Fairness and Respect in Obesity Prevention Policies: A Response to David Buchanan

Document Type: Correspondence

Authors

Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada

Keywords

Main Subjects


In his response to our article1,2, David Buchanan introduces some useful and important distinctions in the concepts of equality and autonomy. He highlights, for example, the distinction between inequality and inequity, which captures the insight that not all differences between people are unjust. Unjust inequalities are a subset of differences between people, and theories of justice can be defined by how they determine which of these differences are unjust. In addition, he points out that autonomy is not simply a matter of negative liberty, but also about a positive capacity to act. This understanding of autonomy is consistent with the account we offered in the paper, which underlines the importance of both the capacity to understand available options, and the capacity to act on the choices that one makes.

While we agree with his distinctions, we would like to raise some questions about the conclusions that he offers. In particular, he puts forward two claims: First, he claims that taxing soda and Sugar Sweetened Beverages (SSB) and banning the sale of larger SSB containers are regressive policies, and therefore unjust. Second, Buchanan claims that telling poor people what they can or cannot buy with food stamps is insulting. We will address each claim in turn.

Taxing soda and banning the sale of larger soda pop containers is regressive and unjust.
Regressive measures are those that take a higher percentage of the income of low-income people. There are countless regressive taxes and only some are considered unfair—for example, a sales tax on groceries is commonly considered unfair because it is excessively burdensome on low-income people. Food is a necessary expense, and a tax on groceries would make these necessary goods more expensive to those already struggling to afford them. For this reason, a regressive tax on groceries is seen as unfair. The same reasoning does not apply to soda. First, soda is not a necessary good. While many people enjoy drinking soda, soda does not alleviate hunger, and it has no nutritional value over and above the calories it contains3. Furthermore, SSB can be harmful to individuals. Along with other unhealthy foods, sugary drinks contribute to high rates of obesity, diabetes, heart disease, and other chronic diseases. Thus, these policies would not restrict access to any necessary good and could promote health, which is necessary for a meaningful life. Second, the policy would only increase individuals’ costs if they continue to drink large amounts of SSB. But, the ban is meant to reduce consumption of soda and other sugary drinks. If the ban is effective, it will decrease the consumption and thereby reduce costs—More fundamentally, the deep unfairness in this context is not the cost of soda, but the higher rates of obesity, and chronic disease associated with obesity, among low-income people. Unhealthy diets cost people their health and their lives, and low-income people bear these costs disproportionately. This is the more morally urgent regressive cost of soda and other unhealthy foods.

Telling poor people what they can and cannot buy is disrespectful and insulting.
The second critique that Buchanan raises against restrictive food policies is that they are disrespectful, particularly to those who are already disadvantaged in society. He levels this critique most directly against policies that would ban the use of food stamps, now called the Supplemental Nutrition Assistance Program (SNAP), to purchase SSB. While we share this concern, we argue that the policy is also likely to send messages about health and nutrition, and it is perfectly appropriate—even important—for the government’s largest food assistance program to send messages about good nutrition.

First, SNAP already places significant restrictions on what participants can purchase using SNAP funds. SNAP is a nutrition program, not a cash assistance program, and as such restricts what participants can purchase with program funds. For example, participants cannot purchase prepared foods, or goods needed to prepare food, or tobacco and alcohol4. These exclusions are justified by SNAP’s authorizing legislation for the program, which explicitly identifies the nutritional concerns of alleviating hunger and improving nutrition among low-income people as the goals of the program.

Accordingly, the most natural interpretation of the policy, and the explanation put forward by its proponents, is that the policy aims to send messages about nutrition. For example: “soda is not a nutritious food”. That said, the meaning of a policy is not fixed, and in the age of social media, the messages about policies that reach the public aren’t necessarily the messages intended by a policy’s designers or supporters. Ironically, in the case of the SNAP policy, hunger advocates and the beverage industry have been offering these negative interpretations, each co-opting these potential messages of the policies to advance their own distinct interests.

Given the inevitable flexibility around the meaning ascribed to any given policy, the real question is: what should be done when there is a risk that a policy will be interpreted as sending negative messages? In these circumstances, government and policy makers have an obligation to actively manage the meaning of the law so as to shape the message of the policy in a fair and respectful way5. Ultimately, though, negative messages are always a concern, and indeed could be levied against any public program that places restrictions on the use of funds—from the overarching SNAP program, to housing support and health programs. Consequently, the mere possibility of these messages is not decisive, but rather points to broader cultural concerns about promoting respect and dignity amongst us all.

  1. Barnhill A, King KF. Ethical agreement and disagreement about obesity prevention policy in the United States. Int J Health Policy Manag 2013; 1: 117–20. doi: 10.15171/ijhpm.2013.21
  2. Buchanan D. Ethical standards to guide the development of obesity policies and programs. Int J Health Policy Manag 2013; 1: 1–3. doi: 10.15171/ijhpm.2013.63
  3. Food and Nutrition Service, US Department of Agriculture 2011, Foods of Minimal Nutritional Value [internet]. 2012. Available from: http://www.fns.usda.gov/cnd/menu/fmnv.htm
  4. Food and Nutrition Service, US Department of Agriculture 2011, Supplemental Nutrition Assistance Program: Eligibility [internet]. 2012. Available from: http://www.fns.usda.gov/snap/applicant_recipients/eligibility.htm
  5. Barnhill A, King KF. Evaluating equity critiques in food policy: the case of sugar sweetened beverages. J Law Med Ethics 2013; 41: 301–9.