No question, bariatric surgery can have benefits for patients with type 2 diabetes. For example, some research has found that bariatric surgery may help obese patients lose a substantial amount of weight, control glucose, and perhaps even send the diabetes into remission. However, critics say the remission of type 2 diabetes after surgery is often only transient, and the long-term effects on glucose control, lipid profiles, hypertension, and other risk factors are still not fully understood. Although bariatric surgery is being touted for patients with a body mass index of < 35 kg/m2, the push may be premature, say researchers from University College of Gjøvik, University of Oslo, Vestfold Hospital Trust, and Oslo University Hospital Ullevål, all in Norway.
In fact, those aren’t the only reasons to hesitate. The researchers point out that bariatric surgery modifies otherwise healthy organs with partly irreversible methods; some patients may feel shame and guilt after surgery; and there’s a contingent that holds the surgery to be part of the “medicalization of modern life, transforming physical states into diseases, persons into patients, and behavioral problems into surgical tasks.” The authors also note that some critics argue that bariatric surgery is “governed by overtly strong professional and commercial interests.”
How to walk the tightrope of those concerns? The researchers reviewed the literature to find appropriate studies and then used the Socratic method to “highlight the most pertinent moral questions.” The purpose of their question-based approach, they say, is not to produce clear-cut answers to all challenging questions from an “ethics ivory tower” but to draw attention to norms, values, and arguments that decision makers may need to account for when selecting the best treatment options for this group of patients.
With the help of the literature search, informal interviews with experts, and patient-interest groups’ web pages, the researchers identified 8 questions as morally relevant. The search revealed 68 articles that could shed light on the questions they were asking.
Those questions included Is bariatric surgery a safe and effective means of treating T2DM? Despite the overwhelming number of studies, the researchers say, the evidence is “of too poor a quality.” Another question was What is the goal of the treatment? That’s a moral as well as a clinical question, they point out, because endpoints indicate the goal of treatment and what is considered to be “a good life.”
Overall, the researchers say they identified several moral issues important on the individual, management, and health policy levels: assessing and informing about safety and patient outcomes, defining and selecting endpoints, assessing stakeholder interests, acquiring valid informed consent, stigmatization, discrimination, and just distribution of health care. The moral challenges seem to arise, they add, from a lack of high-quality evidence, from disagreement on clinical indications, from prejudice against people with “lifestyle diseases,” and from “trying to discipline human behavior through surgery.”
Their study is not exhaustive, although they covered a number of issues, the researchers say. Other relevant questions remain.
Hofmann B, Hjelmesæth J, Søvik TT. J Diabetes Compl. 2013;27(6):597-603.