In order to illustrate our analysis, we use examples of different measures, selected from a wide range, varying from very general information to the public, to increasing the possibilities to adopt a more healthy lifestyle, to interference with family eating habits. Across this range, the ethical issues and balancing will be different. Some measures may not give rise to grave, or even any, ethical worries (e.g., increasing traffic safety in order to enable children to walk or cycle to school) whereas others are more difficult. We focus on the complex ones. Think of putting children on a weighing scale in front of their classmates during physical education lessons, health promotion campaigns with a negative and stigmatizing message about overweight, banning all unhealthy snacks that pupils bring from home (even sugared muesli bars),⁴ forcing overweight children to participate in classes or even summer camps for weight loss,⁵ and advising stomach surgery and weight-loss pills for obese children.⁶

We suggest six ethical issues that should be discussed before a program is launched. The aim of our endeavor is to stimulate and structure the debate on the ethical implications. We do not think that “prefab” ethical answers that everyone will agree with exist.

In the background are three general ethical themes: the effects of moral panics; responsibility; and children’s right to protection from unhealthy commercial influences. Before discussing the six issues, we offer some remarks on these background themes. The first two background themes are discussed briefly. The third issue will be elaborated more extensively, since this is a central topic in the current debate.

A factor that complicates the ethical debate, but also lies at the heart of it, is the sense of urgency that sometimes borders on panic. Children are growing fatter – many children all over the world – and they will suffer the consequences. The spectre has been raised that whole generations will die younger and be outlived by their parents. This has led policy makers to identify childhood obesity as an important and urgent policy priority. In one sense, this identification is correct. Doing something about the problem is urgent; doing nothing would be forsaking our duty to protect the affected and at-risk children. But overstating the urgency, on the other hand, might also incline us to become less critical about evidence and about respecting important moral constraints when it comes to interference with lifestyles. The view that, “We have to do something now. Doing nothing is not an option” may blind us to the fact that doing something where we have very little evidence that it works is, apart from in a political sense, unlikely to be much better than doing nothing. And we also have to remember that doing something without sufficient evidence may later be proved to be a bad idea. A balance is necessary, but certainly difficult.

Underlying many ethical issues in the obesity debate (such as stigmatization, justice and interference) is a fundamental debate concerning responsibility. Whose fault is it anyway? Who is to blame – the individual or his obesogenic environment (with lazy or opportunistic governments, industries who only want to sell their fattening products to gullible people etc.)?

But framing the question this way exposes it as a false dichotomy. The responsibility question is very hard and it cannot be answered by positing just two sets of actors with possible responsibility and then demanding a choice between them. The causal network leading to obesity in the individual child is almost always complex, and the more general causal network creating the observed increase in childhood obesity is even more complex and spans many sectors of society, including the family, the education system, the food industry, the media, the transport sector, designers of the built environment, the government and others. There is no good reason to apportion primary responsibility for the childhood obesity problem to only one of these sectors.⁷ All are to some degree responsible and all have to be ready to implement some changes. It may well be the case that parental behavior and habits are the main causal factors in most individual cases of childhood obesity, but that does not imply that parental behavior is the only or even most legitimate target for intervention. The cumulative effect of small causal contributions to many individual cases of obesity can justify targeting interventions at, for instance, soft drinks companies.

This complex causal network has led to busy washing of dirty hands, to the competition of measuring blame (“I’m to blame but he is more to blame” etc.) and to games of responsibility ping pong: “It is not me. No, it is you”. For instance, the American campaign “Parents step up” focuses exclusively on parental responsibility. To quote from its television spot: “How could you let your kid be so overweight? … He could get diabetes or cancer or heart disease. And don’t blame it on videogames or fast food, you’ re letting him down as a parent.”⁸

Sometimes those who are blamed but feel they are unjustly blamed or exclusively blamed whereas others are as blameworthy, translate this into responsibility for the future. (“If I’m only 5% to blame, then I only have to contribute 5% to the solution.”) This obviously does not contribute to any solution. It distracts. The debate would profit from focusing on responsibility for contributions to solving the problem rather arguing about responsibility for causing the problem and blame and retribution.

Children have a right to be protected against unhealthy influences. The precise scope of this right is difficult to determine because of the wide spectrum of types of such influences.

However, if childhood obesity is a public health problem of such a magnitude that it justifies intervention in family life, it probably also justifies measures affecting companies. In modern societies, the freedom of action of commercial actors is circumscribed in many ways and the relevant question is, therefore, not whether such circumscription is ever warranted, but under what circumstances and for what purposes it can be justified.

