Ethics of recommending weight loss in older adults: A case study

Abstract

Healthcare professionals may confront ethical issues in practice, particularly when their values conflict with that of their patients or clients. This paper explores an ethical case study in which a dietitian who practices Health at Every Size® has an older adult client who wishes to lose weight. The dietitian believes that losing weight is inappropriate for this client. Using a framework for ethical decision making, this article explores the problem or dilemma, identifies the potential issues involved, discusses the relevant ethical codes, laws, and regulations, and explores possible courses of action and their consequences. By exploring an ethical issue that healthcare professionals may encounter in practice, we can gain a deeper understanding of ethical decision making.

Health care providers frequently deal with ethical issues. Many of these are simple, everyday issues that we encounter in our practice. ¹ These may not be what we think of as ethical dilemmas, yet they can lead to moral distress when not addressed.^2–4 Using an ethical decision-making framework to analyze an ethical case study, we can gain increased insight into everyday ethical issues, improve our practice, and reflect on the wider implications of the case at the societal level.

There are many ethical decision-making frameworks that seek to provide health care providers with guidance when dealing with an ethical dilemma.^5,6 One such framework for health care professionals is proposed by Corey, Corey, Corey, and Callanan. ⁷ The steps in their framework are as follows: (1) Identify the problem or dilemma, (2) Identify the potential ethical issues and the stakeholders involved, (3) Review relevant ethics codes and applicable laws and regulations, (4) Obtain consultation and check self-awareness, (5) Consider possible and probable courses of action, (6) Weigh the facts, ethical considerations, and potential consequences, (7) Choose what appears to be the best course of action, and (8) Implement and reassess from time to time. These steps for making ethical decisions will be used to analyze the case study presented below.

As consultation is an integral part of ethical decision making, ⁷ this case was discussed with colleagues in the Aging and Health program at Queen's University: Emily Hladkowicz (EH), Emily Gregg (EG), Stacey Hatch (SH), and Mary Beth MacLean (MBM), and also with my spouse, Keith Mills. I am indebted to them for their comments and insights, which are woven throughout the paper.

The case

Ms M is an 82-year-old woman who is a Community Health Centre client. (Note that Ms M is not an actual client, but a compilation of several clients the author has seen while practicing in primary care). She is referred by her family physician to the registered dietitian for weight management. Her blood glucose values are in the normal range, as are her lipid values (e.g. HDL, LDL, and triglycerides). She does not suffer from hypertension or any other chronic diseases. Her body mass index (BMI) is 27 kg/m².

Both Ms M and her family physician want her to lose weight. Ms M expresses a desire to be thin. Given that she is in the healthy BMI range for older adults (which extends to 27 kg/m² or even 29.9 kg/m² for those 65 years of age and older,^8,9 vs. 25 kg/m² for those 18–65 years of age), weight loss is not indicated. As the dietitian, I know that being underweight is a greater concern for older adults than being overweight. ⁹

After conducting my nutrition assessment, I determine that Ms M is not eating enough for health. I then educate Ms M on healthy BMI ranges for older adults, provide her with nutrition education regarding healthy eating using the healthy plate model, part of Canada's Food Guide. ¹⁰ I also discuss increasing her food intake to help maintain her current level of health and functioning. Ms M insists that she is eating too much and that she needs to lose weight. I discuss the concepts of Health at Every Size (HAES) ^a with her but she is unreceptive to this idea. HAES is founded upon the idea that measures of weight and size do not accurately reflect an individual's health. ¹¹ HAES promotes five principles: weight inclusivity, health enhancement, respectful care, eating for well-being, and life-enhancing movement.^11,12 Studies have shown that HAES-based interventions can improve quality of life, psychological well-being, eating behaviors, physical activity, and cardiovascular status in participants. ¹³ HAES does not suggest that all people are healthy at every size, but rather promotes the idea that “people at every size can be supported to adopt practices that will enhance their health and wellbeing” ¹² even when those practices do not result in weight loss.

After discussing HAES with the client, I mention that weight loss is difficult, and most people are unable to lose weight or maintain weight loss in the long term.^14,15 I then educate her on the physiological effects of inadequate intake and discuss what happens to the body when meals are skipped. I suggest that eating small, frequent meals can help to boost the metabolism and aid in weight loss efforts.

