Laughing at the Obese

Abstract

While the phenomenon has been studied mainly among medical students, it is well known that physicians, even seasoned ones, often make derogatory remarks about certain patients – not in the patients’ presence (it is to be hoped) but to each other. The targets of such medical locker-room humour are often the patients who, the doctors think, brought their illnesses upon themselves. In a focus group investigation of medical students by Wear and colleagues, the almost unanimous conclusion by students was that morbidly obese patients were “fair game” for mockery. Why so? The students reported that it had to do with the patients’ perceived “lack of self-control.” Other patients who fell into the same category included smokers, excessive drinkers, drug abusers, reckless drivers, those who practice unsafe sex, those who engage in unlawful behaviours, and those who do not comply with their physicians’ prescriptions. Instead of feeling empathy for such patients, many students in the focus groups reported feeling generally cynical or indifferent toward them. Mockery may be a way of “letting off steam,” reflecting physicians’ perceived inability to “cure” such patients, and their demoralization in the face of what they perceive to be the hopeless complexity of the clinical situation. John Morreall has studied the philosophy of humour. He suggests another explanation – people laugh at those to whom they feel superior. Doctors tend to feel superior to their patients and may well overestimate the actual “free” choices patients have when it comes to putting on weight. Central to this issue is an increasingly high-pitched debate across North America over what personal responsibility is, and is not. Pundits on the political right and the left (and everywhere in between) betray righteous moral certitude over knowing what constitutes moral responsibility when it comes to eating too much or exercising too little. So what is free choice when it comes to obesity? One of my first summer jobs in college was moving pianos at an elite music school in Victoria, BC. One night I was driving home a 14-year-old Russian prodigy – he could play Rachmaninoff to the awe of his young peers – and he thrust his neck out the bus window. I stopped and asked him to stick his head back in the bus. He told me he couldn’t help it: in Moscow they didn’t have clean air. In Victoria, he was breathing life for the first time. Yes, Virginia, human beings at their core possess free will, and this should be celebrated; we can choose to do good and we can (sometimes) keep away from bad temptation. But when it comes to breathing clean air (in the case of the Rachmaninoff scholar) or eating healthy foods, it depends in part on what our genes have to say and on where we live. A Soviet apparatchik could never breathe – or speak – freely. In this context, freedom of choice is slippery. Context matters. Doctors – like all of us – can be trapped by cognitive bias when judging the moral character of the obese. The heavier patients are, the less respectfully they’re treated, as if it was, somehow, their fault. This is unfortunate, because these patients may end up avoiding the healthcare system altogether. Physician biases mirror the community prejudices that obese persons struggle against every day. When we mock the obese, we show the weakness of our choices and the weakness of our own character.