More than a-third of all Americans are obese.¹

Morbid obesity, variously defined as either BMI > 40kg/m² or BMI > 35kg/m² with obesity-related health problems² is a modern plague in most industrialized societies. This obesity epidemic presents both practical and ethical challenges to the practicing emergency physician. The ethical challenges come in three basic subtypes: the fair distribution of scarce medical resources, the temptation to judge or blame big patients, and legal issues around an elusive standard of care for the morbidly obese.

Justice/fairness and resource consumption

The bioethical principle of justice dictates that fair access to care should occur equitably, according to need. This is a fundamental tenet of the ACEP Code of Ethics for Emergency Physicians.³ Emergency physicians often experience the morbidly obese as very high resource utilizers who appear to consume more than their fair share of emergency department services and time.

Not only are they harder to transport, transfer and examine, but morbidly obese patients have slower transit times. Routine tasks like drawing blood, starting IVs, getting X-rays, CT scans, or doing emergency department bedside ultrasound, may span the spectrum from slightly challenging to utterly impossible. But in most cases, these routine tasks are much more time consuming when a patient is morbidly obese.^4-6

Practical resource challenges are an economic issue when emergency physicians are reimbursed on an RVU, fee-for-service, patients-per-hour basis. Patients who tie up ancillary and nursing staff for longer periods of time incur significant opportunity costs and detract from the ability of the staff to attend to other patients. An unintended result is compromised attention to new patients, slowing of emergency department flow, and an inability to maximize efficiency.⁵

Beyond the excess consumption of medical resources on an individual level, there are fairness issues at the hospital and population level as well. Pre-hospital services require more vehicles to have enough that remain “in service” when transporting larger patients who may require protracted extrication and transport times. This is in addition to the EMS and emergency department staff who miss work or suffer back pain from lifting such large patients.⁶ As emergency departments are stretched to serve an increasingly obese populace, they must purchase larger beds and larger scanners, and have more staff available to move, transfer, and transport more morbidly obese individuals.⁷

The American Medical Association recently classified obesity itself as a disease state and a treatable medical condition for purposes of both nosology and reimbursement, legitimizing the time physicians spend embattled with this condition.⁸ Despite these efforts and the unequal distribution of hospital and economic resources involved, emergency physicians caring for obese patients would do well to remember that the principles of equity and justice mandate that resources be allocated fairly and equitably, according to need.