After the appointment, I feel uncomfortable because I have not remained true to my HAES values. I also feel that both the family physician and I are letting the client down. I am not sure the client appreciates just how difficult weight loss can be. While I chart the nutrition assessment completed and the nutrition education I provided in the client's electronic medical record, I do not discuss my thoughts with the family physician. This also leaves me feeling uneasy, as I wonder if it is because I simply want to avoid confrontation.

In the end, I feel like I neither remained true to my values nor provided the client with what she wanted.

Step 1: Identify the problem or dilemma

The core dilemma could be framed in this way: what should I do when both the client and the physician want the client to lose weight, but where I, as a HAES-informed dietitian, think that weight loss is not in the client's best interest? In this situation, I provided nutrition advice to a client that conflicted with my values, did not address her physician's concerns, and did not meet her needs. As a result, I am feeling uneasy.

As the sole dietitian on the health care team, a patient was referred to me for weight loss counseling by her family doctor. The client also wanted to lose weight. As an advocate for HAES, I believe that weight loss is neither desirable nor achievable for everyone. I thought that weight loss was inappropriate and attempted to provide general healthy eating advice. The client insisted that she needed to lose weight, and so I discussed one approach that I felt was the least harmful.

Step 2: Identify the potential ethical issues and the stakeholders involved

Potential ethical issues in this case include body image norms, sexism, ageism, interprofessional collaboration, clinician–client relationship, resource allocation, and moral distress. These will each be examined in detail below. The moral and ethical principles ⁷ of autonomy, non-maleficence, beneficence, justice, veracity, fidelity, and self-care will be discussed, where appropriate, for each issue.^7,16 The stakeholders involved include me, the client, the family physician, and society as a whole. Society is a stakeholder here as society's norms affect our choices and decisions. ¹ Our ethical values and decisions are also influenced by our contexts within society. ¹

Body image norms

One of my values as a HAES practitioner is weight inclusivity. HAES promotes size acceptance and self-care as opposed to dieting as a way to enhance health and well-being. ¹⁷ Yet society does not value larger bodies; instead body image norms value thinness. ¹⁸ The “drive for thinness is a normative obsession, particularly for women.” ¹⁹ This is a form of weight bias. ²⁰ Society expects everyone, even older women, to be thin.^21,22 Even many people who fall within the “normal” or “healthy” BMI or weight range wish to lose weight. ¹⁹ Yet weight loss is difficult, and most people who lose weight regain it within a few years.^14,15 Recommending weight loss could be seen as unethical. ²³

In discussing weight loss with the client, I am not staying true to my HAES value of weight inclusivity. Additionally, as the physician recommended weight loss to the client, beneficence is not being upheld, because weight loss is encouraged even when it will not help. In advising people to lose weight, we are doing harm, violating the principle of non-maleficence. Looking at society, justice is an issue, as people are treated differently depending on their size and shape. Many healthcare professionals display weight bias, even those who work in the field of obesity.^24,25

Sexism

Body image norms are closely tied to sexism. Women are expected to conform to society's beauty norms.^1,21,22 Many older women remain dissatisfied with their bodies, and their dissatisfaction is greater than older men's.^1,26 I find it sad that even elderly women are pressured to lose weight and be thin, even when weight loss is not medically indicated. Justice is not served, as women and men are treated differently as they age. ²¹ In this case, it is possible both the client has internalized society's norms around body image norms and sexism as she desires to lose weight.

There are numerous associations between body image and physical and mental health.^26,27 Body dissatisfaction leads to emotional distress and poor health behaviors, such as engaging in harmful dieting practices or undergoing risky cosmetic surgery procedures.^26,27 In perpetuating unrealistic body image norms for older women, society is doing harm; thus, the principle of non-maleficence is not being upheld.

Ageism

Aging is also closely tied to body image norms. “The aging and aged body has largely been devalued and feared because of its associations with frailty, loss of control, and death.” ¹ It can be difficult not to internalize these normative cultural messages that surround us. ²⁷ Yet our bodies and how we view them affect our sense of self-worth. ²² These internalized norms “may threaten an older person's autonomy.” ²⁸

Not all healthcare providers remain up to date on the assessment and treatment of older adults. This could be considered ageism. Canadian research shows that up to 58% of healthcare providers display ageist bias. ²⁹ This is a justice issue, as older adults are not treated the same as other patients. The principles of non-maleficence and beneficence are also involved. Harm might occur if a provider is not aware of the appropriate treatments for older adults. Clients cannot be appropriately helped when a provider's knowledge is not current. In this case, it is possible that the physician is not familiar with current recommendations for healthy weights for older adults.

