Denial of Treatment to Obese Patients—the Wrong Policy on Personal Responsibility for Health

Document Type : Perspective


Division of Medical Ethics, Harvard Medical School, Boston, MA, USA


In many countries around the world, including Iran, obesity is reaching epidemic proportions. Doctors have recently taken, or expressed support for, an extreme ‘personal responsibility for health’ policy against obesity: refusing services to obese patients. This policy may initially seem to improve patients’ incentives to fight obesity. But turning access to medical services into a benefit dependent on health improvement is a bad policy. It conditions the very aid that patients need in order to become healthier or success in becoming healthier. Whatever else we may think of personal responsibility for health policies, this particular one is absurd. Unfortunately, quite a few personal responsibility for health policies use similar absurd conditioning. They mistakenly use ‘carrots’ or ‘sticks’ for adherence the basic means to the same health outcomes that they seek to promote. This perspective proposes the following rule of thumb: any conditional incentive for healthy choice should be in a currency other than the basic means to that healthy choice.




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1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224–60.
2. WHO. Obesity. Geneva: WHO; 2013. [updated 2013 March; cited 2013 July 10]. Available from:
3. CDC. Overweight and Obesity: Adult obesity facts. Atlanta, GA: Centers for Disease Control and Prevention; 2012. [updated 2012 August 13; cited 2013 July 10]. Available from:
4. Malekzadeh R, Mohamadnejad M, Merat S, Pourshams A, Etemadi A. Obesity pandemic: an Iranian perspective. Arch Iranian Med 2005; 8: 1–7.
5. Mirzazadeh A, Sadeghirad B, Haghdoost AA, Bahrein F, Rezazadeh Kermani M. The Prevalence of Obesity in Iran in Recent Decade; a Systematic Review and Meta-Analysis Study. Iran J Public Health 2009; 38: 1–11.
6. Singer P. Weigh More, Pay More. Project Syndicate 2012.
7. Campbell D. Doctors back denial of treatment for smokers and the obese. The Observer 2012.
8. Ramirez X. OB-GYNs in South Florida Reject Overweight and Obese Patients. 2011. [updated May 17; cited 2013, July 12]. Available from:
9. Firger J. Doctor Turns Away Obese Patients. 2012. [updated August 29; cited 2013 July 10]. Available from:
10. Zimmerman R. Mass. Doctor Won’t Accept New Patients Who Are Obese. 2012. [updated August 30; cited 2013 July 10]. Available from:
11. Wikler D. Personal and Social Responsibility for Health. In: Anand S, F Peter, AK Sen, editors. Public Health, Ethics, and Equity. New York: Oxford University Press; 2006. p. 109–34.
12. Yousefi P. Overweight/obesity and lifestyle characteristics among Iranian pre-school children. Umeå: Umeå University; 2011.
13. Schmidt H, Voigt K, Emanuel EJ. The ethics of not hiring smokers. N Engl J Med 2013; 368: 1369–71. doi: 10.1056/nejmp1301951
14. Schmidt H, Voigt K, Wikler D. Carrots, Sticks, and Health Care Reform—Problems with Wellness Incentives. N Engl J Med 2010; 362: 1–3. doi: 10.1056/nejmp0911552
15. Asch DA, Muller RW, Volpp KG. Conflicts and compromises in not hiring smokers. New Engl J Med 2013; 368: 1371–3. doi: 10.1056/nejmp1303632
16. Marmot M. Fair Society Healthy Lives. In: Eyal N, OF Norheim, SA Hurst, D Wikler, editors. Inequalities in Health: Concepts, Measures, and Ethics. New York: Oxford University Press; 2013, Forthcoming.
17. Eyal N. Motivating prevention: from carrots and sticks to “carrots” and “sticks”. Virtual Mentor 2008; 10: 756–62. doi: 10.1001/virtualmentor.2008.10.11.oped1-0811
18. Andrews M. Some Doctors Ask Patients To Sign ‘Pain Contracts’ To Get Prescriptions. Kaiser Health News 2011.
19. Eyal N. Why treat noncompliant patients? Beyond the decent minimum account. J Med Philos 2011; 36: 572–88. doi: 10.1093/jmp/jhr051