A nuanced view is provided of the complex causal factors for obesity

  • + Complexity of responsibilities is explicitly acknowledged

  • + Responsibilities are freely adopted

 
0 Attributing responsibilities is unlikely  
− Unbalanced attribution of responsibility is likely 
  • Δ Responsibility for the causes of overweight is attributed to one single party

  • Δ Responsibility for tackling overweight is forced upon individuals, parents, schools, municipalities, social health-care services or commercial organizations

 
Example: A website claims that only parents are to blame for the overweight of their children. 
This programme is likely to involve an unbalanced attribution of responsibility, because responsibility for the cause of overweight is attributed to one single party. 
Question: How does the programme affect liberty? 
Values at stake: 
Liberty 
Autonomy 
Answers Alerts 
+ Promotion of autonomy and freedom of choice is likely 
  • + Education promotes autonomy

  • + Environmental changes enable free choices

 
0 Affecting autonomy and freedom of choice is unlikely  
− Interference with autonomy and freedom of choice of individuals, parents, employers, commercial factors, schools or other organizers is likely 
  • Δ Programme involves regulation and legislation

  • Δ Programme involves financial incentives

  • Δ Programme involves environmental changes

  • Δ Programme involves social influence such as peer pressure

  • Δ Programme involves psychological motivation by providing normative information and influencing personal preferences

  • Δ Programme is implemented in the working sphere

 
Example: A so called ‘fat tax’ is levied on fattening products. 
This programme is likely to interfere with freedom of choice of individuals, because it involves financial incentives. 

It has to be noted that deciding about the acceptability of a programme cannot be based on simply adding up the strengths and weaknesses of a programme, because the answers to the questions only point to their presence without giving a clue about their significance. Instead, decision-making requires a discussion of the arguments and their importance. Some suggestions to structure such discussion are provided in Box 3. These suggestions are based on the criteria we found in other frameworks and in particular in Childress’ framework.7,8,21,26 The discussion should lead to one of the following conclusions: the programme is acceptable, the programme is not acceptable or the programme is acceptable if certain adjustments are made or if certain conditions are satisfied.

Box 3 Steps in the application of the ethical framework

  1. Describe the ethical pitfalls to which the programme is sensitive by explaining choices of answers with a negative sign (−) with as many arguments as possible.

  2. Describe the ethical strengths of the programme by explaining choices of answers with a positive sign (+).

  3. Discuss whether it is possible to adjust the programme in order to minimize its pitfalls and to maximize its strengths.

  4. Discuss whether the programme is likely to be effective in preventing overweight and obesity.

  5. Discuss whether the programme’s pitfalls are outweighed by its strengths.

  6. Discuss whether there is no alternative programme that involves fewer ethical pitfalls.

  7. Discuss whether sound justification can be provided for the remaining pitfalls.

  8. Define whether and under what conditions the programme is acceptable from an ethical point of view.

Discussion

The application of our ethical framework for the prevention of overweight and obesity may be fruitful in any stage of developing a programme: to inform the design of a programme, to check a programme before it is implemented and to evaluate already existing programmes. It could be incorporated in the process of planned development of interventions, such as ‘Intervention Mapping’, a framework for effective decision-making at each step in intervention planning, implementation and evaluation.27 Integrating our ethical framework facilitates making ethically sound choices regarding target group, determinants, techniques for behaviour change and the tone and design of intervention materials.

During the tests of our framework, professionals working in the area of the prevention of overweight and obesity stated that they found it difficult to detect the ethically sensitive issues in their own programme. Indeed that may be difficult if one has been closely involved in its design and if one has certain expectations of its implementation. We therefore recommend that also people who are not involved in the development or implementation of the programme are included in applying the framework. In order to ensure conclusions that are critical, complete and representative for how a programme will be received in society, we advise to consult a diverse and multidisciplinary group of stakeholders. Procedural recommendations are provided in Box 4. The more complex and controversial a programme is expected to be, the more time and energy should be put into applying the framework.

Box 4 Procedural recommendations for applying the ethical framework
• Three groups 
A division into three subgroups, each with about five participants, accounts for a variety of accents in applying the framework. The first group consists of experts, for instance policymakers, experts in the field of medicine or health education, public health, psychologists, ethicists and legal experts. The second group involves the target group of the programme. Some programmes have a target group that is not necessarily obese, for instance parents of obese children or the general public. Even in those situations, the programme may have implications for obese persons, for instance because the societal image of overweight persons may be affected by the programme. In those cases, the second group should include obese persons as well. The third group includes the general public. Even if the target group of the programme is specific, the programme may evoke reactions from the general public regarding its acceptability and fear of potential slippery slopes. 
• Meetings 
A physical meeting including thorough discussion among the stakeholders could ensure a careful application of the framework and outcomes that reflect a broad perspective. Attendants may read the clarification of ethical issues prior to the meeting. The meeting could start with three parallel sessions where the framework is applied by each subgroup with their specific points of view and a joint session to discuss the results and exchange perspectives. The total meeting should take at least 3 h. A neutral moderation of the discussion session is recommended. Designers of the programme should preferably not participate in the discussion in order to create an open atmosphere. The meeting should involve an interactive discussion. Hopefully, listening to each other’s arguments will encourage reflection and stimulate new points of view to come up. In principle, the aim of using the framework is to raise awareness of ethical issues and to reach consensus on how to deal with them. Finding out that disagreement continues to exist after thorough discussion and is in itself an important result because it shows that the programme is likely to evoke debate in society. In dealing with disagreement, minority views must be heard and taken into account and democratic procedures should be followed. Accurate reporting is necessary, both to provide designers of the programme with feedback and to make the process of decision making transparent to the public.1–4 
• Three groups 
A division into three subgroups, each with about five participants, accounts for a variety of accents in applying the framework. The first group consists of experts, for instance policymakers, experts in the field of medicine or health education, public health, psychologists, ethicists and legal experts. The second group involves the target group of the programme. Some programmes have a target group that is not necessarily obese, for instance parents of obese children or the general public. Even in those situations, the programme may have implications for obese persons, for instance because the societal image of overweight persons may be affected by the programme. In those cases, the second group should include obese persons as well. The third group includes the general public. Even if the target group of the programme is specific, the programme may evoke reactions from the general public regarding its acceptability and fear of potential slippery slopes. 
• Meetings 
A physical meeting including thorough discussion among the stakeholders could ensure a careful application of the framework and outcomes that reflect a broad perspective. Attendants may read the clarification of ethical issues prior to the meeting. The meeting could start with three parallel sessions where the framework is applied by each subgroup with their specific points of view and a joint session to discuss the results and exchange perspectives. The total meeting should take at least 3 h. A neutral moderation of the discussion session is recommended. Designers of the programme should preferably not participate in the discussion in order to create an open atmosphere. The meeting should involve an interactive discussion. Hopefully, listening to each other’s arguments will encourage reflection and stimulate new points of view to come up. In principle, the aim of using the framework is to raise awareness of ethical issues and to reach consensus on how to deal with them. Finding out that disagreement continues to exist after thorough discussion and is in itself an important result because it shows that the programme is likely to evoke debate in society. In dealing with disagreement, minority views must be heard and taken into account and democratic procedures should be followed. Accurate reporting is necessary, both to provide designers of the programme with feedback and to make the process of decision making transparent to the public.1–4 

