Ethical issues in pediatric bariatric surgery

https://doi.org/10.1053/j.sempedsurg.2009.04.009Get rights and content

Performance of bariatric surgery in pediatric patients carries profound ethical burdens for all stakeholders: morbidly obese children and adolescents, their parents and families, pediatric physicians and surgeons, pediatric health care institutions, and society. The decision to proceed with a bariatric intervention should be made only after it is established that the patient's comorbidities could not be treated with less invasive means, the patient has a favorable risk/benefit profile, the patient and her/his family have received extensive preoperative counseling and given informed consent, and the pediatric bariatric team has a comprehensive system of short- and long-term care. The patient and her/his family should be counseled about the innovative aspects of the bariatric intervention, in which sustained weight loss and potential complications are unknown. The pediatric surgeons and their respective institutions that offer bariatric surgery should be enrolled in clinical research endeavors that assess outcomes and seek optimal treatment protocols.

Section snippets

Beneficence

Beneficence obliges physicians to act for the good of the patient, seeking ways to heal, restore health, and promote well-being. For pediatric patients who are morbidly obese, the ethical principle of beneficence requires that physicians seek to reverse the physical and psychological derangements that interfere with well-being. If nonsurgical interventions, such as caloric restriction diets, exercise programs, and behavioral therapy, were effective in achieving substantial weight loss with

Nonmaleficence

In taking the Hippocratic Oath, physicians promise adherence to beneficence—“I will use treatment to help the sick according to my ability and judgment …”—and to the obligation of nonmaleficence—“… but I will never use it to injure or wrong them.”7 In considering surgical treatments for morbid obesity, the risks of harm during and after an operation, the likelihood of achieving the desired outcomes, and the potential for unanticipated complications underscore the obligation of nonmaleficence. In

Autonomy (informed consent)

In commenting about obesity intervention and ethics, Holm observed that “the purpose of ethical reflection is to help us decide how to act in the real world  it must take into account all aspects of a proposed course of action, it must rely on good factual evidence …”11 The principle of autonomy has assumed paramount stature in western bioethics, as progressive societies value individual choice and self-governing, especially as it relates to one's body. Autonomy in decision making for pediatric

Justice

The principle of justice (also a virtue) allows that each person receives a fair share of health resources and equitable treatment. Recently, significant disparities were found for adult patients who undergo bariatric surgery, with fewer African Americans, Hispanics, low-income individuals, and males having these operations in the USA than expected based on morbid obesity statistics in these groups.14 How does justice affect the ethics of pediatric bariatric surgery? The manner in which

Virtue ethics and pediatric bariatric surgery

Virtue ethics, with its roots in Greek philosophy, differs from principle-based ethics, which is concerned with the action that causes an ethical dilemma, by setting its focus on the moral agents and the recipients of these actions. In their classic text, The Virtues in Medical Practice, Pellegrino and Thomasma describe several virtues that impact the interactions of physicians with their patients, colleagues, the medical community, and society.16 Trustworthiness implies that patients can rely

Innovation and research in pediatric bariatric surgery

The impetus to conduct clinical research in surgery typically originates from a state of equipoise, in which there is a general lack of agreement among surgeons about the best treatment or operation for a given condition. Unfortunately, the surgical disciplines, and pediatric surgery in particular, have rarely instituted clinical trials for the explicit purpose of determining the optimal procedure for a given condition. Within pediatric surgery, the best examples of “scientifically sound”

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