I am also potentially being ageist myself in assuming that social norms are behind the client's desire to lose weight. My spouse raised the issue that perhaps the client has a sexual partner who is pressuring her to lose weight. I was perhaps being ageist in assuming that she would not be engaged in such a relationship. We may think of older adults as asexual, yet we remain sexual beings as we grow older. ³⁰

Interprofessional collaboration

As a HAES practitioner, I value respectful care and health enhancement. In this case, to provide respectful care and to support clients’ health enhancement, I needed to collaborate with other health care professionals. I was working as a member of an interprofessional primary health care team and should have been collaborating with the physician to provide the client with respectful and patient-centered care. Interprofessional collaboration is an essential component of patient-centered care. ³¹ Many ethical principles govern interprofessional collaboration, including beneficence and justice.^31,32 Yet each discipline can have its own values and its own ideas as to what is considered beneficence.^31,33 Such diversity has the potential to result in conflict.^31,32 It may not be possible to uphold the principle of non-maleficence when team members do not agree, as it may cause harm to the client who may not know who to trust. Fidelity can also be affected, as the client's relationship with one or more healthcare professionals may change when those professionals disagree. In this case, the physician and I disagree on the value and appropriateness of weight loss for the client.

My colleague MBM and my spouse suggested that perhaps the physician knew something that I didn't about the client. I had considered this, then dismissed it, as I had full access to the client's chart. Upon reflection, I agree it is possible the physician knew something that I didn't. The principle of veracity suggests that the physician should chart everything relevant and that I should discuss my concerns with the physician. Additionally, to maintain fidelity in our working relationship, the physician and I should both be open and honest with each other, and constructively work through any disagreements. This would allow us both to uphold beneficence and non-maleficence.

Clinician–client relationship

In addition to interprofessional relationships, respectful care involves the clinician–client relationship. One of the ethical principles involved in the clinician–client relationship is veracity, or truth-telling. ⁷ While I attempted to provide the client with the truth regarding the difficulties of weight loss, I did not emphasize that it would be inappropriate. In the end, I discussed one potential strategy to help with weight loss, while knowing it was not entirely truthful nor appropriate. This raises the question: to what degree can I provide counseling or information that may not be entirely truthful if I believe it is in the client's best interest? Not being truthful not only violates the principle of veracity, but I am being paternalistic in thinking that I know what is best for the client. ³⁴

Autonomy is another principle involved in the clinician–client relationship. Traditionally, autonomy has been upheld as the most important bioethical principle.^1,35 Clients have the right to choose and act in accordance with their wishes. ⁷ In not providing the client with the information she desired, was I was potentially interfering with her autonomy. To respect her autonomy, I should have provided the client with the information that she desired. ³⁶ The principle of fidelity also comes into play. A productive working relationship is built on trust. ⁷ Even though I provided the client with appropriate nutrition education, it is likely that I did not effectively establish rapport and engender trust in my advice, as the client was not receptive to many of the ideas discussed.

Informed consent is also involved. It can be considered an example of autonomy in action. ³⁷ In order for consent to be informed, an individual needs to be able to understand and evaluate the pertinent information.^37,38 When it comes to clients who wish to lose weight, Connors and Melcher argue that they need to be informed of the “possible physical and psychological consequences.” ¹⁹ In this case, I am not sure that informed consent was truly obtained, as the client did not appear to understand the messages I was trying to convey. I also did not disclose all the potential adverse outcomes of attempting to lose weight.

The client's values also need to be considered. Perhaps the client greatly values her appearance, and in trying to dissuade her from attempting to lose weight, I am doing harm. In an attempt to do no harm (non-maleficence), I could actually be inflicting greater harm, whether psychological, relational, or otherwise. In trying to do good (beneficence) I could be doing the exact opposite. In discussing HAES, I could be doing harm by asking the client to confront society's norms around body image, gender, and aging.

