Fatphobia and medical biases follow people after death

For people with a high BMI, donating your body to science may be impossible, which makes care worse for the living.
It's not uncommon that only bodies below 180-200 pounds are accepted for medical donation. Deposit Photos, PopSci

Deciding what will happen to your body after death is one of the more sobering types of planning a person can do. While some might prefer a burial or water cremation as their final resting place, as many as 20,000 others each year in the US find comfort in the idea of donating their body to science. 

Through this decision, donors hope to improve the health and lives of those they leave behind by furthering disease research and teaching young medical students human anatomy. Yet for some would-be-donors and their families, this altruistic dream can come crashing down over some seemingly minor measurement: How much does the body weigh? The question puts in place a barrier that can impact how higher-weight bodies are treated not only in medical school, but in doctor’s offices as well.

This was the case for Robin Epley, a California-based reporter who attempted to honor her mother’s wishes by enrolling her in a body donation program after her death in 2019. In a personal essay Epley wrote about the ordeal, she described the “ultimate fat-shaming experience” as her mother’s body was turned away by program after program on the basis of her weight alone. 

“BMI is a problem because it was devised using something that is not a scientific method.”

While higher weight restrictions for body donation can come as a shock to many trying to navigate the system for the first time, they have been in place at institutions for several decades, says Brandi Schmitt, Executive Director of Anatomical Services for the University of California. Body donation programs can run either through medical schools or independently and will have slightly different criteria for which donations they’re willing to accept, but it’s not uncommon for these limits to cap at 180 to 200 pounds. Even stricter still, some will look at a donor’s body mass index (BMI) alone to determine whether or not they’ll be accepted.

This means that in death, as in life, those who carry their weight “better” may be more favorable and be accepted into donation programs, while those with a less lean appearance and higher BMI will not. This is a problem for a number of reasons, says Sabrina Strings, sociologist at the University of California, Irvine and author of the book Fearing the Black Body: The Racial Origins of Fat Phobia.

“BMI is a problem because it was devised using something that is not a scientific method,” Strings says. “Effectively, there were a handful of white American and white British doctors who were very concerned about what they considered to be the growing problem of obesity in the West. So they devised to set up their own limits on how much a person could weigh.”

Instead of being based on scientific inquiry, this index was derived using data from life insurance companies and considers only a person’s height and weight (notably ignoring compositional differences like muscle mass or bone density) to determine whether or not someone is a “healthy” size. 

BMI has been debunked repeatedly as an accurate predictor of health outcomes by medical literature, yet Strings says it remains in general medical use because it “feels scientific.”  It’s also notable, says Strings, that the data sets used to determine this so-called universal health measurement focus largely on white men, meaning it cannot be applied accurately to other races or genders.

While Schmitt says that research and education programs will sometimes request diversity “in certain criteria, such as gender, age, body mass, existing medical conditions,” Strings says that using racially derived criteria like BMI could still be a huge barrier to participating in these programs, especially for Black and brown women whose health cannot be determined by the value.

Angela McArthur is the director of the University of Minnesota’s Anatomy Bequest Program, which, like the UC system, has a comparatively higher weight criteria of 250 pounds. She says that there are a number of reasons for this limit, including the load capacity and dimensions of medical tables used to hold donors’ bodies. Schmitt concurs and says that staff safety in moving donors above this weight limit can be a safety concern. 

Part of this concern with safety comes from the fact that the embalming process can add additional weight to bodies after they’ve been admitted to a donation program, McArthur says. She explains that bodies being prepared for a wake or short viewing at a funeral home may only have a negligible pound or two added during embalming, while those  assigned to medical students can tack on an extra 64 pounds on average.

This discrepancy is due to the amount of time a donated body needs to stay preserved, says Michael Lubrant, director of the University of Minnesota’s mortuary science program. “[Bodies] may be held at ambient room temperatures in gross anatomy labs for extended periods of time—sometimes from one to two years,” he notes. “Embalming is necessary to ensure long-term preservation, and to maintain the integrity of the tissue and structures being studied.” 

While hoisting donor’s bodies can be an injury risk to the backs of embalmers, Lubrant says that lifts used in many embalming rooms can significantly reduce this risk. Some of the machines even have a weight capacity to “easily” hold up to 900 pounds. 

Apart from logistical concerns, extra adipose tissue (or fat) on donated bodies may also be less desirable in first-year gross anatomy labs, where medical students glean the basics, simply because it can be more time-consuming or physically challenging to study the internal structures under layers of tissue. Instead, says Schmitt, bodies with more adipose tissue may be requested for specialty courses further along a student’s medical training, such as in bariatric research.

Outside the lab, however, bodies with additional adipose tissue are a common focus in doctor’s offices, hospitals, and drug research. In the US, roughly three quarters of Americans are considered overweight or obese based on their BMI, which means it’s likely that such bodies may make up a large portion of patients that medical students will go on to treat.

This lack of early and positive exposure to bodies with more adipose tissue can be a dangerous breeding ground for weight bias and fatphobia, says Adeline Goss, a neurohospitalist—neurologist focused on in-patient care—at Highland Hospital in California who contributed to a 2020 paper that looked at negative language used to describe bodies with more adipose tissue in gross anatomy labs. 

In her research, which covered first-year medical students from the University of Pennsylvania’s Perelman School of Medicine from 2015 to 2018, Goss found that students who dissected bodies with more adipose tissue described the bodies as “disgusting” and “difficult” and would try to avoid them in lab work. 

Goss and colleagues also found that the students were more likely to make comments about the health status of the bodies with more adipose tissue—and attribute weight as a factor in their deaths, despite not having health status information about any of the donated bodies. Students reported hearing such negative comments from their instructors as well, Goss and colleagues found.

“Then we can imagine how this might reinforce or enhance weight bias that we know plays out when these students become physicians.”

“What worries me is the idea of an environment where students carrying their own pre-existing biases into medical school and into the anatomy lab are then equipped with new perceptions that people with overweight and obesity … are more difficult to work with, harder to learn from, and unhealthy,” says Goss.

“Then we can imagine how this might reinforce or enhance weight bias that we know plays out when these students become physicians,” she continues. “We know that physicians, much like the general population, often hold negative attitudes toward people they perceive as having excess weight … and this has been shown to have a negative impact on the doctor-patient relationship and the quality of care.”

One intervention that Goss hopes could change this prophecy is to include more sensitivity and weight-neutral education into early medical school curriculums to redirect how students see these bodies in the lab. As for the donation programs, both Schmitt and McArthur say that they’ve seen increasing requests for higher-weight donors by researchers at their institutions. However, neither the UC system or University of Minnesota plans right now to expand their weight criteria.

To see change, Strings says it will be important for those who oppose body-donation biases to speak up. “We should be willing to approach the medical establishment with the demands that they end the use of BMI or any weight limits because they are discriminatory against the majority of the [US] population,” Strings says. “We must be willing to demand that they revise these policies full scale.”

Correction: Robin Epley‘s mother passed in 2019, not 2020 as previously stated.