I noticed several news stories about an article in the Journal of the American Medical Association advocated removal of obese children from their parents and putting them into foster care as a way of preventing harm. To say the least, that seemed a very provocative and controversial notion—and indeed, apparently set off a bit of a firestorm—so before commenting, I wanted to read the actual article.
I now have. Written by Lindsey Murtagh, JD, MPH and David S. Ludwig, MD, PhD, the authors do indeed call for removing the most obese children as a potential remedy to the health dangers that extreme overweight would cause. However, it is a very limited call. First, the authors set up the problem. From “State Intervention in Life-Threatening Childhood Obesity” (Subscription needed: JAMA, July 13, 2011—Vol 306, No. 2. Here’s the JAMA link:)
MANY BIOLOGICAL, PSYCHOSOCIAL, AND BEHAVioral factors affect energy balance and, therefore, childhood weight gain, with parents playing an important mediating role. Ubiquitous junk food marketing, lack of opportunities for physically active recreation, and other aspects of society promote unhealthful lifestyles in children. Inadequate or unskilled parental supervision can leave children vulnerable to these obesigenic environmental influences...Even relatively mild parenting deficiencies, such as having excessive junk food in the home or failing to model a physically active lifestyle, may contribute to a child’s weight problem. Typically, the potential harm involves an increased risk for obesity-related chronic disease later in life.
But that type of overweight is not what the authors are addressing. Indeed, they state clearly that such cases of overweight children (what used to be called “husky” when I was a somewhat overweight child) does not call for legal intervention.
The authors then ID the type of condition that they think could warrant state intervention, perhaps even removal:
Severe obesity, characterized by a body mass index (BMI) at or beyond the 99th percentile, represents a fundamentally different situation. Whereas typical children consume about 100 kilocalories per day more than requirements state, the energy imbalance for severely obese children may exceed 1000 kilocalories per day,1 suggesting profoundly dysfunctional eating and activity habits. Obesity of this magnitude can cause immediate and potentially irreversible consequences, most notably type 2 diabetes. This complication, reflecting years of progressive metabolic deterioration, carries a dire prognosis. In addition to hyperglycemia, youth with type 2 diabetes typically severe insulin resistance, low diet quality, sedentary lifestyle, and poor adherence to medical treatment—risk factors that together could rapidly accelerate development of macrovascular and microvascular diseases. Without major weight loss, type 2 diabetes usually becomes permanent several years after onset due to irreversible pancreatic beta cell death, which decreases life expectancy significantly.
The question becomes whether such a circumstance rises to the legal level of abuse or neglect permitting formal state intervention. It is an area with some legal ambiguity:
Improper feeding practices, causing undernourishment and failure to thrive, have long been addressed through the child abuse and neglect framework. However, only a handful of states, including California, Indiana, Iowa, New Mexico, New York, Pennsylvania, and Texas, have legal precedent for applying this framework to overnourishment and severe obesity. Nevertheless, mandated reporter laws may obligate physicians to contact child protective services in the cases of children for whom chronic parental neglect has resulted in severe weightrelated health complications.
The authors go through several health consequences that flow from severe obesity, including the potential of an undiagnosed genetic condition. They conclude:
In severe instances of childhood obesity, removal from the home may be justifiable from a legal standpoint because of imminent health risks and the parents’ chronic failure to address medical problems. Indeed, it may be unethical to subject such children to an invasive and irreversible procedure without first considering foster care. Nevertheless, state intervention would clearly not be desirable or practical, and probably not be legally justifiable, for most of the approximately 2 million children in the United States with a BMI at or beyond the 99th percentile...[T]he decision to pursue this option must be guided by carefully defined criteria such as those proposed by Varness et al, with less intrusive methods used whenever possible.
And therein lies the rub. The article is entirely reasonable in its approach and conclusion. But I have seen far too many cases in my law and public advocacy careers, in which nuanced legal criteria were applied in the trenches in a far broader manner than the actual policy intended.
Still, fears about mission creep do not invalidate the author’s conclusion. In very rare and truly severe cases of morbid obesity, I do think that some form of state action is warranted to protect the health and welfare of children.
But Art Caplan sees it differently.
PS: The photo above is of Joe Cobb, the original fat kid in the Our Gang silent comedies. Interestingly, he lived to the ripe old age of 85.
