When teens are still fighting to lose weight and are considering bariatric surgery it is important to understand how your doctor will make the decision to recommend surgery or not. The major ethical considerations that are typical of treating children who seriously ill are beneficence, non-maleficence, patient autonomy, and justice, all of which are a part of the Hippocratic Oath. Doctors are often encouraged to use a family-centered approach for decision-making in regards to children who are seriously ill. When children with obesity need invasive medical treatments such as gastric bands, the first thing a doctor will consider is what is in the best interest of the child. The “best interest” standard is directly related to the ethical principle of beneficence. Conflicts often arise when there is a disagreement over what is in a child’s best interest and which outcomes and risks are acceptable and which are not.
The disagreement in many childhood obesity cases is rooted in whether to withhold or withdraw treatment from a child. It is especially complicated when the doctor is suspect of the caretakers motives. For example, doctor shared with me that they had concerns about "healthy weight" parents who have obese children and whether their motives may be more aesthetics based rather than improved health and well-being for their child. A doctor would be right to question the motives of any decision made to withhold or withdraw treatment which may be made in the best interest of the caretaker and not necessarily in the best interest of the child. Conversely, not treating a child for obesity because the caregiver does not perceive the child as “ill” is not benefiting the child.
Non-maleficence means that doctors should avoid causing patients harm or unnecessary suffering. Especially since the child with obesity may have already unnecessarily suffered both physically, emotionally and spiritually before entering the care of the doctor. Children with obesity need even more vigilance by the doctors and nurses to prevent further harm and suffering. In her paper entitled, “Ethical Issues in Pediatric Bariatric Surgery,” Caniano discusses non-maleficence and its role in treating obese children. “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 non-maleficence. In fact, the risks of bariatric operations give the strongest argument against surgery for pediatric patients as noted by Wilde in a 2004 law review article. He observes that physicians trust that morbidly obese adult patients can put all known risks and complications into perspective before agreeing to a bariatric operation. It is not clear that pediatric patients and their families have that same perspective, given the necessity for postoperative lifelong compliance with eating and behavioral modifications and the uncertainty of outcomes decades after the operation.” It is worrisome that children and their families are making decisions with very limited information to help them make the correct choice.
In the US between 2000 and 2009, there was a threefold increase in bariatric surgeries performed on teens age 13 to 18 years. The International Pediatric Endosurgery Group (IPEG) guidelines discuss professional liability and risk management in regards to bariatric surgery. It states “the three most common causes of litigation are death, postoperative complications and failure of informed consent.” Failure of informed consent includes failure to inform patients and families of non-surgical alternatives and alternative operations or failure of a clinician to explain why they are recommending one surgical treatment over another.
Children and teens are especially vulnerable when undergoing preventative procedures because they are "legally incompetent to give fully informed consent for medical procedures, are frequently unable to understand the implications of a proposed treatment, are more susceptible to coercion, and are often powerless to refuse treatment." During intensive treatments for pediatric obesity, clinicians and parents take on the role of health care proxy for a child. Until the recent past, it was often the case that clinicians and parents made health care decisions for children. There has been a shift in our culture that recognizes the autonomy of children, especially teens and their right to special legal and ethical protections. Because of this shift, the assent of the child is recommended before an intensive weight management intervention.
Autonomy is the acknowledgment of a person’s right to self determination and is central to the ethical principle of respect for person. In the cases of obese children over the age of six, they are granted some autonomy however, children under six are not considered autonomous and rely on caregivers and physicians to make decisions for them that are in their best interest. Autonomy of the child is considered utmost importance because the likelihood that the child will grow into an obese adult with chronic illnesses is great.
And finally there is justice as it relates to poverty, health disparities, and access to affordable health care. Treatment may not be an option for many seriously ill children suffering from obesity. Nine million young people between ages 6 and 19 are considered overweight or obese, according to the Centers for Disease Control and Prevention. Some of these children are obese due to social policies that have deprived them of access to affordable fresh fruits and vegetables, healthy and safe play areas, as well as the influences of genetics and family eating behaviors. Teens with obesity are also the result of a failed health care system, the prevalence of health disparities in society, and the role of poverty in the epidemic. Teens with obesity will face many barriers to becoming healthy adults. Access to affordable, safe, effective obesity treatments will significantly impact the health outcomes of this vulnerable population. Not only do hospitals have a duty to provide access to services where they are most needed, they must not exclude patients based on socioeconomic status.
Caniano DA.Ethical issues in pediatric bariatric surgery. Semin Pediatr Surg. 2009 Aug;18(3):186-92. doi: 10.1053/j.sempedsurg.2009.04.009.