Weight bias is a form of discrimination that is pervasive in medical encounters yet often unacknowledged in medical education. In this essay, we reflect on instances of weight bias we witnessed during our clerkship year. Using vignettes gleaned from clinical encounters—an IVF patient with a body mass index (BMI) of 44 accused of “doctor shopping”; a transgender man whose changing body size is emblematic of his transition; and a child receiving a striking visual lesson about fatty foods—we outline how weight bias violates the three fundamental principles of justice, autonomy, and non-maleficence. We propose a beneficent approach to BMI and weight bias that upholds these ethical principles in the clinic and medical classroom.
Medical education emphasizes body mass index (BMI) as a key indicator for health risks. Electronic medical records alert us to BMIs greater than 25 with bolded red exclamation points. As medical students, we learn that a BMI over 30 defines obesity, a disease to be treated with diets, medications, and surgeries. Yet curricula often overlook the link between BMI and weight bias—a pervasive form of discrimination in healthcare contexts.
Countless patient narratives and international expert consensus state that weight bias exhibited by physicians damages health and undercuts human rights (1). This reality inspired the three of us (AMM, BB, MKV) to start a working group to address weight bias at our school.
As third-year medical students at the end of our clerkship year, we reflect on how weight bias in clinical teaching spaces is doubly dangerous: it both undermines patient care and condones ongoing bias in future physicians. We present three cases in which the indiscriminate use of BMI came into direct conflict with the physician’s responsibility to uphold three fundamental principles of medical ethics: justice, non-maleficence, and autonomy (2). These principles form an ethical framework emphasizing patient self-determination, welfare, harm prevention, and equitable healthcare access. By reimagining what a beneficent approach to addressing weight with patients and learners could look like, we argue that centering key ethical principles when caring for patients of diverse body sizes can help to reduce weight bias and promote patient-centered care.
Case 1. “Kara is a 35-year-old new patient, hoping to undergo a second egg retrieval for in vitro fertilization. When I asked why she transferred care from a local private practice, she cited dissatisfaction with her prior care, saying ‘before I could ask what the lab work or hormone levels meant, the doctor was hurrying out of my room.’” Dr. C, the attending, interrupted my presentation, scoffing, “That’s not why she left the old practice. Her BMI is 44. Patients like her are always shopping for a new doc.”
I (MKV) was on a reproductive endocrinology service, presenting Kara’s case. My initial reaction to Dr. C’s correction was to worry about my own performance. Did Dr. C think I was unable to elicit an accurate history? But another question worried me as well—why were we assuming that Kara was being untruthful?
Several studies have shown that physicians spend less time with patients who have elevated BMIs compared to those with normal-range BMIs, raising concerns about inequitable allocation of healthcare resources on the basis of BMI (3–6). Patients whose BMI falls into the overweight or obese categories are also less likely to experience the same respect or emotional rapport with their physicians as their thinner peers (7, 8). A recent scoping review suggested that when patients with elevated BMIs change doctors, they usually do so because of differences in treatment—such as shorter visit times and stigmatization—rather than impulsiveness (9).
As medical students, we often adopt our instructors’ heuristics and habits. As Dr. C corrected my history-taking, I was at risk of incorporating his weight bias—often implicit—into my own practice. The incident illuminated that curbing the transmission of physician weight bias and addressing the resulting healthcare inequities requires raising awareness among both learners and educators. Awareness of weight bias in trainees, combined with self-awareness of how we interact with patients, can help us recognize and replace bias with empathy for patients’ past healthcare experiences and curiosity about their goals while in our care.
Case 2. Taylor is a transgender man who recently started gender-affirming treatment. At his annual visit, his primary care physician expressed concern about the increase in his BMI from 26 to 32 since starting testosterone. He counseled Taylor to reduce his caloric intake, prescribed phentermine-topiramate, and quickly moved on to see his next patient. As the door closed, Taylor’s body language became tense. Sensing his frustration, I asked him how he had been feeling about his new body size. He shared that he sometimes worried about the health implications of his weight gain, while also feeling that it helped align his appearance with his gender identity.
I (AMM) reflected that if we had elicited Taylor’s experience at the outset, we could have seen past his BMI, validated his resilience, and helped him identify alternative ways to increase his body size. For example, working with a trainer could have centered his gender affirmation journey, helping him to build muscle mass while simultaneously optimizing his metabolism.
