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.
July 16th, 2011 | 4:25 pm
If we’re talking about morbid obesity at the 99th percentile then I can understand how, if parenting practices (rather than underlying medical problems) are the cause, that COULD be construed as child abuse. But would I want it to be? The problem, as you say, is where to draw the line. Will we be risking “endangerment creep,” in which the criteria broaden over the years to include whitewater rafting, or potentially hazardous contact sports such as boxing, wrestling and football? Will the parents of some Little League player who gets beaned by a bad pitch be accused of endangering their child’s welfare by letting him play? As they say, the road to hell is paved with good intentions. Maybe we should leave well enough alone.
HW
jb Reply:
July 16th, 2011 at 7:20 pm
@HistoryWriter, I agree.
Susan Reply:
July 17th, 2011 at 11:41 am
@HistoryWriter,
Well stated. I would like to know what “The State” has in mind for providing adult health literacy education.
July 16th, 2011 | 7:48 pm
I AGREE WITH HW.
*If* there were extremely strict protocols in place that included a program that worked extensively with parents to help them to gain access to, and understanding of, nutritious food, and *parents had these things* AND there were interventions for behavioral and disciplinary helps for the family AND THE FAMILY REFUSED ALL HELP… THEN I can see possibly, maybe considering removal of a *seriously ill* child.
But only in those circumstances.
July 17th, 2011 | 7:25 am
I agree with HW–for the first time in history!
The State makes a lousy parent–we must proceed with utmost caution in the amount of meddling we will allow it to do in family life. Better to spend the energy supporting true family life, eg by honoring religious freedom, letting the Church help families form and flourish, and maybe even embracing marriage prep programs such as Texas’ Twogether in Texas.
And of course, by rejecting counterfeit forms of marriage and family, such as “gay marriage” or the adoption of children by homosexual couples.
(Whoops, I guess my agreement with HW was limited and short-lived!)
HCM Reply:
July 17th, 2011 at 7:29 pm
@Joe DeVet, So you’ll support a system of rule that has led to countless LGBT suicides throughout history? That’s not morality; that’s blind, dogmatic obedience to authority.
QED.
And for the record, we now have evidence showing that lesbian couples make better parents:
http://www.time.com/time/health/article/0,8599,1994480,00.html
http://www.boxturtlebulletin.com/2010/06/07/23300
Wesley J. Smith Reply:
July 17th, 2011 at 7:48 pm
Enough already. This isn’t about gay parents or gay anything. I won’t post comments that go there on this thread from hereon out.
HCM Reply:
July 17th, 2011 at 11:32 pm
@Wesley J. Smith, My apologies, Wesley. I couldn’t resist.
Wesley J. Smith Reply:
July 17th, 2011 at 11:40 pm
Obsolvo, but next time resist. Thanks.
HCM Reply:
July 18th, 2011 at 2:28 am
@Wesley J. Smith, Thanks Wesley. I will do so. :)
July 17th, 2011 | 2:38 pm
Obesity alone doesn’t constitute child abuse.
Many genetic and/or psychological conditions can lead to obesity. That doesn’t mean US orphanages should get any larger simply because of it.
Education, I feel, is the answer. Teach children how to make their own meals, and about the RDI’s healthy dietary standards, and we’d likely see a rapid drop in childhood obesity.
Now, if parents offer children nothing except Mickey D’s, we might have a case to take children away from their parents.
July 17th, 2011 | 5:35 pm
I just read a comment on this topic at the Baltimore Sun. The commenter said, “Moral or not, I don’t care,” then went on to say he didn’t want to have to foot the bill for diabetes treatments for this future Medicaid recipient.
HCM Reply:
July 17th, 2011 at 7:30 pm
@holyterror, That’s callous and putrid. Most people don’t desire to be that obese. And even if they are, it’s a stretch to immediately assume that their juvenile diabetes was due solely to overeating.
holyterror Reply:
July 17th, 2011 at 9:18 pm
@HCM, I agree with you. That kind of thinking is disgusting for many reasons.
HCM Reply:
July 17th, 2011 at 11:33 pm
@holyterror, Indeed. A bean-counter approach towards health, life and death is never good for anyone.
Except super-healthy bean counters, of course. Excuse me while I gag myself and lose the meals of the last 24 hours.
pentamom Reply:
July 18th, 2011 at 10:38 am
@holyterror, Besides being reprehensible, it’s stupid. Does the poster think foster care is cheaper than diabetes treatment?
Wesley J. Smith Reply:
July 18th, 2011 at 10:43 am
Do you people read the post or the original article? If parents let a 12 year old weigh, say, 300 pounds, shouldn’t something be done–just as we would if the child weighed 75 pounds? The problem is that the actual practice would not be limited to tiny subset the authors identified. But their article is entirely reasonable.
holyterror Reply:
July 18th, 2011 at 11:54 am
@Wesley J. Smith, If a child weighs 75 pounds and is not that way due to chemotherapy or some other identifiable medical history, then the issue is a simple one: not getting enough food.
But obesity is much, much more complex in its origin. For example, I live in Baltimore city where, in some neighborhoods, the responsible caretaker does not allow his/her child to go outside during the day or night because it is too dangerous. In the same neighborhood you will also have the problem of a lack of access to fresh foods (no supermarkets will set up in the neighborhood), and generational misunderstanding of food and nutrition. Add to this lack of money to afford nutritious food and/or lack of time to prepare said food, and you have a whole host of factors that equal a situation which is not one of direct neglect, but more of a parent just doing their best…and in this case it isn’t “good enough” to make a child healthy as possible.
July 17th, 2011 | 9:35 pm
The interesting thing about this topic is something that no one is discussing: morbidly obese children get their food from their parents. I don’t know enough about the problem to have an opinion (a rare admission on a blog!) but I do know that unless kids have an independent income and access to a store, they can’t eat what isn’t in the house. Sure, kids can become fat by eating too much junk food and snacks, some of which they might purchase themselves. But truly morbid obesity requires a LOT of food. What is the reason that parents will buy it?
HCM Reply:
July 17th, 2011 at 11:56 pm
@Gail F, Perhap it’s just another way to keep children quiet (like substituting TV for a babysitter).
Nothing that can’t be fixed with parental education courses. :)
July 18th, 2011 | 2:01 pm
It would have been nice for the article to delve deeper into the states that have the framework for it. In dilemmas like this where the dividing line between action and inaction is very vague, it would be helpful to see where the states draw the line and if they have “mission creep” issues or they have window dressing regulations that are completely ineffective or hard to enforce… the beauty of federalism!
July 19th, 2011 | 7:20 am
It seems to me the policies are already in place for this.
The state needs to use the least intrusive method – that means educating the whole family, either by setting up behavioral classes (and/)or by having a worker go into the home and give one-on-one assistance.
Only if the parents refuse to cooperate should taking the child out of the home even be considered.
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