Community-based interventions in relation to childhood obesity may target commercial actors like food producers, food retailers or the media. This may include measures such as differential sales taxes on high energy foods, planning requirements restricting the site of certain kinds of food outlets in relation to schools or sports fields, or specific labeling requirements. The more intrusive those measures are, the stronger the requirement that they are evidence-based.

Research suggests that up to 80% of today’s children have diets that are considered “poor” or “in need of improvement”.⁹ According to the Global Prevention Alliance, it is widely acknowledged that marketing plays a significant role in determining children’s dietary behavior and preferences, thereby undermining the objectives of the WHO Global Strategy on Diet, Physical Activity and Health.¹⁰ Parents are misinformed by confusing information about the health value of food products. And children (who influence household purchase decisions at an estimated value of $500 billion annually) are tempted through commercial messages from children’s icons and brightly colored packages that often include toys.¹¹ The strong negative influence on children’s diets, suggests that marketing aimed at children should be circumscribed.

Some people argue that the problem is not so much about misleading information, but about people’s lack of equipment to distinguish facts about nutrition from fiction. Therefore, one should empower children and parents to cope with the temptations that will always be present in a commercial society, among other things, by providing correct information about nutritional value.

Others, however, stress that it is an illusion to think that information provided by governments and consumer organizations can ever counter the effect of information provided by the food industry, as the budget of the latter is extremely small compared to that of the former.

To what extent can we restrict the promotion of unhealthy behavior by corporations? The level of marketing restrictions that is accepted by the public and is morally justifiable is different for different types of unhealthy behavior. With regard to smoking tobacco, current health policy is probably most restrictive. In many countries, commercials are completely banned. Marketing strategies to promote alcoholic beverages are generally not as strict: commercial messages are permitted, provided that they contain a warning message about health risks. However, with regard to foods and beverages that are high in saturated fat, sugar and salt, but of poor nutritional quality, there is hardly any boundary to the freedom of corporations. Most countries seem to accept misleading messages about the health value of products (“consuming this light drink is equivalent to going to the gym”) and allow the promotion of chocolates, potato chips, soft drinks and large fast food meals. It is quite unthinkable that a ban on eating hamburgers or oversized ice creams in public spaces would be accepted at the present time. Why are some marketing strategies that promote unhealthy behavior granted more freedom than others?

The willingness to accept restrictions is influenced by the awareness of health risks. Twenty years ago, even non-smokers opposed paternalistic anti-tobacco measures. But now that the health risks of smoking are common knowledge, the current strict non-smoking policy evokes less criticism. The idea that food products rich in saturated fats and sugars pose a threat to our health is relatively new. It will take time for society to become fully aware of the urgency of the problem. The growing public awareness will surely influence the arguments about (unjustified) paternal-istic meddling in commercial freedom.

Restrictive policy is also more easily accepted if an unhealthy behavior comes to be understood as non-essential or even unnecessary behavior. Whereas cigarettes and alcoholic beverages are “luxury products”, eating is a primary need in life. It would be absurd to stop corporations from marketing and selling food products altogether. Admittedly, having breakfast with a bottle of cola and a king-size bag of chips cannot be considered necessary at all. But with regard to many food products, it is difficult to draw the line between necessary products with nutritional value and luxury products, which are bad for health. Is butter healthy or unhealthy? What about strawberry yoghurt, for example? Should we only allow commercials for sugar-free cereals and mineral water? The necessity of eating and the difficulty in drawing a clear line between healthy and unhealthy food may be a reason why food policy is not as restrictive as anti-smoking policy.

A third reason for restricting the promotion of some behavior more than others involves harm to other people. Smokers and drunken persons pose a threat to their environment. Consuming junk food and soft drinks is not dangerous for others. I do not get diabetes if my neighbor is a junk food addict. But, so one could argue: there are other costs involved, such as increased costs of the health care system. We will not go into that argument here,^12,13 but do want to mention that such harms are of a very different nature, compared to direct threats to the health and the safety of third parties.

The promotion of unhealthy products poses a specific threat to children. Children are vulnerable to influences from their environment. It is often more difficult for them to separate fact from fiction in commercial messages. They are not capable of making autonomous choices about their lifestyle. They are, to a great extent, dependent on their parents, who are also misled by commercial information. The vulnerable position of children provides a good reason for restricting the marketing of products that are high in saturated fat, sugar and salt, either directly targeted at children or via their parents. This was recognized in December 2007 when eleven major European food and beverage companies announced a common commitment to change the way they advertise to children. They declared that they would neither advertise food and beverage products in primary schools, nor to children under the age of 12 (except for products that fulfil specific nutrition criteria).¹⁴

So far we have covered the background themes. In the following sections we explore some ethical issues that should be raised, analysed and thoroughly discussed before implementing interventions to prevent childhood obesity.

