A few years ago at a meeting of the ad hoc ethics committee at my hospital, we were discussing the issues that arise when treating obese patients. Someone brought up the case of an ICU patient, a young woman who weighed 500 pounds. The ICU nurses complained, sometimes loudly, every time she needed to be moved. Their grousing appalled our chief medical ethicist, but I understood the nurses' reactions. They likely feared incurring a serious injury from lifting such a heavy patient. This conundrum-how do nurses safely provide high-quality care for people who are obese-will become ever more relevant as the prevalence of obesity in the United States continues to rise.
Seeking a better understanding of why a person might become extremely overweight can help clinicians in caring for such patients. Roxane Gay's Hunger: A Memoir of (My) Body (HarperCollins, 2017) offers a powerful exploration. In this unsettling book, Gay recounts a horrific childhood trauma that altered her life and led her to become "super morbidly obese."
Gay begins the book by declaring what it isn't: "The story of my body is not a story of triumph. This is not a weight-loss memoir." She reveals that at her heaviest she weighed 577 pounds, a number she describes as "unfathomable." This weight was recorded at an all-day meeting for patients considering gastric bypass surgery. Gay opted not to proceed, but she admits to being mesmerized by the before-and-after pictures of people who had undergone the surgery. She would very much like not to be as heavy as she is. She would like not to feel continually burdened by and ashamed of her body.
Which leads to the question: why is Gay extremely overweight? She explains in six short, chilling sentences: "What you need to know is that my life is split in two, cleaved not so neatly. There is the before and the after. Before I gained weight. After I gained weight. Before I was raped. After I was raped." When she was 12 years old, Gay was gang-raped by a group of male classmates that included a boy she thought she loved. They held her down, laughed as they took turns assaulting her, and then told everyone at school that she was a slut, ensuring she would be socially ostracized. "Those boys treated me like nothing," she says starkly, "so I became nothing."
Paradoxically, becoming nothing involved purposefully overeating until she was so large that, in her mind, no man would ever again want to hurt her. She saw obesity as a desexualized and therefore protective state. Now in her early 40s, Gay describes her body as "a cage of [her] own making." Yet despite years of dieting, working with personal trainers, starting and abandoning exercise programs, and wanting to be thinner, she can't resist her own compulsion to be large. Her hunger can never be satisfied, because it isn't physical hunger but rather something integral to who she is: "I know what it means to hunger without being hungry[horizontal ellipsis] hunger is in the mind and the body and the heart and the soul."
Gay's book changed my view of morbidly obese patients. In the past I often deployed a bland empathy that, to be honest, was tinged with judgment and a belief that overweight was a matter of eating too much and exercising too little. I feel a deeper empathy now because I understand that traumatic experiences can literally shape a life, and that it can be difficult to live with the enormous problems an enormous body can cause. And I hadn't realized how, for someone who is obese, daily life is fraught with constant humiliations. Gay describes several, including finding armchairs painfully imprisoning, hearing strangers yell degrading insults from their car windows, and being criticized for the contents of her grocery cart.
But although having greater empathy is important, it isn't enough. The practical problems for health care workers remain. Empathy won't help the nurse who must struggle to lift a heavy patient. We need institutional solutions, such as lift teams and so-called "bariatric" hospital rooms. Care that puts nurses at risk for injury is bad for everyone, nurses and patients alike-and these patients deserve to be seen as the complex individuals they are, rather than for the physical difficulties they present.