CW: discussion of paying people to lose weight, with an eye to showing its flaws, both medical and moral.

Saturday morning I was perusing my email and ran across the most recent Ethicist column in the NY Times. I enjoy and respect philosopher Kwame Anthony Appiah’s thoughtful answers to sometimes thorny, sometimes appalling social and moral questions. We don’t always agree, but then again, what two philosophers are always on the same page? We even manage to make a living (if not a very handsome one) disagreeing.

Back to the issue at hand. The Ethicist was called to weigh in on the following question:

If you’re in a hurry, here’s the answer: no.

For those of you who prefer pictures to words:

Before I get into what I think is wrong with paying people to lose weight, let’s hear from Appiah. He was his usual measured self, but he came down strongly on NO. Here’s a bit of the question:

Several years ago, my husband and I purchased a house for our son, with an agreement that he would pay us back. He remodeled it from scratch and has been making his payments to us fairly regularly, though he misses occasionally when other priorities arise. We both agree that we would like to gift him the remaining balance on the house...

Our son, however, is morbidly obese, and my husband wants to condition the gift on his getting on a GLP-1 program, which would mean using about half his monthly savings to pay for the medication. I feel that a gift is a gift and you should not extort a grown man, even when it is in his best interests. Your thoughts? —

Basically they’re asking if it’s okay to withhold giving the house to their son (which they had already planned to do) until he starts taking a GLP-1 weight-loss drug for weight loss.

What does The Ethicist say in response? Here’s an excerpt:

It’s not always wrong to attach conditions to a gift. Sometimes the conditions are intrinsic to what’s being given. There’s nothing coercive about a college fund that requires enrollment…

By contrast, your son is fully capable of judging the evidence and deciding what to do with his own body. His choice not to pursue treatment may be misguided, but it’s his to make, and the condition is unrelated to the gift. What your husband is considering isn’t extortion; withholding a benefit isn’t the same as imposing a penalty. But it’s disrespectful. 

…not only does your husband’s plan treat your son like a child, it also may not be effective in the long run.

So consider another gift, the kind where the condition is intrinsic to what’s being given: Offer to defray the costs of his treatment. You have the means, and this way you’d be giving him something without saying anything about how much you trust his judgment. He may still decline. If he does, you’ll need to make your peace with the fact that it’s his body and his life.

Okay, I think that is an okay, if overly mild-mannered answer.

Here’s my non-mild answer, which is in three parts, in increasing levels of non-mildness.

Part one: Paying people to lose weight isn’t effective long-term.

There are loads of studies examining the effectiveness of financial incentives for weight loss (as well as smoking cessation and other health-related behaviors). What’s the upshot? Some people respond in the short-term (that is, during the period of the study or cash payments). In this 16-week study, participants were put into three groups: 1) playing a lottery in which they won money if they hit target weight; 2) depositing their own money and receiving funds if they complied with protocols and also hit target weight; 3) control group.

What happened? After four months weight loss in experimental groups was higher (13–14lbs) than in the control group (3.9lbs). But at the seven-month follow-up, differences were not statistically significant. And few of the participants opted to continue the financial incentive study.

There are loads of such studies, along with systematic reviews, and they generally show the same outcome: maybe a little weight loss to start, but 1) it’s a small amount; and 2) participants regain weight after the study ends. Which is demonstrably bad for health– yo-yo dieting leads to lots of bad health outcomes.

Part two: paying people to lose weight is coercive, showing disrespect for them as autonomous persons.

In the studies I looked at, the participants tend to report lower incomes, and the financial rewards are typically in the $300–500 range. This amount may convince someone who needs the money to participate, but it preys on their economic insecurity rather than appealing to whatever motivations they have about any health-directed behavior change. We see this pattern in other global health care ethics issues, in particular around surrogacy tourism, where vulnerable populations have been targeted for coercive financial arrangements. Read more here about surrogacy tourism in India.

Am I saying that paying people to lose weight is ethically just like paying them for surrogacy, or for their organs? No. But, once money is in the mix, exploitation, coercion and abuse have quickly followed, and this is well-documented.

What Appiah suggests instead is that the parents offer to cover the costs for GLP-1 meds IF their son wishes to take it. That’s the mild-mannered approach I mentioned above.

Here I part ways with him. Is offering to pay for another person’s GLP-1 meds a sketchy move? Yes. Why? Making such an offer is implicitly making a negative judgment about another person’s weight (namely, that it should be lower), conveying that judgment to them, and forcing a confrontation/discussion about the person’s own weight and health values and goals, which are nobody else’s damn business.

To be sure, we commonly negotiate uncomfortable and personal discussions with people we are close with, especially about health-directed behaviors. Sometimes those discussions are useful, resulting in extra support that is appreciated.

However, in the case of body weight, I argue that silence about it is always golden. We are all aware of what our bodies are like, and are reminded constantly of the ways they may fail to conform to unrealistic media standards. In short, the son knows what his body size is like, and is doubtless well-versed in general population concerns about body weight ideals. Which leads me to part three:

Part three: making an unsolicited offer to pay for another person’s GLP-1 meds reinforces the culture of weight stigmatization and discrimination, and burdens the other person with a vivid reminder of it in the face of someone they care about.

Yeah, pretty much that. The son is getting a clear message that his parents think his body is unhealthy, too big and needs to be smaller. And they are considering leveraging his need and desire for a HOME against their desire for him to change his body size. Ew.

And even Appiah’s soft-soap approach still conveys the parents’ thoughts and judgments, even if it doesn’t implicitly threaten him (yes, they are making a positive claim– giving the him a house– but there’s a negative one underneath–making him continue house payments).

Just as the son certainly knows what the parents think about his body weight, he also probably knows that they will help him if he asks. IF HE ASKS.

So, my advice is saying nothing until and unless he asks for financial help in paying for GLP-1 meds.

My dear readers, you may agree with me, or you may disagree. As a philosopher, I welcome all comments. So tell me what you think…