Bariatric Surgery: Ethical Considerations in Adolescents and Adults with Cognitive Disabilities

The clinical benefits of bariatric surgery in adult obese patients with type 2 diabetes are well-documented in studies such as Cleveland Clinic’s STAMPEDE (Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently) trial. The related bioethical issues are typically fairly straightforward.

Yet when it comes to two special populations — adolescents and adults with cognitive disabilities — the ethical considerations for bariatric surgery are more complex and multilayered, says Kathryn Weise, MD, MA, of Cleveland Clinic’s Department of Bioethics.

The standard of care at Cleveland Clinic is to seek the expertise of an ethicist on a case-by-case basis in either of these patient populations.

“Adults who don’t have cognitive issues are able to weigh the risks and benefits of bariatric surgery for themselves as long as they are given enough information to make a decision. From an ethics standpoint, the issues that arise for adolescents parallel those of adults but tend to be more complex,” says Dr. Weise. Two of her specialty areas for ethics consults include Cleveland Clinic Children’s and the Bariatric and Metabolic Institute.

Special ethical considerations in adolescents

Cleveland Clinic follows American Academy of Pediatrics guidelines in qualifying adolescent patients for weight-loss surgery. The guidelines focus on the patients’ BMI and obesity-related health issues; the duration of previous physician-supervised weight management attempts; and the attainment/near attainment of physiologic and skeletal maturity. It’s important to rule out underlying medical issues (e.g., thyroid deficiency) that could be treated nonsurgically.

Some ethical considerations that arise for adolescents include:

• Understanding the procedure’s permanency: Patients must understand that bariatric surgery will require major lifestyle changes. Ethics consults with adolescents prior to surgery should include an assessment of their emotional and intellectual maturity to ensure that they understand how the procedure will permanently alter their anatomy and lifestyle. They also must demonstrate the ability to comply with postoperative requirements.Experts have found that adolescents’ views of bariatric surgery can be overly optimistic if they believe it’s going to be their “fix.” Dr. Weise explains: “In general, it can be difficult for some young people to fully comprehend how their actions in the present might affect their long-term future.”
• Comprehending the procedure’s potential long-term The qualifier “potential” is a key part of the equation, Dr. Weise says. Experts have found that adolescents may minimize potential risks and long-term complications.“We have good data in adults on the longer-term effects of surgery, such as the STAMPEDE outcomes,” she explains. “With adolescents, more data have been accumulated in the past decade regarding short-term outcomes and complications, but we don’t yet have good longer-term data.”
• Ensuring that the adolescent has a stable psychosocial environment. “Bariatric surgeries are elective, so it’s important to take the time to ensure that patients have a strong enough support system to help them through this,” Dr. Weise says.
• Adolescents can provide assent, but not consent. In the United States, the legal age for consent is 18 years. Younger adolescents can — and should — provide assent for bariatric surgery by demonstrating that they understand and accept its risks, benefits and alternatives, explains Dr. Weise. However, while U.S. parents and guardians can sign a legal “consent” form for pediatric surgeries, ethically this is considered “parental permission,” and not consent.When there is concern about parental pressure, ethicists may need to ensure – often with a psychologist’s help — that the adolescent is undergoing surgery of his or her own volition.

Ethics consults for patients with cognitive impairment

When cognitive impairment is an issue for adults or for adolescents (e.g., due to developmental delays), many ethical considerations for bariatric surgery are similar to those already discussed, Dr. Weise says. In short:

• A legal guardian should sign a consent form, but ethicists must look for assent from the patient.
• It’s important to ensure that the patient understands the surgery’s risks and benefits.
• The patient must have a stable psychosocial environment and support system in order to adhere to postoperative instructions and to make permanent lifestyle changes.

Multidisciplinary approach

While a bioethicist is a primary facilitator for assessments of assent and permission, a multidisciplinary approach is standard at Cleveland Clinic, Dr. Weise says. The ethicist relies on input from bariatric surgeons, endocrinologists, psychologists and/or psychiatrists, and social workers.

“We consider the severity of patients’ existing health complications, and whether we believe they will be able to sustain any improvements,” she says. “Using a collaborative approach, we look at the health benefits and the psychological issues — and where the balance of all these considerations lies.”