The first issue concerns evidence and good reasons:

Do we have enough evidence or good reasons to support the proposed program?

No conclusive evidence is available on the effectiveness of most measures to promote healthy behavior, but recent reports from (among others) WHO have stated that the urgency of the problem makes waiting for such evidence undesirable.¹⁵ Although this strategy is based on sound reasons, we should ensure that in the process of implementing interventions we are not over pressured by government, or panic, or by some other pressure because something has to be done now.

The less clear the benefits of a campaign are, the stronger the moral burdens weigh. This raises important questions regarding effectiveness. Is a campaign only effective if it creates weight loss? Or when it creates awareness? Or should it make people feel happier about their weight? How sure must we be about the effectiveness of a measure before implementing it? These are important issues to think about. It is important to realize that an intervention always creates costs, in financial terms but also in moral terms, by intervening in lifestyle. The benefits have to outweigh the burdens.

But in many cases we are not sure about the effectiveness and this does not automatically mean that a campaign should be stopped. In June 2007 government funding for a Dutch clinic for obese children was stopped because politicians claimed it was too costly to proceed without evidence. But others argued that as long as scientific evidence for long-term effects was lacking, we should rely on experiences, which suggested effectiveness. Accordingly, the project had to continue precisely to gather scientific evidence.¹⁶ More generally, there is an obligation to rigorously evaluate the effectiveness of interventions for which there is currently little evidence, so that the evidence base can be improved over time.

The second issue is stigmatization:

Does the program or intervention target obesity as a state of being or the underlying behavior? What are the consequences in terms of possible stigmatization?

Targeting obesity and the creation of stigma

Overweight and obese children face stigmatization every single day of their lives. They are bullied, laughed at, called names and associated with bad moral character traits (being lazy, stupid etc.). In thinking about interventions for treatment and prevention of obesity it is important to note that they must necessarily differ from interventions aimed at reducing tobacco use or excessive consumption of alcohol. Obesity is a state, not a behavior, and whereas the action of smoking can be targeted directly (e.g., it can be prohibited in public places) targeting obesity would target the obese person, not the behaviors leading to obesity. Focusing on obesity directly, instead of on behaviors that are healthy whether or not a person is obese (e.g., physical activity, eating a balanced diet) may increase the social stigma already attached to obesity.

Those measures that aim to promote a healthy lifestyle in general, without focusing on overweight or emphasizing obesity, are often more acceptable, not only from the point of view of stigmatization but also from the perspective of fairness, as all participants may benefit from such measures. Healthy lifestyles are, after all, also healthy for slim children. We are aware that this can be used as a sham argument: pretending that “of course it is not focusing on over-weight”, although actually it is.

Targeting vulnerable groups is also sensitive from the stigmatization angle. (“You get breakfast at school because your parents don’t care for you and they are poor.”) Special attention to the justification and possible effects is necessary. Targeting, however, may sometimes be necessary, even ethically required, in order to reach persons and groups that will not be reached by general measures or programs. For American Indian and Alaska Native children, The American National Centre for Chronic Disease Prevention and Health Promotion designed “The Eagle’s Books” program. To quote from the program: “The eagle represents balance, courage, healing, strength and wisdom, and is seen as a messenger or a teacher. In the Eagle Book series, the wise bird teaches children how to use these values to prevent diabetes and grow safe and strong. … Mr. Eagle reminds the young boy of the healthy ways of his ancestors.”¹⁷

Will children across the whole BMI range profit from the measure (even if they do not lose weight) because the proposed measure increases their possibilities/options for a healthier lifestyle? Or will they just hear that they are too heavy?

