When families cannot or will not make an adequate effort to decrease the impact of their child’s obesity, what should be done? How should we determine whether a particular case constitutes medical neglect? With the previous analysis of the 3 conditions necessary for medical neglect and the categories defined in , we can address these questions.
For category 1 (obese children who have no comorbid conditions), the charge of medical neglect would not be justified. The mere presence or degree of obesity, in the absence of comorbid conditions, does not reliably predict a high likelihood of serious imminent harm. Although these children have increased risk for the development of adult diseases, it is difficult to justify violation of individual or family autonomy because something bad might happen, particularly if the child could reverse or reduce this risk when he or she reaches adulthood and assumes responsibility for his or her own health.
For category 4 (obese children who have comorbid conditions that constitute serious imminent harm in childhood), charges of medical neglect might be warranted if all in-home approaches and alternative options to coercive state intervention have been exhausted. In cases in which the child already has a severe comorbidity (eg, obstructive sleep apnea with cardiorespiratory compromise), the risk of severe imminent harm exists. In these cases, there often is effective treatment for the comorbidity itself (eg, bidirectional positive airway pressure therapy). In the setting of severe comorbidities, treatments with reasonable probabilities of success (such as lifestyle interventions) might be justified. Although lifestyle interventions are not 100% effective, in the right settings they might decrease the impact of comorbid conditions. In very limited cases of obesity with comorbidities that represent serious imminent harm in which alternative options have been exhausted, it seems that removal of the child from the home might be warranted to provide the necessary medical and lifestyle treatments.
The middle 2 categories of children are more difficult. For category 2 (obese children who have comorbid conditions that predict serious harm but are reversible after the child reaches adulthood), it seems unlikely that coercive state intervention would be warranted. For instance, although research is ongoing, it seems that most of the risk of cardiovascular disease related to childhood obesity is reversible. Although there may be low likelihood that the child will succeed at weight loss as an adult, there is not a known imminent harm that could justify something as serious as a charge of medical neglect and removal from the home.
For category 3 (obese children who have comorbid conditions that predict serious harm and are not reversible after the child reaches adulthood), a charge of medical neglect might be considered if, for instance, the child showed hepatic fibrosis resulting from nonalcoholic fatty liver disease. In such a case, it might be helpful to ask what the child would want if he or she fully understood that his or her life span was going to be shortened by 30 years as a result of a condition that could be treated effectively. It seems reasonable to assume that the child would be grateful that someone intervened on his or her behalf.