Some studies indicate that bariatric surgery may be effective on short and medium term weight loss which, is associated with a reduction of comorbidities, such as diabetes. Furthermore, it is generally believed that several types of bariatric surgery are cost-effective. This poses a moral imperative to provide surgery to a vulnerable group of patients in need of help. However, high quality evidence on safety, efficacy, effectiveness, efficiency, and cost savings for children and adolescents is lacking. Exposing young people to potentially harmful treatment with uncertain outcomes is morally problematic. Hence, it is difficult to assess the risk/benefit ratio [63
] and there is a moral imperative to provide high quality evidence.
Moreover, bariatric surgery for children and adolescents poses predicaments with informed consent and assent due to the complexity and uncertainty of information, reduced decision making capacity (e.g., due to potential psychiatric comorbidity), and lack of voluntariness due to family bonds. As obesity is frequently considered to be a life-style disease, it is associated with parental responsibility. The involvement of third party agents (parents) and the association with responsibility and guilt complicate issues of consent, assent, justice [30
], and the assessment of the best interest of the child.
Obesity is subject to prejudice and discrimination, posing challenges with prioritization and just distribution of health care. As prejudice is identified also among health professionals it may alter the patient-professional relationship and trust in the health care system. Widespread bariatric surgery for minors can advance ideals on health and beauty which, may be part of the primary problem. Hence, bariatric surgery is more than a mere medical intervention shaping biological bodies – it shapes and is shaped by culture.
Whether obesity is a disease, how it is defined and classified, and the selection of end-points for outcome assessment strongly depends on social commitments and moral conceptions, e.g., on what we believe to be harmful and how we think we can provide the best help. Accordingly, it may be important to avoid the critique that bariatric surgery for obesity in minors is a medicalization of their life-world and a quick fix [225
The ethical analysis in this review does not end with simple answers or concrete recommendations. The reason for this is fourfold. First, the (Socratic) approach does not aim at presenting clear cut conclusions. Rather it aims at revealing important moral issues that are relevant for open and transparent decision making processes. Second, decisions have to be made in context and contexts are different, e.g., the conceptions of the autonomy of minors is assessed differently in different countries. Arguments have to be assessed, values weighted, and alternatives appraised in the context of decision making. Third, the conclusions may change rapidly as new methods and new evidence emerges. Still, many of the moral issues are generic and may be relevant and have to be addressed in order to implement and offer bariatric surgery to obese minors in a morally acceptable way. Fourth, this review is written by an ethicist with special interest in surgery, biotechnology, and health technology assessment. Despite this competence, it is far from obvious that the opinion of experts in ethics should have special weight or priority [226
]. Others may be as well qualified. In particular, we should listen to the group in question, and their voice is not always loud or apparent in the professional literature.
The analysis presented here displays the values at play in, and related to, the assessment of bariatric surgery for obese minors. In particular, it tries to highlight the evaluative aspects of what is regarded as fact. In that manner it does the preparatory work for the decision making process. Even more, it tries to direct the process towards openness and transparency. Ignoring unpleasant, but important, value issues may become more difficult when they have been explicitly pointed to and highlighted.
Moreover, the selection of questions and challenges discussed in this review is by no means value neutral [31
]. Nevertheless, the review does not represent specific interests, such as patient interest groups, surgeons, industry, health care managers, health insurers, or health policy makers.
Other methods may, of course, have been applied [35
]. Nevertheless, the approach applied here is fairly well established for assessing health technologies and is able to highlight many of the challenges that are identified in the literature. It has also been applied to bariatric surgery for adults [28
] and bariatric treatment for adults [29
Sources of data other than the professional and scientific literature could also have been applied. In particular, primary studies with qualitative interviews of eligible persons for bariatric treatment, surgeons, industry, health insurers, and health policy makers could shed new light on the issue. However, primary research has been beyond the scope of this review.
How specific are the reviewed moral challenges for bariatric surgery? Are they as relevant for other health care interventions as well? This may well be, but bariatric surgery poses particular quandaries for minors because it uses medical interventions to alter everyday behavior (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. It provides no cure but, offers symptom relief and prevents other diseases. Moreover, the disease that bariatric surgery is directed at alleviating is special in that it is considered to be self-inflicted, resulting from lack of self-control, and is subject to prejudice. The evidence for the outcome is also of poor quality for minors.
Accordingly, it can be argued that to operate or not to operate, is not the question. The important questions are; when is the right time for surgery? Which are the right patients? How should they be prepared for surgery? [25
], and how should they be followed up? [25
]. Surgery very early in the development of obesity can have serious consequences, but surgery late in the development of severe obesity may also be harmful [99
]: ‘[a] stitch in time versus a life in misery’ [230
]. This dilemma corresponds well with a long tradition in medical ethics framed by the Greek concept kairos
, finding the right time for intervention. It also reminds us of Macbeth: “one must ‘make assurance doubly sure.”