Measures to do something about obesity might reinforce stigmatization as, whatever measures are proposed, the underlying idea is that children should not be overweight and certainly not fat. What does this mean for those who already are fat, for example, children that are born in families where everyone has been obese for generations and did very well, thank you? What price will such children pay if the strongly promoted image is that one should not be overweight? Take, for example, the Singaporean “Trim and fit” campaign, which mentions on its website that over-weight children “tend to be clumsy”. Parents are informed that “trim and fit children” are not only healthier and feel better, but also look better.¹⁸

Programs like “Epode”, the French cities that aim to be a motivating environment for a healthy lifestyle,¹⁹ are interesting examples of programs that would provide positive answers to the above questions. Another positive example is the “Kids in balance” campaign from the Netherlands, which offers workshops to promote an active lifestyle for children. It stresses emotional health, instead of focusing on overweight. To quote from the program: “Feeling good about yourself, being emotionally fit, is just as important as eating brown bread and doing sports!” Those who do not lose weight but do develop a healthier lifestyle are not stigmatized as the “losers”, “the ones for whom the program did not work”.²⁰

Several experts argue that negative, stigmatizing and scary campaigns are not only ethically problematic but also ineffective. Instead, people need positive tools and motivation to work on behavior change.

The third cluster of questions has to do with parents.

In some cases, individual parental involvement is not an issue as the measure is on a very general level, for example, restricting commercials for sweets on television at certain hours. Parents are involved in a general way as citizens, of course, but not in a more personal, individual way. Other interventions, however, do involve the individual parents. After all, programs directed at informing children about a healthy diet and the importance of physical exercise are unlikely to be sufficient as long as the parents are not involved. What is the use of knowing that vegetables contain vitamins when all that is ever offered at home are French fries?

Is it possible to inform and/or involve parents without undermining their parental autonomy? Can they be involved in a respectful way? Can they be convinced instead of overruled or bypassed?

Interventions that involve the individual parents vary from cooking classes in the local supermarket to supervision from social workers in families, or even putting obese children into care.²¹ The balance between parental autonomy and the interests of the child, in particular with regard to health, is an important area of the ethical debate. It is an issue that is debated in many different fields: from child abuse, refusal of vaccination, school and leisure, to choices of diet. Parents need (and have the right) to raise their children in their own way, according to their views on what is proper or good for children. Interference against their will is controlled and limited to serious cases where the interests of a child leave no other option. What can be done if parents do not provide breakfast, give the child some money to buy a hamburger for breakfast and the kitchen is stocked with soft drinks and junk food, whereas apples are considered to be something exotic that led to dire consequences in paradise, anyway?

Programs can also involve parents in a harmless way, such as the Australian “Walking school bus” campaign, where parents take turns to accompany their children to school.²² There are programs where schools provide what the parents do not provide, compensating for what is absent at home: for example, breakfast in the classroom, tasting classes, cooking classes, subsidized fruit and vegetables during school breaks.

And programs are often directed at informing the parents. Take, for example, the “Hello World!” campaign that provides information for future parents, such as health quizzes by email that can be stopped if they are unwelcome.²³ This kind of campaign enables parents, or is aimed at enabling them, with the possibilities to provide themselves what is good for their child. They may already know, but might simply not manage.

Are parents’ arguments and reasons for having a particular lifestyle analysed and taken seriously?

Many, probably most, parents do want the best for their children and are not a priori against information and options to do the best for their children.

What if parents just do not change their lifestyle? Think of parents who during lunchtime brought their children hamburgers because they thought the lunches provided by Jamie Oliver, the well-known television cook who is campaigning for healthy food for young people in the UK, were not good, not enough, not good enough for their children. Is their right to respect for parental autonomy undermined by what seems to be a lack of responsibility? An answer to this question will, at least partly, depend on why the parents behaved in this way. Had they been involved in discussions about the changes to the school meals, had their views been taken into account, had the children been involved, and so forth? The fact that parents or children react against imposed policies is only a sign of irresponsibility if they have at least been engaged in discussion about the policies and their rationale. To involve parents in a serious way is probably not only ethically right but also helpful from a strategic point of view.

The fourth issue has to do with the durability of proposed skills, virtues and habits:

Will the children develop skills/virtues/habits that will also serve them later in life?

In every society, in every individual life, there will be temptation. To be equipped to deal with temptation is a good thing. (And by the way does not necessarily mean that one always has to say no and never yield to temptation … to choose to yield is very different from impulsive surrender.)

In the prevention of obesity there are also virtues at stake. Self-control and carefulness and the ability to say “no” are probably the most important – skills that are also relevant in relation to use of alcohol, safe sex, internet addiction, gambling, and so on. Teaching these skills means that children can learn something they can profit from and let others profit from for the rest of their lives.

