The hypothetical future thin person fallacy in healthcare

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While progress toward weight-neutrality is absolutely being made, our healthcare is predominantly based in the weight-centric paradigm. This paradigm currently considers simply existing in a higher-weight body to be a disease and weight loss to be the cure. (Now, there is no shame in having a disease, it’s just that simply existing in a larger body does not qualify.) One of the most dangerous harms within this paradigm is the hypothetical future thin person fallacy.

This claim rests on the idea that all fat people can (and should) become thin. This is absolutely not supported by evidence but it creates a healthcare system that (consciously or subconsciously,) doesn’t see  higher-weight people as valid human beings who deserve the highest-quality care now, but rather as potential future thin people who can have equal access to healthcare just as soon as they cease to exist in their current form and become thin. Thus the message becomes that they can’t offer the highest level (or sometimes any) care to a higher-weight patient, but they would be more than happy to treat the hypothetical future thin version of that patient at some unknown later date.

One example of this is healthcare research. Many of the best practices, tools, and pharmacotherapies in the healthcare system were created using research that did not include higher-weight people. Instead of rushing to fill the gaps by creating research based on higher-weight people, research continues to be created excluding higher-weight people. To add insult to injury, when these best practices, tools, and pharmacotherapies don’t work as well for higher weight people, their weight is blamed and the suggested solution is weight loss and not proper inclusion and accommodation.

Another example is facility procurement. Rather than making sure that the facility has the largest possible gowns, blood pressure cuffs (preferably troncoconical) in all the places vitals are taken, etc. there can be bare minimum efforts (the Emergency Room at this hospital doesn’t have a thigh cuff, we would have to get one from elsewhere in the hospital,) unhelpful workarounds (anyone who has ever told someone who was not accommodated by a gown to “solve” this by wearing two too-small gowns should go ahead and try that for themselves,) and more. Instead of creating the most accommodating healthcare spaces, there can be a tendency to think or outright suggest that patients who are not accommodated just need to shrink their bodies until they are.

Another example of that that can be fatal is size-based denials of care. This occurs when a healthcare procedure is denied unless or until the patient reaches a certain BMI, weight, or loses some predetermined percentage of weight. These are typically justified based on claims that higher-weight patients have higher surgical risks and/or post-surgical complication rates. There are some questions about the research used to make these claims but, even if it is true, an option would be to work hard to improve surgical tools, techniques, and aftercare for higher-weight patients. Instead the healthcare system very often demands that they, instead, become thin patients, holding their healthcare hostage for a weight loss ransom most patients won’t be able to pay.

Higher-weight people are far better served by a healthcare system that seeks to support their actual health rather than a health-care system that seeks to shrink them. Healthcare should fit the people who need it, people shouldn’t have to change themselves to fit healthcare. We must create a healthcare system from the viewpoint that higher-weight people exist, will always exist, and deserve excellent care in the bodies they currently have. 

My online workshop this month is about dealing with BMI-based denials of care for patients, providers, and advocates including the types of denials, common justifications and arguments against them, three options for dealing with the denial and the pros and cons of each, specific steps and scripting and more. 

There is a pay-what-you-can-afford option so money isn’t a barrier and all registrants will get a video of the workshop and Q&A. 

Details and registration are here.

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More Research

For a full bank of research, check out https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings: Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison: Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.