Shame as a Public Health Intervention

The bioethicist Daniel Callahan has recently argued for ‘stigmatisation lite’ as a way to reduce the incidence of obesity. ‘The force of being shamed and beat upon socially’ worked for him when he stopped smoking, and a positive application of social pressure has been influential in behaviour change related to, for example, the reduction of drink driving, so why can’t we shame people into losing weight? Criticism of the paper was swift and multifaceted, but it turned out that he didn’t intend to stigmatise the obese at all – only to use social pressure (if that is possible) on the not-yet-obese or just a little overweight. Nevertheless his paper provides an opportunity to re-evaluate the use of stigma and shame as interventions in public health policy.
Public health policy is an enterprise which outwardly promotes personal choice, but encouraging and facilitating decision making based on capitulating to social conformity seems at odds with respecting personal autonomy. Health professionals spend a good deal of time and energy trying to increase self-esteem in stigmatised groups, and so a suggestion that we deliberately increase stigma, lite or otherwise, seems odd. Public health policy which aimed to increase stigma might be acceptable if it worked, but Callahan offered no evidence that it would.
But the rejection of stigma and shame as public health tools to reduce obesity does not necessarily reject the use of social emotions in public health policy. Differences between guilt and shame are discussed and I argue that in some circumstances fostering guilt for direct harms to others may be ethically acceptable. Television anti-smoking campaigns are used as examples it is tentatively concluded that Callahan’s ill-received paper promoting obesity shame should not obscure the possibility of using social emotions in public health policy elsewhere.