Taylor’s narrative highlights that by reflexively defining BMI as a fixable problem, clinicians may default to paternalistic management rather than shared decision-making. This approach curtails autonomy, which hinges on patients having the chance to voice their preferences and make informed decisions. Concerningly, some medical ethics scholars have argued that it can be acceptable to limit the autonomy of patients with elevated BMIs insofar as it helps them lose weight (10). However, not only is there no evidence that paternalistic counseling helps patients lose weight (11–13), but a wide body of research demonstrates that patients who feel disrespected (7), dehumanized (14, 15), or stigmatized (6) by their physicians are less likely to adhere to medical advice (16, 17), more likely to be lost to follow-up (18), and experience poorer long-term health outcomes (19).
The intersection of weight bias with other prejudices—such as sexism, racism, homophobia, transphobia, and xenophobia—further amplifies stigma experienced by marginalized patients once they enter a doctor–patient relationship (20, 21). Taylor’s experience shows how even subtle forms of weight bias encourage premature closure of the medical encounter, denying patients the opportunity to contextualize their attitudes toward food, exercise, and body image.
Case 3. A medical student, Rick (fictitious name), shares excitedly about a “creative” intervention he learned for tackling obesity in pediatrics while seeing a 10-year-old boy with a BMI consistently at the 99th percentile. At the suggestion of his attending, Rick showed the child how many grams of fat are contained in potato chips, pizza, and cookies by measuring equivalent portions of lard into clear baggies. The patient was shocked to see his favorite foods transformed into fatty lumps and related this to his own body. Months later, the patient’s mother joyfully updated the pediatrician that her son had lost 5 pounds. Rick expressed satisfaction that the intervention made a positive impact on the boy’s health.
This story made me (BB) reflect on my own experiences at the pediatrician’s office as an “obese” patient, which were punctuated by admonishments about my position on the growth chart and terse directives to eat less and exercise more. My repeated attempts to implement my doctor’s guidance fueled patterns of obsessive food restriction, culminating in a diagnosis of anorexia that consumed my teenage years.
While such graphic efforts might seem fruitful in bringing about weight loss, clinicians often do not scrutinize the potential long-term harms of this approach. A wide body of literature disproves the once-popular notion that shame is ethically justified if it motivates weight loss (10). Moreover, creating associations between food and shame in children puts them at increased long-term risk for developing eating disorders (22, 23). Beyond eating disorders, weight bias in healthcare settings impacts patients’ willingness to seek care to avoid the discomfort of feeling stigmatized (9, 24), leading to withdrawal from care, delayed diagnoses, and worse disease progression (8, 15).
The contrast between Rick’s genuine belief that he had helped his patient and my own personal experience with my pediatrician emphasizes the insidious nature of weight bias. Without learning how to identify and combat weight bias, clinicians can unknowingly cause iatrogenic harm.
As we reflect on the pervasive weight bias we observed throughout our clerkship year, we hope to identify ways to provide more beneficent care for patients of all body sizes. The assumptions made about Kara’s motivations for “doctor-shopping,” and the ways biases can be transmitted to trainees, motivate us to advocate for addressing weight bias in medical education. Taylor’s story inspires us to learn about our patients’ relationships with their bodies, irrespective of BMI. Rick’s enthusiasm for the lard-based teaching intervention reveals how even well-intentioned healthcare professionals can cause harm by centering the goal of weight loss without exploring the long-term consequences of inflicting shame.
We believe that teaching medical students about weight bias is essential to reduce its ethical, emotional, and physical consequences. Trainees should learn evidence-based, weight-neutral clinical skills that empower patients to optimize their health—such as teaching mindful eating, promoting increased fruit and vegetable intake, and encouraging enjoyable physical activity (24–26). As future physicians, we will work with patients to understand the complexities of their health; in doing so, we have valuable opportunities to help patients cultivate healthier relationships with their bodies. Unchecked weight bias undercuts the healing potential of this privilege—and that is truly a shame.
Funding: None.
Conflicts of interest: None.
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Authors’ contributions: All authors contributed according to journal authorship guidelines.
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