Ethics challenge winner 2017/2018. Bariatric surgery for adolescents

Paediatric bariatric surgery presents a unique ethical challenge for physicians, healthcare institutions, patients, and their families. It is a topic that deserves thorough discussion among healthcare providers due to the ethical implications of performing surgery on a vulnerable population. Obesity in children and adolescents is defined as a body mass index (BMI) at or above the 95th percentile compared to peers of the same age and sex. From 2011-2014, the prevalence of obesity in children and adolescents in the US aged between two and 19 years was 17%, with 12.7 million children and adolescents affected. In Ireland, obesity in children and adolescents increased ten-fold among boys and nine-fold among girls from 1975 to 2016. Obesity in adolescence is associated with type 2 diabetes, hypertension, obstructive sleep apnoea (OSA), dyslipidaemia, non-alcoholic steatohepatitis, polycystic ovary syndrome, and various musculoskeletal diseases. In addition, there are serious psychological consequences of obesity, such as low self-esteem and social exclusion. Research shows that obese children are at a higher risk of becoming obese adults. In addition, these adolescents will incur disproportionately higher medical care costs as adults. More harrowing is the knowledge that the risk of dying from obesity increases by 6-7% for every two years lived with obesity. Although recent trends show that obesity in children and adolescents has plateaued in high-income countries, there remains a large paediatric population battling obesity and its associated complications. Currently, the principal approach to obesity in adolescence is conservative medical management with behavioural and dietary modifications. However, strategies such as family-based behavioural therapy coupled with caloric reduction and physical activity have proven effective in only 50% of patients with severe obesity. This suggests a critical need for a more effective weight reduction solution for many adolescents. Paediatric bariatric surgery provides an intervention that may be more effective than a strictly medical or lifestyle approach, with the aim of intervening early to prevent or halt the progression of comorbidities associated with obesity. In the adult population with morbid obesity, bariatric surgery has become the only intervention that reliably produces significant and sustained weight loss. In recent years, there has been an increase in the use of bariatric surgery for treatment of obesity in adolescents. Despite this, bariatric surgery in this population remains relatively underutilised, most likely due to multifactorial barriers such as concerns regarding safety, ethical implications, and long-term effects on the growing adolescent. In addition, there is a general consensus that non-operative treatment remains superior. The ethical debate regarding paediatric bariatric surgery centres on the principles of beneficence, non-maleficence, autonomy, and justice, taking into account the risk and safety profile of the procedure and the current lack of knowledge concerning the long-term implications of bariatric surgery in the paediatric population.