My colleagues indicated that the clinician–client relationship between the family physician and the client also needs to be considered. Health care providers, especially physicians, have more power than clients, even when care is provided in a client-centered manner.^37,39 Perhaps the client believes she needs to lose weight because the physician indicated that this was necessary. Is the client's choice truly her own in such a situation? Feminist ethics suggests it is not truly her own choice, as our decisions are influenced by our relationships and our contexts.^1,37

Resource allocation

Another of my HAES values is health enhancement, which involves supporting and developing health services that equalize access to health services and information. In this case, due to human resources and funding constraints, I was the only dietitian on the team. I was not able to transfer care to another dietitian who might have better met the client's needs, thus I was not upholding my value of health enhancement. Additionally, nutrition assessment appointments were limited to 60 min. Perhaps if I had more time with the client, I could have done a better job of establishing rapport, building a trusting relationship, and genuinely listening to the client's concerns. With such limited time, however, I was unable to delve deeply into the client's weight concerns.

There are many principles involved with resource allocation, but the primary among them is justice, both procedural and distributive justice. Concerning procedural justice, by not having access to a different dietitian, the client may not have been receiving the best quality care. Perhaps, a dietitian with a more weight-focused lens would have provided her with the care that more closely met her needs. Distributive justice is also involved, as time with the dietitian was a scarce resource; this limited the amount of time I was able to spend with the client.

Moral distress

Moral distress is defined by Campbell, Ulrich, and Grady as “one or more negative self-directed emotions or attitudes that arise in response to one's perceived involvement in a situation that one perceives to be morally undesirable.” ³ In this case, I felt uneasy because I neither held true to my values nor did I provide appropriate care. Additionally, moral distress can arise when not all members of the healthcare team can agree upon goals or on what is best for the patient.^31,40 Disagreeing with the physician may have contributed to my moral distress.

The principle of self-care is important when dealing with moral distress. ⁴¹ Self-care “involves taking adequate care of ourselves so that we are able to implement the moral principles and virtues that are fundamental ethical concepts.” ⁷ Self-care, in the form of physical activity, healthy eating, and reflection, have always been a component of my practice.

Step 3: Review relevant ethics codes and applicable laws and regulations

Multiple laws govern the practice of dietetics in Ontario, where I practice. Among these are provincial laws, including the Regulated Health Professions Act (1991), the Dietetics Act (1991), the Health Care Consent Act (1996), and the Personal Health Information Protection Act (2004). Federally, dietitians must practice in accordance with the Personal Information Protection and Electronic Documents Act (2000). There are also standards, guidelines, and policies to which dietitians should or must adhere. ⁴² The Jurisprudence Handbook for Dietitians in Ontario provides dietitians with both ethical guidance and outlines their responsibilities under the law. ⁴³

The dietetic profession in Canada has a code of ethics that outlines a dietitian's responsibilities. ⁴⁴ The Code of Ethics for the Dietetic Profession in Canada “sets out the ideals that guide dietitians.” ⁴³ This code is aspirational, as opposed to prescriptive. ⁷ Additionally, the College of Dietitians of Ontario also has a code of ethics. ⁴⁵ This code of ethics clearly articulates four ethical principles: respect for autonomy, beneficence, non-maleficence, and justice. ⁴⁵ A dietitian should ensure that they “collaborate with interprofessional colleagues, participate in and contribute to decisions that affect the well-being of clients.” ⁴⁵

Step 4: Obtain consultation and check self-awareness

In this case, I consulted with my peers and my spouse while completing this ethical analysis. In practice, I could discuss my concerns with other dietitians, including other HAES practitioners. Additionally, dietetics colleges have advisory services that provide guidance to clinicians dealing with ethical issues.

In terms of self-awareness, I need to consider my values. As a HAES practitioner, Connors and Melcher state that “it is crucial, first, that health care professionals understand the meaning of fatness in the culture and come to terms with its personal impact in their own lives, so that they can effectively apply this knowledge to their work.” ¹⁹ In analyzing this case study, I have gained a deeper appreciation for the fact that we are all influenced by society's norms, and these norms are extremely hard to challenge. While I try to embrace the HAES principles in my dietetic practice, I am nevertheless terrified of gaining weight and becoming “fat” myself. If I am unable to apply HAES principles in my own life, can I genuinely embody HAES values in my practice? This is something I need to continue to investigate and reflect upon.

