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Childhood obesity

Bariatric surgery and children: a moral dilemma

Papers examines issues such as patient consent, long term outcomes and the effects of life changing surgery

Obesity in children and adolescents is associated with many of the serious health consequences witnessed in adults (hypertension, dyslipidemia, insulin resistance/diabetes, fatty liver disease), however, there is limited evidence on effectiveness of preventive measures (lifestyle interventions, pharmacological treatments). In addition, there are several surgical procedures available for children and adolescents however, the long term effects of these procedures are unknown.

In their paper, ‘Bariatric surgery for obese children and adolescents: a review of the moral challenges’ featured on BioMed Central, researchers from University College of Gjøvik and the University of Oslo, Norway, conclude that “Cutting into children’s healthy organs in order to discipline their behaviour, to satisfy social ideals for body shape, or to compensate for poor parenting should be avoided. More evidence on outcomes is needed to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.”

The paper discusses many moral challenges of performing bariatric surgery in children and adolescents, which they claim are important “in order to make open and transparent decisions on bariatric surgery for children and adolescents.”

Although the authors acknowledge that the ability to “help obese minors to avoid serious health problems in the best possible way,” is the right thing to do, they stress that the “lack of high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this patient group makes it difficult to do so.”

To identify the moral issues involved with bariatric surgery for children and adolescents, the researchers poised a series of morally relevant questions highlight the issues concerning a medical intervention. Whereby, they hoped to “inform decision makers (on various levels) about values, viewpoints, and arguments” before making actual decisions. They performed a literature search for articles which resulted in 1,177 references.

Benefits and long term outcomes

The review found that there is little evidence to support the efficacy, effectiveness, and efficiency of bariatric surgery youngsters. The vast majority of papers concentrated on the adult population and there is an inherent risk of extrapolating this data onto the younger population. Therefore, they also note that if low complication rates are seen after 100–150 procedures, “this indicates that bariatric surgery in children and adolescents should be performed in specialized, high volume centers.”

They also note that few studies acknowledge the intense psychological and social development and turbulence effects of bariatric surgery, such as how surgery will influence a young person’s everyday life and restrict their life-style choices.

The researchers also examine issue such as patient/parental/informed consent, as well as the morality of ‘discipline through organ modification’ and psychiatric comorbidity.

“To alter a normal and well-functioning organ in order to discipline human behavior may appear conceptually and morally challenging. Hence, conceptual questions, such as whether obesity is a disease and how it is to be defined, pose a series of moral issues with bariatric surgery, especially for children and adolescents,” they write.

For example, previous studies have noted that one third of the adult candidates form bariatric surgery were identified as victims of sexual abuse as children, therefore assessing the mental capacity of young surgical candidates is fundamental and should be part of the screening process.

Prejudices

Young people are also subjected to prejudice even more so it they are obese, and the authors state that healthcare professionals tend to be pessimistic about obese people’s ability to manage their situation and are sometimes reluctant to refer children to bariatric surgery.

“This also raises the question of whether pharmacological and surgical interventions are medical solutions to social problems (of unsound attitudes and discrimination),” they write.

The researchers also examine the relationship between ‘stakeholders’ such as surgeons and industry, and argue that there is a moral imperative for high quality research in this group of patients.

“How specific are the reviewed moral challenges for bariatric surgery? Are they as relevant for other health care interventions as well?” the authors ask. “This may well be, but bariatric surgery poses particular quandaries for minors because it uses medical interventions to alter everyday behaviour (diet therapy, exercise, cognitive-behavioral therapies), as well as modifying organs and processes that otherwise appear healthy and because it does not remove the multifarious complex and in part unknown causes of obesity on persons who often cannot give valid informed consent or assent.”

“Therefore, to cut or not to cut, is not the question,” they conclude. “The important questions are; who to operate on, when to do it, who is to decide, how to decide, who is to operate, how best to prepare, and how to follow up, and last, but not least, how to generate more high quality evidence in a morally acceptable manner.”

Next article: Gastric bypass: solution to the resolution of T2DM

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