Is severe childhood obesity a life-threatening form of abuse that justifies removing a child from his or her parents?
Doctors, lawyers and child welfare experts have grappled with this question in recent years, and the debate was renewed this summer by a high-profile commentary in the Journal of the American Medical Assn. Dr. David Ludwig, director of the obesity program at Children's Hospital Boston, and Lindsey Murtagh, a research associate at the Harvard School of Public Health, argued that when children are near death due to morbid obesity, state intervention should be considered. The practice is uncommon, but it has been done in rare instances in the U.S. and abroad.
Severe childhood obesity has been shown to trigger diseases that haunt people throughout their lives, including liver dysfunction, respiratory problems and diabetes. In the most extreme cases, these diseases can prove fatal before the age of 18.
Those in favor of temporarily removing morbidly obese kids from their parents say that if social workers don't step in, children may die. Those against it say it's an overreach of government power and that the unproven benefits don't justify the trauma of removal.
Read on for two takes on the issue.
For a small number of morbidly obese children, state intervention could be lifesaving.
Dr. Norman Fost is a professor of pediatrics at the University of Wisconsin in Madison and chairman of the University of Wisconsin Hospital Ethics Committee.
The standards for state action on child obesity cases are clear: There must be a high probability of serious, imminent harm; a high probability that intervention will help; and it ought to be the last resort after all other alternatives have been tried and exhausted.
But there is a small percent of severely obese children who are going to die soon if there's no state intervention. The goal of state action is not to fix obesity — it's to prevent death in cases that are the worst of the worst, children who as best we can tell aren't going to make it to adulthood.
In 2009, I co-wrote an article on this topic in the journal Pediatrics that was triggered in part by the case of a teenage girl who was so obese that she couldn't breathe anymore. She was near death, requiring admission to an intensive care unit for mechanical ventilation. She was saved, but it was a wake-up call to her parents, and in this case they voluntarily embarked on a program that kept her out of the danger zone. The case showed how dangerous morbid obesity can become.
As a doctor, if you believe that state action is a last resort, you try everything else first: education, home health services, a nutritionist going to the home, even money to buy more healthful food. If all that fails, the child may be removed. The child may be able to stay with a relative, and he or she would have regular visits and contact with the parents. Over the course of probably three to six months, you would work on diet, and you would hope to get the child on an exercise regime.
Removing children for nutritional neglect is fairly common, but the form of nutritional neglect is usually undernutrition — children who are starving — not overnutrition. Morbid obesity is just another form of malnutrition. It doesn't require new legislation or a change in the criteria for state intervention.
A misconception is that the reason for state action is to punish parents. We do not think punitive action toward the parents is warranted or helpful. These are caring parents, and the removal is a therapeutic action to help them keep their child alive.
It is emotionally traumatic to remove a child from a home, of course, but that's true in all cases of child abuse. Even children who are severely physically abused don't want to be taken out of their homes. But it doesn't make sense to allow a child to die to avoid emotional trauma.
State intervention doesn't have proven results, and families of obese kids can learn how to help their children while they remain in their homes.
David Orentlicher is a professor at the Indiana University School of Law in Indianapolis and co-director of its Hall Center for Law and Health.
There are a few problems with the idea of state intervention in child obesity cases. One is that, in effect, we are blaming parenting for the child's obesity when we really don't understand why people become obese. There are important genetic factors, there are environmental factors, poverty plays a role — so we are singling out parents for responsibility when we don't know how much of the responsibility belongs to them.
The second thing is, if we do think that poor parenting is part of the problem, the way to address that is by working with the family and providing in-home assistance so they can correct their practices, whether it's an unhealthful diet, not enough exercise or too much TV.
What strikes me as odd about this proposal is that the proponents want to take the child out temporarily and return the child once they feel it's safe. Well, the only way they are going to make it safe is to work with the family and teach good practices, and since they are going to have to do that anyway, why take the child out? We are not taking about an abuse situation where the child could be killed at any moment. Obesity is a long-term problem, so there's no real urgency to take the kid out.
The proponents also want to reserve this for only extreme cases, but when we try to implement these kinds of policies and limit them to only the appropriate cases, it just doesn't work out. We know that decisions are sometimes made in arbitrary ways, and there are often racial and socioeconomic undertones. So removal from the home may not be done in a fair way.
In some cases, the state may be too quick to intervene. An intensive process of working with the family can take time and resources, and child protective workers often are overworked, with caseloads that are frequently too high. If putting the child in foster care is a choice that requires less time and supervisory involvement, it may be very tempting to take that path.
When a child is taken away from his or her family, it's very traumatic. So before you do that, you want to make sure you absolutely have to do it. It's a matter of what's best for the child. We know that removing a child from parents is harmful and psychologically damaging for the kid, and we don't yet know that state intervention will help with obesity, so you are weighing an almost certain harm against a speculative benefit.