Steps 5 and 6: Consider possible and probable courses of action and weigh the facts, ethical considerations, and potential consequences

A few possible and probable courses of action will be discussed, as well as their ethical considerations and potential consequences.

Proceed as I did. As this resulted in moral distress and did not live up to the aspirations outlined in the Code of Ethics, ⁴⁴ I would not proceed in the same manner again.

I could have a discussion with the family physician and other relevant members of the healthcare team. I could provide education on healthy BMI ranges for older adults ⁴⁶ and introduce HAES. ¹² I could provide evidence that diets are inappropriate for older adults. ⁴⁷ This would be in line with accepted practices.^32,45 As EH indicated, sending a note to the family physician would be a good first step, in line with the College of Dietitians of Ontario's Code of Ethics. ⁴⁵ A communicative ethics approach could be used. Such an ethic “based on deliberation and negotiation and leading to improved communication, clarification, and consensus-building” ³² can be useful when different disciplines hold dissimilar values. The physician could be receptive, improving their care of older adults. This would uphold the principles of beneficence and non-maleficence, as older adults would receive appropriate care. Justice would also be upheld, as older adults would be treated no differently from younger individuals. Alternatively, the physician could reject the information provided and continue to practice as before. Our working relationship could be adversely affected if they no longer considered me a reliable practitioner. They could stop referring patients to me, impacting the care of clients who could benefit from nutritional counseling. If such patients were no longer referred to me, the principles of beneficence and non-maleficence would not be upheld, as clients would not be receiving appropriate nutrition care.

I could advocate to spend more time with the client. This would allow time to discuss HAES in more detail and outline why weight loss would not be appropriate. I could fully describe the potential consequences of attempting to lose weight. Using a narrative ethics approach,^1,48 I could listen to the client's story and delve into why she wanted to lose weight. I could seek to understand what she truly values. ⁴⁹ In understanding why the client wanted to lose weight, I could either address those issues myself (if it were within the dietetic scope of practice) or could make a referral to a more appropriate member of the team (i.e. social work). Recognizing that autonomy is relational, ¹ I could address how both my actions and those of the client affect us. We could discuss how society's norms affect our choices and decisions. ¹ EH emphasized the importance of making my values explicit with such an approach. The College of Dietitians of Ontario states that I should “inform my client when personal values prevent the recommendation of some form of therapy.” ⁵⁰ Here, my HAES values prevent a weight loss recommendation. Communicative ethics would support informed consent by making sure the client was “part of the decision-making team for the resolution of issues and dilemmas.” ¹ With this approach, the client could feel truly heard and appreciated. The client could conclude that she did not want to pursue weight loss. Alternatively, she could continue to want to lose weight but have a better understanding of the reasons why and the potential negative outcomes. This course of action would uphold the principles of veracity and fidelity, as I would have more time to both build rapport with the client and present her with the truth about weight loss. However, justice could be negatively affected, as taking more time with this client could result in insufficient time available for other clients.

On a societal level, I could continue to promote HAES principles by engaging on social media, holding workshops, writing blog posts, and delivering in-service workshops. I could discuss why a focus on weight loss is harmful, not just for older adults, but for people in general. This could help change the discourse around body image norms with the hope that more individuals would accept a wider diversity of body shapes and sizes. I could also work to combat ageism, as “it is the social views on aging and the old that ought to change.” ⁵¹ Those working with older adults can help change the discourse around the value that older individuals possess, emphasizing the intrinsic value that each person holds by merely being alive. ¹ Potential outcomes of this approach include helping to change society's norms around bodyweight and aging. This could positively affect individuals if they are able to challenge society's norms and adopt a healthier self-image. I could also be opening myself up to criticism from others who adhere to society's norms. It could affect my future career prospects if an employer, who either strongly believes in current norms or who agrees with my position, comes across my views. On a societal level, I would be upholding the ethical principles of beneficence, non-maleficence, veracity, and justice.

Several colleagues suggested that I could offer to follow up with the client. I typically follow up with clients, so I assume in this case the client declined this offer. Had she acquiesced, I could have used a narrative approach as outlined in option 3.

