Obesity is a serious public health problem in America, and policy solutions are fraught with ethical challenges; how can this multi-faceted problem be tackled while maintaining individual freedom of choice and avoiding stigmatization?
Fairness, respect, and consistency in government public health policies are crucial to the answer, according to an opinion from experts at the Johns Hopkins Berman Institute of Bioethics and California Food Policy Advocates published in the American Journal of Public Health.
Focusing specifically on the ethics of various strategies for reducing obesity through disincentives to consume sugar-sweetened beverages (SSBs), the opinion draws key connections and distinctions between three strategies:
(1) restricting sale of SSBs in public schools,
(2) levying significant taxes on SSBs, and
(3) prohibiting the use of Supplemental Nutrition Assistance Program (SNAP; formerly food stamps program) benefits for the purchase of SSBs.
"Obesity is truly a national epidemic in the United States, affecting one in three adults and one in six children, says Nancy Kass, co-author of the opinion, a professor at the Berman Institute of Bioethics and Bloomberg School of Public Health at Johns Hopkins University. "We focus on sugar-sweetened beverages because they are the largest single contributor to Americans' caloric intake."
Regarding accusations of a "nanny state" and government interference in individual choice, the authors suggest that framing is incorrect, and that in addition to the health implications of being overweight, the wide economic disparities of obesity create a government duty to enact policies to prevent injustice.
"[T]he systematically higher rates of obesity among food-insecure individuals compared with the food-secure raise questions whether public policy around obesity prevention should be labeled government interference with individual preference, or government responsibility in the name of social justice," the opinion states.
A ban on school sales of SSBs and, to a lesser degree, taxation of SSBs, score well in terms of fairness, the opinion says, because they apply across demographics, while the proposed food stamp ban targets SNAP participants exclusively. Such a practice, proposed in California, Florida, Missouri, Wisconsin and Texas, would not "pass ethical acceptability."
"[A]SNAP exclusion, implemented alone, sends a public policy message that poor people require government intervention to manage their food choices whereas higher- income persons do not," the opinion states. The authors dismiss the objection that a sales tax is unfair to lower-income individuals, saying "regressive taxation becomes most troubling from a fairness perspective when applied to basic necessities -- such as clothing, housing, or food. Sugar-sweetened beverages, containing no nutritional value, are not a basic necessity." Rather, taxes reflect the preferences of a society valuing free choice, opting for disincentives rather than prohibitions, with SSBs remaining widely available on the market, the opinion states. It goes on to say that taxation would be most fair if those who "enable and benefit" from the sale of SSBs share in the burden through excise taxes, with the portion passed on to the consumer only adding to the disincentive of a sales tax. The opinion addresses the "nannying" concerns squarely by highlighting that under all of the policies considered, SSBs remain widely available to the public. Further, data increasingly show that much human eating behavior -absent any policy intervention -- is widely influenced by factors such as portion and container size and price, and thus remains at least as much the result of external influences as the result of "free choice."
Finally, the opinion underscores that not all liberties are created equal. Governments have essential duties to protect our fundamental freedoms. But in providing disincentives to unhealthy products such as SSB, the government simply is discouraging the consumption of less healthful products. "Although a central responsibility of government is to protect foundational liberties from unwarranted intervention, it does not necessarily follow that fundamental liberties are threatened when public policy discourages consumption of unhealthy products or prohibits government spending on them," the opinion states. "The personal pleasure to be derived from consumption of SSBs is absolutely worthy of consideration, and yet such pleasure does not rise to the level of a fundamental freedom."
- Nancy Kass, Kenneth Hecht, Amy Paul, Kerry Birnbach. Ethics and Obesity Prevention: Ethical Considerations in 3 Approaches to Reducing Consumption of Sugar-Sweetened Beverages. American Journal of Public Health, 2014; e1 DOI: 10.2105/AJPH.2013.301708
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