Abstract
New surgical technologies may challenge societal values, and their adoption may lead to ethical challenges. Despite proven cost-effectiveness, obesity (bariatric) surgery and its public funding have been questioned on ethical arguments relating to, for example, the self-inflicted or non-disease nature of obesity. Our aim was to analyze the ethical issues relevant to bariatric surgery. A comprehensive health technology assessment was conducted on bariatric surgery for morbid obesity using the EUnetHTA method, including a fully integrated ethical analysis. The ethical arguments suggesting that obesity should not be surgically treated because it is self-inflicted were rejected. Medicalization of obesity may have both positive and negative effects that impact the various stakeholders differently, thus being difficult to balance. Informing bariatric surgery patients and actively supporting their autonomy is exceptionally important, as the benefits and harms of both obesity and bariatric surgery are complex, and the outcome depends on how well the patient understands and adheres to the life-long changes in eating habits required. Justice considerations are important in organizing surgical treatment of obesity, as the obese are discriminated against in many ways and obesity is more common in socioeconomically disadvantaged populations who might have problems of access to treatments. Obesity should be treated like other diseases in health care, and obesity surgery rationed like other cost-effective treatments. Positive actions to ensure patient autonomy and just access to surgical treatments may be warranted.
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References
Mitka M. Surgery for obesity: demand soars amid scientific, ethical questions. JAMA. 2003;289:1761–2.
Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547–59.
Colquitt JL, Picot J, Loveman E, et al. Surgery for obesity. Cochrane Database Syst Rev 2009; CD003641.
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37.
Eurostat. Potential widespread causes of health problems. In: Europe in figures: Eurostat yearbook 2006–07. Luxemburg: Office for Official Publications of the European Communities; 2007.
Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350:1075–9.
Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring Md). 2009;17:941–64.
Banta D. The development of health technology assessment. Health Policy (Amsterdam, Netherlands). 2003;63:121–32.
Ikonen T, Anttila H, Gylling H, et al. Sairaalloisen lihavuuden leikkaushoito [Surgical treatment of morbid obesity]. Helsinki: National Institute for Health and Welfare; 2009. In Finnish.
Heitman E. Ethical issues in technology assessment. Conceptual categories and procedural considerations. Int J Technol Assess Health Care. 1998;14:544–66.
Van der Wilt GJ, Reuzel R, Banta HD. The ethics of assessing health technologies. Theor Med Bioeth. 2000;21:103–15.
ten Have H. Ethical perspectives on health technology assessment. Int J Technol Assess Health Care. 2004;20:71–6.
Reuzel R, Oortwijn W, Decker M, et al. Ethics and HTA: some lessons and challenges for the future. Poiesis Prax. 2004;2:247–56.
Lehoux P, Williams-Jones B. Mapping the integration of social and ethical issues in health technology assessment. Int J Technol Assess Health Care. 2007;23:9–16.
Hofmann BM. Why ethics should be part of health technology assessment. Int J Technol Assess Health Care. 2008;24:423–9.
Hofmann B. On value-judgments and ethics in health technology assessment. Poiesis Prax. 2005;3:277–95.
Grunwald A. The normative basis of (health) technology assessment and the role of ethical expertise. Poiesis Prax. 2004;2:175–93.
Braunack-Mayer AJ. Ethics and health technology assessment: handmaiden and/or critic? Int J Technol Assess Health Care. 2006;22:307–12.
Lampe K, Mäkelä M, eds. HTA core model for medical and surgical interventions 1.0R: http://www.eunethta.net/upload/WP4/Final%20Deliverables/HTA%20Core%20Model%20for%20Medical%20and%20Surgical%20Interventions%201%200r.pdf; 2008.
Lampe K, Mäkelä M, Garrido MV, et al. The HTA core model: a novel method for producing and reporting health technology assessments. Int J Technol Assess Health Care. 2009;25 Suppl 2:9–20.
Saarni SI, Hofmann B, Lampe K, et al. Ethical analysis to improve decision-making on health technologies. Bull World Health Organ. 2008;86:617–23.
Droste S, Gerhardus A, Kollek R. Methoden zur Erfassung ethischer Aspekte und gesellschaftlicher Wertvorstellungen in Kurz-HTA-Berichten—eine internationale Bestandsaufnahme [Methods for the assessment of ethical aspects and moral concepts in society in health technology assessment reports—an international survey]. Schriftenreihe HTA des DIMDI vol. 9. Köln; 2003.
Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity 1950–2000. Obes Surg. 2002;12:705–17.
Feiring E. Lifestyle, responsibility and justice. J Med Ethics. 2008;34:33–6.
Allison DB, Downey M, Atkinson RL, et al. Obesity as a disease: a white paper on evidence and arguments commissioned by the Council of the Obesity Society. Obesity (Silver Spring Md). 2008;16:1161–77.