My colleagues also mentioned that professional colleges typically have an advisory service that provides guidance to clinicians dealing with ethical issues. The College of Dietitians of Ontario has one as well that responds to “inquiries about the standards, laws, and ethics that impact dietetic practice.” ⁵² Therefore, one alternative would be to call the advisory service anonymously and ask them for their thoughts on the issue. Outcomes of this consultation could include greater confidence in proceeding with one or more of the above options, and greater clarity on my duties as a dietitian. This course of action would support the ethical principle of self-care.

I could engage in more than one of the above options.

Step 7: Choose what appears to be the best course of action

Corey and colleagues suggest that health care professionals should evaluate all the information that they have gathered and the feedback that they have received through consultation when choosing the best course of action. ⁷ They also recommend considering how that course of action fits with the code of ethics for your profession, whether it considers the client's experiences, how others might view your actions, and what you learned from the ethical dilemma. ⁷

In this paper, I have explored the ethical issues and principles involved in the case, obtained feedback from colleagues, and examined the code of ethics for dietitians practicing in Canada. A combination of the alternative courses of action proposed may well have been the best approach to take. I could have a discussion with the physician, to determine whether there was any information about the client I should know and to educate the physician on appropriate weights for older adults. I could also offer the client a follow-up appointment and use a narrative ethics approach to try to understand the client's wants and needs. On a societal level, I could continue to promote HAES and combat ageism.

Step 8: Implement and reassess from time to time

If I am faced with a similar situation again, I would implement the best course of action as described and then assess the outcomes. Just as reassessment is part of the nutrition care process, ⁵³ it is also an essential component of ethical decision making.

Discussion

This case has been analyzed with only one of many different frameworks for ethical decision making that are available to guide health care professionals. This particular framework was chosen because it applies to all of the “helping professions” ⁷ and dietetics is one of many helping health care professions. This framework outlined clear steps to use when analyzing an ethical issue and provided me with an opportunity to reflect on an ethical issue that commonly occurs in practice. However, other frameworks include different or additional steps, and using a different framework would have resulted in a different analysis.

Additionally, while research has shown that the use of ethical decision-making frameworks can help improve ethical decision-making ability and quality, these frameworks do not take into account that decision making is a complex process.^5,6 Also, despite their frequent use and recommendation, these frameworks have not been extensively studied. ⁶ It is also possible that, despite my consultation with colleagues, other health care professionals could have come up with additional ethical issues and courses of action that could have been taken. No single code of ethics or ethical decision-making framework can provide all the answers to ethical dilemmas.^6,54

Conclusion

Through this analysis, I have gained a deeper understanding of the importance of ethical issues in everyday encounters with clients. Ethics is not something that is explicitly taught in dietetics programs. ⁵⁵ I now appreciate that ethical principles need to be weighed whenever dealing with clients, particularly when their values are different from my own.

This case shows that there are many issues involved, including ones at the societal level. Healthcare professionals need to confront their own assumptions, ideas, and biases when dealing with clients and with other members of the healthcare team. It is not merely enough to try to do good; dietitians need to remember that good is not universally defined. Healthcare providers need to consider that clients and other healthcare professionals may hold different values.

Healthcare professionals could also consider the value and importance of a communicative or narrative approach. This “has the capacity to reveal what matters most to elders.” ¹ It can help us identify “our core values, beliefs, needs, and identities” ¹ and enable us to challenge social norms associated with aging. While Holstein and colleagues state that “older women must find ways to develop and maintain positive bodily attitudes,” ¹ perhaps it is too much to expect that those who are already marginalized can challenge the dominant discourse. Those of us who hold more power may need to speak out against harmful ageist norms.

Some healthcare professionals may equate autonomy with choice and informed consent. However, autonomy is contextual and relational. “The proper understanding of autonomy involves appreciating how individuals are interconnected.” ⁵⁶ Relational autonomy also “takes into account the effect that external factors have upon the individual.” ¹ None of our decisions are made in a vacuum; we are influenced by our relationships and our social and cultural contexts.

This case study has examined ethical issues and explored one approach to ethical decision making. It has revealed how viewing autonomy as relational can be useful. When confronted with ethical issues in practice, using an ethical decision-making process such as the one used here can help healthcare professionals decide on the best course of action, one that upholds both their values and those of their clients.