But don’t parents have the right to spoil their children and turn them into little manipulating spoiled brats (obese or not obese) if they want to? Why is self-control an important skill? It is important because people without self-control, or who are out of control, often end up in difficult and unpleasant social and emotional situations. One needs self-control in order to survive in a society, and in order for societies to survive. Self control is, to some extent, something one has to learn, from one’s parents, among others. Parents do not mind saying “no” (or rather yelling “no”) when a child is going to touch a hot stove, and the direct prevention of harm is at stake. But many parents find it more difficult when it comes to restricting or denying pleasures. However, this is something the child will have to accept in his or her life. If it is not “no” to the sweets, it will be “no” to something else. One will have to live with requests being refused from time to time.

This means that one has to illustrate the advantages of self-control: the enjoyment of tasting instead of the “mindless stuffing”, the idea that you are not the victim of habit, feeling or an urge stronger than you, but that you are the master of yourself. That is a reward in itself. Also, control is more effective if embraced rather than imposed. Self-control actually increases freedom. And it also has to be compared to the alternatives: bariatric surgery at the age of 14 is not an attractive proposition.

This does not mean that one can rely on self-control and that it is, therefore, not necessary, for example, to remove soft drinks vending machines in schools. But removing the vending machines without changing the idea that one needs gallons of soft drinks every day is not helpful either.

However, we also want to stress that the importance of engendering self-control and carefulness in relation to eating should not be conceived in an overly moral-istic frame. Many obese adults and children do exhibit self-control and carefulness even in their eating. Although they eat too much for their caloric needs they do so in a controlled way. They do not stuff themselves but have become habituated to eating large portions. So what is needed in many cases is to re-set the perception of what is a normal meal.

The fifth question concerns proportionality:

Is there a balance between the goals, the chosen methods and the possible ethical impact?

Can a certain goal be reached with less intrusive measures? For example, to take all children with a BMI above 28 out of parental care and raise them in foster families or clinics is clearly disproportional (apart from being quite unrealistic).

How can one evaluate proportionality? The Nuffield Council has designed a framework to evaluate public health measures that can be used in the debate. It is a ladder that indicates different levels of intrusiveness, from “do nothing” up to “eliminate choice”. The higher up the ladder, the more intrusive a program is and the stronger its justification needs to be.²⁴

We want to emphasize the distinction of enabling versus enforcing.

Enabling versus enforcing

Enabling means that the opportunities are provided for children and parents to choose the healthy habit or lifestyle, whereas enforcing means they have no choice. There are important arguments to prefer enabling to enforcing. The chances that a certain healthy lifestyle or certain eating habits will be integrated, incorporated or embraced is greater if people themselves learn to appreciate them and feel better, enjoy the advantages, rather than when they feel they are submitting to dictates put upon them by others as the internal motivation may then be lacking.

The sixth question regards the slippery slope:

Are the measures sensitive to the argument of the slippery slope?

The slippery slope concept is that if one measure or intervention is permitted then this will result in further, more intrusive measures being taken in the future which would then significantly infringe upon an important right or ethical principle, such as adults choosing whether to exercise or not. Fears of “1984”, total health control, or moral imperialism are enlisted in this argument along with the notion that we will all die sooner or later and that there is no point in living a frugal life with no pleasures. These slippery slope fears are often accentuated when proposed interventions are either novel or vague in their definitions and boundaries.

In many areas of public health, especially for injury prevention, tobacco control, and to some extent infectious disease control, regulations are enacted which place restrictions on individual behaviours in addition to changing the environment. Influencing personal choices regarding behaviour is also used in the prevention of overweight. This varies from the subtle pushing message “Please take the stairs” that one may encounter as health promotion notices at the base of the stairs²⁵, to employers forcing their employees to walk by locating the cafeteria far away from the office building²⁶, to imposing a ‘ fat tax’ on fattening foods²⁷, imposing higher insurance premiums for obese people²⁸ or banning cars from city centres and around schools²⁹.

With programs requiring physical exercise for obese adolescents in Singapore³⁰ and university diplomas being withheld from obese students in Pennsylvania³¹, it is understandable that people are concerned about a slippery slope in directive programs for the prevention of obesity.

Although fear of a slippery slope does not imply that there is an actual risk of a slippery slope, it is important to discuss whether enough safeguards against heading down slippery slopes have been incorporated, and whether the limits of the intervention are clearly communicated to the public.

These six issues are aimed at inspiring and structuring debate on the ethical presuppositions and goals of measures. They are not a simple set of criteria to be passed in order to have ethical “approval”.

Within the process of developing and testing interventions to prevent overweight among children, it is crucial to pay attention to their normative aspects. Ethical analysis will help to develop measures in line with values that are deeply important to many of us. That analysis is worthwhile in its own right, and may also contribute to effectiveness.