Blogborygmi thinks my Oreos bit was a little too paternalistic, and a little too idealistic. And again we get into the difficult, where-to-draw-the-line ethical quandary. Where does patient autonomy stop, and good health “paternalism” begin? I want to let patients be in control of their lives, and therefore, their health care, but will I try to persuade them to stop smoking? Sure. Is it paternalism in every case, if medical professionals simply have a greater knowledge, education, and experience of health and disease? Or is it bad medicine not to convince someone of a particular treatment?

I’m all for patients making their own choices. But why not (yes, ideally) change the structure of the system such that they’re coerced encouraged to make the healthier choice? Wonder why fast food burgers are so cheap? Beef subsidies. Why not structure the system such that salads and fruit are cheap? And oats? And whole wheat breads and tofu? (People might argue that these don’t “taste as good,” but if they were bought and sold in the quantities that Twinkies and Big Macs are, markets would create tasty options.) Why not tax bleached flour and corn syrup? People aren’t just horses that respond to carrots and sticks; I believe that many people will choose the “right” choice (in this case, the healthy one) as long as they’re educated about the choices, know the benefits and costs, and can acquire it at an equitable price. If we could provide healthy options at similar or lower prices (by subsidizing costs), I think you could change a significant number of people’s diets. Or support more local farmer’s markets? Or why not build more bike lanes and encourage bicycling with Clean Air Cash , like Stanford does? I’m just trying to make the point that there are structure- and policy-related issues that determine the way many people live their lives. From what food we buy to how our homes and communities are designed and built; from where our jobs are located to what our options are for recreation and entertainment on the weekends. A lot of these things are already set in stone, but that doesn’t mean we can’t begin to change them today.

Personal responsibility is in the mixture, too, but it’s absolutely worthless if people aren’t educated about the short and long-term effects food can have on their minds, bodies, and relationships. (Example: people that smoked in the early part of the last century didn’t know it was bad for you–some even thought it was good for them. Without the knowledge that smoking causes cancer, should they have been held personally responsible for developing lung cancer?) Children are especially vulnerable to advertising (and a lot of food advertising is aimed directly at them); what parent has time to let them know that those Chicken McNuggets aren’t so great for them?

Obesity is a complex problem, and I am but a lowly first-year medical student. So I’ll yield to a source of higher authority: The Institute of Medicine. From their report, Promoting Health: Intervention Strategies from Social and Behavioral Research ,

bq(quote). “It is unreasonable to expect that people will change their behavior so easily when so many forces in the social, cultural, and physical environment conspire against change. If successful programs are to be developed to prevent disease and improve health, attention must be given not only to the behavior of individuals, but also to the environmental context within which people live.”

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