Discrimination in our healthcare is one of the more unpleasant facts of life for the fat. It’s a pervasive problem that results in undertreatment, mistreatment and treatment delays:
- Having important symptoms dismissed as “weight-related.”
- Having a prescription for “weight loss” subsituted for effective treatments that would be offered to thinner patients.
- Being treated and diagnosed with medical equipment inappropriate for our size.
- Receiving inadequate physical exams
- Being labelled as “noncompliant” because of a “failure” to lose weight.
- Being faced with old-fashioned bigotry and hostility in people we need to trust with our health.
- etcetera (yeah there’s more but you get the idea.)
It makes you wonder how much our supposedly poorer health is really a product of poorer healthcare.
Discriminatory Guidelines and Heart Transplants
One of the things we may not think about is how medical “guidelines” can actively encourage even the most conscientious doctors to undertreat us. Or to delay treatment until a magical “ideal weight” is (never) achieved.
An interesting article at Web MD reports on a study urging revision of discriminatory heart transplant guidelines, which recommend doctors keep “obese” patients off transplant lists. The study was presented at the Annual Meeting of the International Society for Heart and Lung Transplantation (ISHLT) which puts out said guidelines.
According to the study, which examined the outcome of 18,662 patients who had heart transplants, patients with a BMI of between 30 and 35 (the vast majority of the “obese”) had no significant difference in survival from “normal weight patients.” Another smaller study presented at the Conference looked at results for children and found — again — that “overweight” children receiving heart transplants do just as well as normal weight children.
In other words, “official guidelines” tell doctors to deny and delay lifesaving transplants to fat people even though they’d do just as well as anyone else. What did the guidelines ask physicians to tell their fat patients in need of heart transplants? According to the guidelines: “weight loss should be mandatory to achieve a BMI <30 kg/m2 or PIBW <140% before listing for cardiac transplantation.”
If weight loss is a grueling and ineffective process for us healthy fatties, imagine trying to do it when you’re close to death. The mind boggles.
I hope the ISHLT will revise its guidelines. But it sounds like we can still expect people who are at the heaviest BMI ranges — with a BMI over 35 — to be denied transplants. Not because they wouldn’t be far better off with them, but because they fare slightly worse than an “ideal” candidate. But rationing is the logic of transplantation. For organ transplants, a tragically finite quantity, those may just be the breaks.
Rationing and the Vicious Cycle
Of more concern, I think, is increasingly we’re seeing “rationing” used as an excuse to deny treatment even where there is no fundamentally limiting factor like organ supply, but where certain quarters simply want to find reasons not to pay. In cases like that combing the data for groups which don’t do quite as well as an “ideal” candidate seems like a good excuse for denying treatment. That the patient can still vastly benefit from the treatment is, I guess, not the main consideration.
Sandy Swarcz recently wrote one of her characteristically thoughtful and comprehensive articles on denial of join replacement to the fat on the grounds of a supposedly “worse outcome” (pointing out, by the way, that the data doesn’t actually show that fat patients do worse). Fertility treatments is another area where the same logic has been used to deny fat people extremely effective treatments.
My worry is that healthcare “rationing” just perpetuates a vicious cycle. Where rationing, combined with the myriad forms of healthcare discrimination, leads to poorer outcomes for the fat, which in turn makes us look sicker and riskier to treat. And this in turn could lead to further discrimination and further “rationing,” as fat people become increasingly viewed as “too much of a risk” to get the care and procedures we need.