Self‐responsibility, rationing and treatment decision making – managing moral narratives alongside fiscal reality in the obesity surgery clinic

Abstract

BackgroundAddressing the prevalence of severe obesity and its concomitant morbidities is widely acknowledged as one of the most pressing global health priorities. Nevertheless, a paucity of effective interventions and universal pressure on health‐care budgets means that access to obesity treatments is often limited. Although health‐care rationing can be conceived as a socially constructed process, little is known about how decisions emerge within the context of face‐to‐face doctor–patient interactions.MethodsIn this study, we used in‐depth interviews and clinic observations to investigate clinicians’ (n = 11) and patients’ (n = 22) experiences of the rationing of obesity surgery and to examine how broader cultural assumptions around personal responsibility for health emerged in the context of clinical interactions.ResultsPatients and clinicians worked within similar frameworks when it came to self‐responsibility for health and the appropriateness of providing publicly‐funded weight loss surgery. Issues around personal accountability dominated consultations, and patients were expected to provide narratives of the development of their obesity and to account for the failure of previous interventions. Clinicians faced the added pressure of having to prioritise a limited number of patients for surgery, which was predominantly managed through mandating pre‐referral weight loss targets.DiscussionAlthough clinicians sought to maintain an empathic attitude towards individual patients, in practice they were conflicted by their responsibility to ration health‐care resources and tended to rely on entrenched models of behaviour change to allocate treatment. As a result, the content of consultations was mostly focused on issues of personal responsibility, reflecting wider stigmatized attitudes towards extreme obesity.

Moral discourse in general practitioners’ accounts of obesity communication

“…Furthermore, whilst framing obesity as an important health problem that should be addressed rather than ignored, GPs simultaneously describe body weight as central to one's sense of self and a personal attribute, which they feel reluctant to criticise. Thus GPs appear to be trapped in an ambiguous space, occupying a professional role which requires the Aligning with other studies, our findings highlight the pervasive nature of moral discourse surrounding obesity (Bombak et al, 2016;Owen-smith et al, 2018). Whilst we suggest that GPs' constructions of obesity are broader and more complex than being a simple reproduction of moral discourse, it is important to emphasise that the majority of their discursive constructions were based on assumptions that individuals should and could lose weight through changing their eating practices and/or through physical activity.…”

Levels and Trends of BMI, Obesity, and Overweight at National and Sub-national Levels in Iran from 1990 to 2016; A Comprehensive Pooled Analysis of Half a Million Individuals

“…39,40 Considering the complexity of background and increasing complications of obesity, a scientific view of the problem needs the required information for parallel individual and population interventions, which would be designed for specific target groups. 31,[41][42][43][44] As a noticeable suggestion, individual and social behaviors that are related to weight gain should be more subject to research studies. 45 In this nationally representative study of adults in Iran, the age-standardized prevalence rates of obesity and average BMI in 2016 were 40.4% and 27.9% in the female and 35.0% and 25.9% in the male population -a tripled prevalence of obesity compared to 1990.…”

Priority setting and personal health responsibility: an analysis of Norwegian key policy documents

“…Policies prescribing lower priority or higher copayments for lifestyle diseases may also be implemented as deterrence policies, as the prospect of this future risk is thought to have the effect of discouraging individuals from engaging in harmful behaviours 32. Prospective health responsibility at the clinical level can also entail the stipulation of contracts between the patient and the healthcare provider, which clarifies the expectations and requirements that must be fulfilled to be eligible for treatment 7 33…”