Our framework is aimed at evaluating a broad range of programmes for obesity prevention: it is applicable to governments’ programmes, but (with some adaptations in the wording of the questionnaire) the tool may also be applied to other parties’ initiatives, such as weight loss activities for employees in a company, a television programme about acquiring a healthy weight by a commercial television station or a website about childhood obesity initiated by parents. All types of initiatives aimed at weight loss have to do with ethical issues and may benefit from a sound ethical analysis. The ethical aspects involved in programmes to prevent overweight and obesity overlap to a great extent with ethical aspects of the prevention of other types of unhealthy behaviour. This makes it worthwhile to explore under what conditions our framework could also be applied to other types of unhealthy behaviour. Due to our broad perspective on all potential ethical issues that may occur in overweight prevention, the clarification of ethical issues in programs to prevent overweight is concise. A more extensive overview including examples of programmes has been published elsewhere.5

Applying the framework will not resolve all disagreement. We have aimed to develop a framework that is a tool for ethical discussion instead of an automat for answers. We have avoided taking position in debates as much as possible, in order to stimulate discussion among various professionals with a variety of opinions. For instance, the question whether individuals have a duty to behave in a healthy way is open to discussion. Applying the framework may lead to disagreement at two levels: first, opinions may differ on the likeliness that the programme will actually have unintended ethically problematic consequences and secondly, the importance that should be attributed to such problems. This is inevitable because people hold different perspectives and value patterns. The framework is not meant to remove all sources of disagreement; instead, it offers a way of systematically thinking them through and balancing them for decision-making. Concluding that disagreement exists is itself an important result, for if it happens in applying the framework it may also happen in society.

Among the strengths of our framework is that our analysis started from the concrete ethical issues in programmes to prevent overweight and/or obesity, instead of from abstract ethical principles. Our framework includes several characteristics that, according to the assumptions provided in Supplementary Box 1, will make it practically useful. It is applicable to concrete programmes to prevent overweight and/or obesity, it maps negative as well as positive normative aspects of a programme and it addresses all ethical issues that may be involved in programmes to prevent overweight and/or obesity, that is, effectiveness, psychosocial effects, equality, information, liberty, responsibility, privacy and cultural values. We believe that our framework facilitates deliberation about the ethical aspects of programmes, because it includes an instrument to guide the evaluative process, because it frames questions for discussion and because it provides possible answers and alerts. No simple solutions seem to be available for dealing with ethical conflicts.8 We argue that deciding about the acceptability of a programme requires a discussion of the arguments and their importance, and we offer suggestions to structure such a discussion. Finally, in order to enhance the framework’s practical feasibility, we include procedural recommendations for applying the ethical framework. We did not find this element in other frameworks.

The framework has been tested and adapted two times during its development. We recommend further research, monitoring and evaluation to assess the implementation, use and results of the framework.

Supplementary Data

Supplementary Data are available at Eurpub online.

Funding

The Netherlands Organisation for Health Research and Development.

Conflicts of interest: None declared.

Key points

  • An ethical framework for the prevention of overweight and obesity is needed.

  • The framework presents questions and alerts regarding eight potentially ethically problematic aspects of a programme to prevent overweight and obesity.

  • Six steps in the application of the framework are suggested to enable evaluating to what extent programmes to prevent overweight or obesity are acceptable from an ethical point of view.

  • Procedural recommendations are provided to facilitate application of the framework by public health professionals who design, develop and implement programmes to prevent overweight.

Acknowledgements

This study is part of a PhD project about the ethical aspects of prevention of overweight and obesity, which was funded by ZonMw. In drafting this study, we benefited greatly from our participation in the workshops of the international and interdisciplinary project ‘Eurobese’, which was funded by the European Union. We thank all its participants for the inspiring discussions, and Sofie Vandamme, Suzanne van de Vathorst and Soren Holm in particular for their contribution to the framework. We are grateful to Pedro Teixeira for his efforts to make our workshop on the ISBNPA 2009 conference a success. Finally, we thank the attendants of our workshops for their enthusiastic participation and critical comments.

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