In a field rife with controversy and disagreement, there is strong consensus among obesity experts at home and abroad that bariatric surgery is life-saving, cost-effective and reduces pain and suffering for patients with severe and complicated obesity.
More people than ever need surgery.
Data from the Irish longitudinal study of ageing (TILDA) suggest that 8 per cent of Irish adults over 50 years' old, or 92,573 people, fulfil current surgical criteria. Although only some will pursue that option, their access to it in Ireland is dreadful, with fewer than one per 100,000 operations done here annually, compared to 70 per 100,000 in Sweden and France, and 50 per 100,000 in the US.
Delayed surgery causes harm, with one study showing a three-fold increased mortality over a decade compared to timely care. Although the Irish Government has recognised obesity as a disease since 2005 and has committed to developing bariatric services as part of its recent Obesity Policy and Action Plan, programmatic funding is still completely lacking and inadequate bariatric resources continue to frustrate health professionals and distress patients. A recent collaboration between UCD, NUIG and St James's Hospital explored how this constitutes a violation of the four principles of contemporary biomedical ethics.
The first principle, autonomy, refers to an individual’s right to self-determination and their ability to make decisions about treatment based on their own beliefs and values. Autonomy requires intentionality, understanding and an absence of undue influence or coercion. Constraining treatment choice for patients breaches their autonomy. Although the archaic, pejorative view that obesity represents a lack of discipline and self-control has largely been dismissed, discourse about obesity remains derogatory and misogynistic. Doctors are as biased as the general public against people with obesity and 24 per cent of nurses in one US study described feeling “repulsed” by obese patients. Experiences of poor treatment can lead to distress and avoidance of care in affected patients. Half have weight bias internalisation, or self-stigmatisation, which is known to hinder weight-loss. Where stigma and bias limit access to proven, efficacious interventions, it constitutes an unacceptable breach of patients’ autonomy.
There is no real doubt that the provision of bariatric surgical care to appropriately selected patients “does good” and fulfils the second ethical principle of beneficence. A recent Cochrane review of 22 trials found surgery was more clinically effective and cost-effective for treating severe obesity than medications or lifestyle modification. One Swedish study showed 15 per cent weight-loss maintained for 20 years after surgery, with improvements in co-morbidities such as diabetes. Another showed a 58 per cent reduction in mortality after four years in patients with diabetes.
Costs of surgery
The costs of surgery fall well below conventional thresholds for cost-effectiveness. In patients with diabetes, for example, surgical costs are recouped within three years through reduced direct healthcare costs driven by fewer prescriptions, as well as reduced indirect costs such as State disability allowances, where patients return to paid employment.
The third principle, non-maleficence, means first doing no harm. This goes beyond a consideration of complications from bariatric surgery. John Stuart Mill developed the so-called "harm principle" to inform thresholds for acceptable harm and in particular the extent to which legislation should be enacted to mitigate perceived public-health risks. Essentially, where individuals risk harm only to themselves through specific actions, there is less of an imperative to restrict personal freedom than if those actions pose risks to others. Thus, legislation to reduce the effects of exposure to passive smoking or excessive vehicular speed is warranted.
Exposing obese individuals to potential harm because their excess body weight imposes costs on others has been espoused even recently by ethical scholars such as Peter Singer, who argued that heavier airline passengers should be charged more to fly. He noted Quantas were paying Aus$1 million a year more on their London to Singapore route because the average passenger was two kilogrammes heavier than in 2000. He argued that such harms and costs caused by obese people justified public policies "that discouraged weight gain".
Politically, adverse lifestyle choices seem to forfeit the right to healthcare
Others went further in proposing coercive public-health measures to try to induce overweight people to be thinner. This focus on making obese people aware of their lack of moral fibre and self-control pervades popular media, leading to self-stigma, which aside from diminishing autonomy, also causes harm. The culture of acceptance of that harm drives aspects of our public-health policy today, such as childhood obesity screening programmes which may cause harm, without evidence they do any good. Christopher Mayes, research fellow at the Centre for Values, Ethics and the Law in Medicine at the University of Sydney, counters that these approaches rely on "superficial readings of public-health research to amplify the harm caused by obese individuals and ignore pertinent epidemiological research on the social determinants of obesity".
He argues that structural and environmental factors rather than individual choice should be the focus for obesity-prevention strategies. Otherwise, we risk “harming the already harmed”. The reliance on coercive public-health measures that magnify stigma and harm may also perpetuate a pejorative, moralistic view of severe obesity that diminishes the political imperative to provide patients with the bariatric healthcare they need.
The fourth and final principle of medical ethics is justice, which reflects the need for a fair and equal distribution and allocation of healthcare resources in society. There are three domains to the concept of ethical justice. Firstly, there is recognition that all resources are finite. Secondly, the rights of individuals need to be respected and, thirdly, morally established and accepted laws need to be upheld.
Suggestions that inadequate resources justify the failure to provide bariatric surgical services to severely obese adults do not stand up to scrutiny, because the science tells us that it is certainly cost-effective. For example, a health technology assessment in the UK suggested the cost per quality adjusted life year (QALY) was less than €5,000 for bariatric surgery. By way of comparison, the cost per QALY for the cystic fibrosis drug Orkambi is between €369,141 and €649,624, according to the HSE’s own analysis in 2016, which deemed it to be prohibitively poor value for money. It was funded all the same.
Politically, adverse lifestyle choices seem to forfeit the right to healthcare. This is reminiscent of the approach taken to patients with Aids in the 1980s, where an emphasis on ethical behaviour was preferred to prioritising treatment for those who developed the disease. In the US, the American Disability Act provides some protection for obese people from discrimination at work. The European Court of Justice has ruled that it is illegal to discriminate against employees with obesity where it constitutes a disability. Article 12 of the International Covenant on Economic, Social and Cultural Rights outlines obligations of nations to respect and protect their citizens’ right to health.
So, the current denial of bariatric care not only constitutes a breach of ethical justice but also seems unwise. Patients stand to benefit from it, reliance on other strategies such as coercive public-health measures may be harmful and surgery represents good value for money.
However, because of pervasive bias and stigma, severely obese patients are not a political priority.
It is yet another scandal waiting to happen, unless you think that they should just eat less, get active and have more expensive airline seats.
– Hilary Craig is a graduate of the masters programme in healthcare and law at RCSI and the regional oncology programme manager at St James's Hospital in Dublin. Francis Finucane is a consultant endocrinologist at Galway University Hospitals and an honorary personal professor in medicine at NUIG