“Should employers offer financial incentives for employees who monitor and report “ideal health behaviors”? Should employers offer financial incentives for employees who meet BMI requirements? In this commentary, I take issue with these practices as described in the case above, arguing that labeling behaviors that influence a person’s weight in normative terms contributes to a phenomenon called healthism, an ideology that emphasizes one’s personal responsibility for one’s own health. Engaging in practices that support healthism is morally wrong, because healthism ignores social factors that constrain individuals’ choices and reinforces oppressive social hierarchies. Thus, we ought not to label behaviors influencing a person’s weight in normative terms. This conclusion extends to companies offering financial incentives for employees who engage in “ideal” personal behaviors that may influence their weight. Additionally, as I will explain below, the use of BMI as a marker of health is fraught and ought to be avoided by company wellness programs.
Healthism is a term coined by sociologist Robert Crawford in his 1980 discussion of a then-emerging homeopathic “health consciousness” and its associated social movements. Crawford defines healthism as “the preoccupation with personal health as a primary—often the primary—focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of lifestyles, with or without therapeutic help.” In other words, healthism is the view that personal health is the vehicle of well-being and that health is achieved through the modification of personal habits. Healthism locates the locus of moral and causal responsibility for health in the individual. For example, healthism would hold that quitting smoking is one’s personal responsibility (as is picking up the habit in the first place); one is morally culpable for their smoking habit because one’s health is one’s own responsibility.
[..] the behaviors that we associate with smaller body shapes and lower body weights—cooking whole foods, eating lots of vegetables, going to the gym—are not equally accessible to all. These behaviors are influenced by social facts about a person. For example, one’s social class constrains the choices one can make. For example, author Barbara Ehrenreich describes trying to make ends meet while working in low-wage jobs like waitressing and hotel housekeeping. She discovered that if one can’t put up 2 months’ rent to secure an apartment, one must rely instead on a weekly rate motel and a hot plate, and one is forced to consume meals like fast food and gas station hot dogs regularly. Having fewer choices can lessen one’s agency and make one less morally culpable for one’s actions. Consider cases of coercion: we tend to see people who are forced to engage in some behavior and left with little or no choice as less morally culpable for that behavior. People whose health-related behaviors are constrained should be seen the same way.
[..] when doctors or wellness program directors say or imply that certain things like eating whole foods and exercising regularly will cause one to have an ideal body shape (and therefore improve one’s health), doctors and other institutional figures reinforce the idea that one can improve one’s metabolic health through behaviors for which one is personally, morally, and causally responsible. While this claim may be literally true with respect to one’s causal responsibility, it ignores possible social barriers to making behavioral choices, as discussed above. When an institution has a policy based on healthist views, that policy reinforces healthism’s power as an ideology by giving credence to healthism and penalizing employees who might have unseen constraints on the diet and exercise behaviors in which they can engage. Since healthism views people as morally responsible for their health behaviors, the implication that people who are fat fail to discipline themselves appropriately permits their being made targets of stigma and shame. If institutions ought not promote policies that reinforce oppressive social hierarchies, it follows that institutions shouldn’t promote wellness programs that incentivize engaging in “ideal” health behaviors related to weight.
[..] higher BMIs are associated with a higher risk for diseases like hypertension, coronary heart disease, respiratory illness, sleep apnea, and diabetes, among others. Higher BMIs are also associated with higher health care costs. If company wellness plans aim to reduce health care costs and the incidence of diseases comorbid with BMI, those plans could focus on behaviors like eating whole foods and exercising without referring to BMI itself. This seems like a reasonable proposal to me, as long as the modified wellness plans don’t use normative terms like ideal, good, or bad to label certain behaviors and instead refer to behavior in normatively neutral ways. For example, a plan could encourage fitness as a way to increase metabolic health and make clear, objective claims about the relationship between, say, fitness and heart disease or eating a plant-based diet and reducing one’s risk for cancer. These plans should also lower barriers to accessing things like fitness and whole foods in order to avoid reproducing social inequities. Lowering barriers might include more common forms of aid—group fitness classes, free gyms or gym memberships, providing whole foods in the workplace cafeteria—but they might necessarily involve other, uncommon forms of aid like free childcare so that employees have unencumbered time in which they can shop, prepare food, or exercise.
Company wellness programs that label some behaviors in normative terms like ideal or healthy can reinforce healthist ideology and reproduce social inequities. By avoiding labeling behaviors in normative terms, a company wellness plan can instead offer more objective information about the relationship between, say, diet and exercise and reducing one’s risk of disease. By employing nontraditional forms of aid, company wellness plans can also lower socially based barriers to the behaviors associated with reduced risk of disease and increased metabolic health.”
Full article, M Ward, AMA Journal of Ethics, July 2023