This dissertation provides an ethical justification of surgical weight loss interventions for the treatment of obesity. Situating obesity as not merely a public health concern but also fundamentally a problem of clinical medicine confronting individual patients and physicians, the dissertation argues that the time frame of public health interventions is too long for individuals presently facing obesity and its deleterious physical and social co-morbidities. It argues that failure to address weight loss on an individual level, and specifically to consider the clinical appropriateness of weight loss surgery (WLS), raises serious questions about failure to respect autonomy and promote patient welfare. Moreover, social skepticism or rejection of WLS as a treatment option raises concerns about fairness, as this failure indicates that obesity is not regarded in relevantly similar ways to other life-threatening and health-impairing conditions. The dissertation examines various reasons that obesity and its myriad interventions, including WLS, are inadequately addressed in the clinical setting. It argues that considerations with cultural and ethical valence play a critical role in obesity's different and unfair treatment within clinical medicine. Gendered and theologically informed attributions of blame, self-blame, shame, and self-stigma influence the attitudes and actions of both patients and clinicians with regard to addressing obesity. Inappropriate and conceptually confused ascriptions of responsibility impede social acceptance of, and access to, WLS. The dissertation's criticism and subsequent reconceptualization of these ascriptions of responsibility from a perspective informed by feminist epistemology and ethics provide the foundation upon which to consider reform of current clinical practices surrounding treatment of obesity. This dissertation concludes that WLS is both ethically and clinically justified. / McAnulty College and Graduate School of Liberal Arts; / Health Care Ethics / PhD; / Dissertation;

The increasing burden of chronic disease in ageing populations has shifted focus towards illness prevention and the self-management of health. Middle-aged and menopausal women’s transitioning bodies, specifically with respect to weight gain and changes in body fat composition, have received much attention by public health officials during the alleged obesity epidemic. In addition to these transformations, socioeconomic status has been shown to interact with obesity by decreasing the psychosocial health of vulnerable women. Although public health actions have targeted the health practices of clinically obese women throughout the menopausal transition, their effectiveness is limited because of existing socioeconomic inequalities, narrow focus on body weight interventions, and the psychosocial impact of an obesity stigma. Drawing on Bourdieu’s sociocultural theory of practice, and namely his concepts of body habitus and symbolic violence, this study aims: (a) to identify the norms and values of clinically overweight and obese postmenopausal women from contrasting socioeconomic backgrounds with regard to the ways they treat and care for their body, and (b) to outline the socio-cultural processes which incline them (or not) to pursue weight-loss strategies. Forty semi-structured interviews were conducted with clinically overweight and obese postmenopausal women from underprivileged (n=20) and middle class (n=20) milieus in the city of Sherbrooke, Québec. An intersectional (gender, age, socioeconomic status) thematic analysis was employed in order to analyze the data and identify emergent themes within and between both socioeconomic groups. This thesis is composed of two distinct studies. The first identifies the diverse contexts of occurrence of obesity stigma and weight shaming, as well as the contrasting responses between the two socioeconomic groups. Although all participants experienced obesity stigma, participants from lower social positions were more vulnerable to the psychosocial impact of dominant obesity discourses. In contrast, a higher access to social, economic, and educational resources provided middle-class women with more protection from weight shaming and discrimination. In the second article, from a public health perspective, the analysis of hierarchies of priorities, perception of control, as well as barriers and facilitators show that weight management needs to be understood as the outcome of a social process in which living conditions, material and psychosocial, offer a number of conditions of possibilities. Globally speaking, middle-class conditions privileged the adherence to public health recommendations, while socially deprived conditions inclined women to adopt unsustainable and risk-oriented weight-loss practices.

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Given the high number of people living with obesity, obesity must be considered a worldwide health issue. Apart from physiological impairments and co-morbid diseases, obesity has also a negative impact on the psychological well-being of those concerned. People with obesity are negatively affected on the social level due to obesity-related stigmatization. Up to this date, the understanding of stigma in the previous research has been limited by neglecting the sociological perspective and thus key questions such as by whom stigma is created and imparted and to what extent the socioeconomic status (SES) determines weight bias. Identifying stigmatizing groups and addressing the sociological dimensions of stigma research could not only contribute to a more comprehensive understanding of stigma but might also improve the development of effective interventions. The general aim of this dissertation project was therefore to identify social groups that stigmatize and discriminate against people with obesity. Within the systematic literature review (Bernard et al., 2019a) a comprehensive summary of published literature targeting the association between weight bias and SES in the general population was provided. The first empirical study (Bernard et al., 2019b) provided data from Germany focusing on weight bias in the form of non-altruistic behavior in a one-on-one situation. The second empirical study (Bernard et al., 2019c) investigated in contrast weight bias on a more structural level. The results of the systematic review and both empirical studies are discussed with respect to theoretical approaches, cultural and governmental structures, and methodological shortcomings. This work provides thus a) theoretical implications as potential orientation for further research and b) methodological implications with regard to the assessment of weight bias.