Ludwig DS, Pollack HA. Obesity and the economy: from crisis to opportunity. JAMA. 2009;301:533–5.
Swinburn B, Egger G. The runaway weight gain train: too many accelerators, not enough brakes. BMJ. 2004;329:736–9.
Blakemore AI, Froguel P. Is obesity our genetic legacy? J Clin Endocrinol Metab. 2008;93:S51–6.
Ogden J, Clementi C, Aylwin S. The impact of obesity surgery and the paradox of control: a qualitative study. Psychol Health. 2006;21:273–93.
Beauchamp T, Childress J. Principles of biomedical ethics. 6th ed. (1st ed 1979). New York: Oxford University Press; 2008.
Daniels N. Justice, health, and healthcare. Am J Bioeth. 2001;1:2–16.
Ogden J, Flanagan Z. Beliefs about the causes and solutions to obesity: a comparison of GPs and lay people. Patient Educ Couns. 2008;71:72–8.
Parsons T. The Social System. Glencoe: Free Press of Glencoe; 1951.
Throsby K. “How could you let yourself get like that?” Stories of the origins of obesity in accounts of weight loss surgery. Soc Sci Med. 2007;65:1561–71.
Ells LJ, Lang R, Shield JP, et al. Obesity and disability—a short review. Obes Rev. 2006;7:341–5.
Atlantis E, Baker M. Obesity effects on depression: systematic review of epidemiological studies. Int J Obes. 2008;32:881–91.
Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9:788–805.
Roehling M. Weight discrimination in the American workplace: ethical issues and analysis. J Bus Ethics. 2002;40:177–89.
de Vries J. The obesity epidemic: medical and ethical considerations. Sci Eng Ethics. 2007;13:55–67.
Pomeranz JL. A historical analysis of public health, the law, and stigmatized social groups: the need for both obesity and weight bias legislation. Obesity (Silver Spring, Md). 2008;16 Suppl 2:S93–S103.
Oakley J. Patients and disclosure of surgical risk. In: Ashcroft RE, Dawson A, Draper H, et al., editors. Principles of health care ethics. 2nd ed. Chichester: Wiley; 2007.
Madan AK, Tichansky DS, Taddeucci RJ. Postoperative laparoscopic bariatric surgery patients do not remember potential complications. Obes Surg. 2007;17:885–8.
Zimmerman M, Francione-Witt C, Chelminski I, et al. Presurgical psychiatric evaluations of candidates for bariatric surgery, part 1: reliability and reasons for and frequency of exclusion. J Clin Psychiatry. 2007;68:1557–62.
Walfish S, Vance D, Fabricatore AN. Psychological evaluation of bariatric surgery applicants: procedures and reasons for delay or denial of surgery. Obes Surg. 2007;17:1578–83.
Salant T, Santry HP. Internet marketing of bariatric surgery: contemporary trends in the medicalization of obesity. Soc Sci Med. 2006;62:2445–57.
Brown I. Nurses’ attitudes towards adult patients who are obese: literature review. J Adv Nurs. 2006;53:221–32.
Tolonen P, Victorzon M, Mäkelä J. 11-year experience with laparoscopic adjustable gastric banding for morbid obesity—what happened to the first 123 patients? Obes Surg. 2008;18:251–5.
Sjöstrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.
Buchwald H, Oien DM. Metabolic/bariatric surgery Worldwide 2008. Obes Surg. 2009;19:1605–11.
Ruger JP. Ethics of the social determinants of health. Lancet. 2004;364:1092–7.
Wilde ML. Bioethical and legal implications of pediatric gastric bypass. Willamette Law Rev. 2004;40:575–625.
Uli N, Sundararajan S, Cuttler L. Treatment of childhood obesity. Curr Opin Endocrinol Diab Obes. 2008;15:37–47.
Inge TH, Xanthakos SA, Zeller MH. Bariatric surgery for pediatric extreme obesity: now or later? Int J Obes. 2007;31:1–14.
NIH Conference. Gastrointestinal surgery for severe obesity Consensus development conference panel. Ann Intern Med. 1991;115:956–61.
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The study has been funded by the National Institute for Health and Welfare, Finland.
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The authors declare that they have no conflicts of interest
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The study is based on a health technology assessment of surgical treatments for morbid obesity. The assessment was conducted by Finnish Office for Health Technology Assessment and published in Finnish as Ikonen et al. [9]. Full report is available at: http://www.thl.fi/thl-client/pdfs/739965e6-bf7f-4d48-9d29-31b2275c9976.
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Saarni, S.I., Anttila, H., Saarni, S.E. et al. Ethical Issues of Obesity Surgery—a Health Technology Assessment. OBES SURG 21, 1469–1476 (2011). https://doi.org/10.1007/s11695-011-0386-1
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DOI: https://doi.org/10.1007/s11695-011-0386-1