Ethical Issues Associated with Bariatric Surgery

John Alioche’s Blog Entry
Ethical Issues Associated with Bariatric (Weight Loss) Surgery
October 21, 2006
The United States is experiencing an epidemic of obesity. Under the widely used classification developed by the National Institutes of Health, 34% of the adult population is "overweight" (BMI 25-29.9) and another 27% meet criteria for "obesity" (BMI>30). The overall prevalence of obesity has increased more than 75% since 1980. Obesity is associated with increased type II diabetes, cardiovascular disease (especially hypertension), osteoarthritis and multiple conditions. An obesity-related process called "Syndrome X" or "metabolic syndrome" that includes insulin resistance, abdominal obesity, hypertension, and diabetes and lipid abnormalities.
Bariatric surgery is a textbook example of an area of health care calling for evidence based management of utilization and ethically guided deliberation about coverage policies. At one extreme bariatric surgery can be seen as a life saving, medically necessary intervention that potentially reverses the inevitable trend to sometimes fatal medical conditions. At the other extreme it can be seen as a technical fix for a subjectively distressing result of choices with regard to eating and exercise. The surgery has risks and represents a significant cost (approximately $15-20K). In the past year alone the number of patients that are having Bariatric Surgery has doubled.
Bariatric surgery has risk. Mortality from the surgery itself is less than 1% but post-surgical leakage into the abdomen or malfunction of the outlet from the stomach pouch can require further surgery. Vitamin deficiencies, gallstones, and osteoporosis are among the other complications that can occur. With regard to the basic objective of weight reduction the surgery is not foolproof-some patients ultimately regain the weight they lost, through varying combinations of enlargement of the stomach pouch and return to compulsive patterns of eating.
1. In a culture that is deeply conflicted in its approaches to weight and obesity, how can we best pursue the mission of "improving the health of the population we serve and the health of our society?
2. Should we seek cost effective opportunities to support "upstream" services aimed at shifting the trajectory of obesity earlier in the clinical course with the objective of reducing suffering and medical morbidity and possibly obviating the need for surgery itself? or Encourage optimal education so that members can make well-informed decisions about surgery with full understanding of and commitment to the lifelong post surgical requirements?