Conscience and Consent

(This continues from the previous post, on weight loss surgery and consent.)

Now think about another area. Courts are asked to decide if a 14-year-old girl can get birth control without parental consent. Even with consent, how old should a child be before puberty blockers and cross-sex hormones may be prescribed?

Cases are being argued about sexual reassignment surgery. Although not quite as impactful, bariatric surgery also changes the body irreversibly and brings lifelong consequences. A recent article about weight loss procedures says,

Institutions that offer MBS for pediatric patients will benefit from collaborating with ethics consultants to develop a structured approach that helps ensure that ethical principles have been adequately addressed for patients presenting for MBS.

[…] Ethical issues remain possible for each case… Specifically, ethical issues related to principles of autonomy, justice, beneficence, and non-maleficence may need to be resolved based on patient characteristics, including preadolescent patients and those who present with intellectual disabilities.

What kinds of stressors could affect children and violate the principles of beneficence and non-maleficence? In some cases, there has seemed to be pressure to consent. Blogger s.e. smith wrote,

When your doctor is leaning on you to get the surgery, and so are your parents, and you’re being tormented at school for your weight, are you really making an independent choice?

Parents, too, have an additional fear in the form of multiple reported cases of fat children being seized by child services for being fat. Having a fat child is viewed as evidence of unfit parenting… Those parents might be forcing diets and exercise and other measures on their children, and could respond positively to a recommendation for weight loss surgery when these measures don’t work.

In regard to medical ethics and moral accountability, a surgeon in the field, Dr. Aparna Govil Bhasker, wrote about the danger of overzealous adults pressing for surgery that can lead to “unanticipated negative consequences several years into the future”:

These children are too immature to understand the gravity of the surgery being performed on them. For many years to come, they will not be able to apprehend the demands and exigencies of a bariatric procedure… It is also not justifiable to surgically modify healthy organs of an innocent toddler in absence of any clear evidence regarding safety and future outcomes.

There is a fear that over-enthusiastic media attention can have the effect of coercing parents into consenting to surgery for obese toddlers and children. Aside from the purely physical consequences, by agreeing to bariatric surgery, parents are signing up their children for a lifetime of surveillance, as if there were not enough of that sort of thing already. Maybe it would be better to direct more energy toward figuring out what causes runaway obesity, and dispense with the surgical option except in the most extreme cases.

Along with the need for a multi-disciplinary team in advance of any surgical intervention, everyone agrees on the necessity of long-term followup. This is crucial both for the patient’s sake, and for the collection of data necessary to make surgery safer and more effective for the next generation of patients.

Your responses and feedback are welcome!

Source: “The Role of Ethics Consultation in Decision Making for Bariatric Surgery in Pediatrics,” ScienceDirect.com, 01/18/20
Source: “Fat Hatred Kills: Marketing Weight Loss Surgery to Children Has Got to Stop,” Meloukhia.net, 03/12/12
Source: “Bariatric Surgery — Should Children Have It?,” AparnaGovilBhasker.com, 12/17/18
Image by Jon Collier/Flickr

Bariatric Surgery, Qualifications, and Conscience

The previous post discussed an article published by The Journal of Lancaster General Hospital, written by Jennifer C. Collins, M.A., M.S. and Jon E. Bentz. The authors recall a National Institutes of Health panel discussion of decision criteria for metabolic and bariatric surgery (MBS). Does the candidate possess and demonstrate the following qualities?

(1) awareness of the procedure and capacity to give informed consent;
(2) motivation for surgery;
(3) awareness of and capacity for compliance with post-surgery restrictions and behavior change;
(4) current stressors, behavioral and eating practices that might be barriers to the life style changes that are necessary for a successful outcome; and
(5) current psychological well-being and stability, self efficacy, resiliency and coping resources to manage stress.

Obviously a seven-year-old can not be fully aware of what the procedure entails. Additionally, operating on an obese patient involves special challenges to the medical staff. She or he is more difficult to move, and to position in whatever way is required by the specific procedure. The insertion of breathing tubes and management of airways is more difficult. Establishing the correct level of sedation is trickier. For scalpel or scope, body fat can hinder access to the patient’s internal organs. Because of factors like poor blood supply to the wound, the chance of infection goes up.

One expert enumerates the physical problems that may arise after a gastric bypass:

[…] low blood sugar […] constipation, dumping syndrome (nausea, vomiting, and weakness caused by eating high sugar meals, sodas, and fruit juices) […] possible leaks in the new connections […] body aches or fatigue (vitamin or mineral deficiency may be the cause). You may feel cold. Dry or sagging skin, hair loss or thinning, and the inability to process certain vitamins (B12 and D) and minerals (iron, folate, calcium)…

In the short term, incision care is an important responsibility. Depending on the technique and other factors, internal and external scarring can be a problem. The body might reject any inserted device, like the band in lap-band. The post-op patient may need to taper off from pain meds, and/or stick to a liquid diet for some time.

Any surgery described as “minimally invasive” involves the insertion of carbon dioxide to create space and spread things out so the surgeon can visualize the organs and maneuver the instruments around. Here is Elizabeth Wolinsky’s description of her immediate post-op days:

Even though you just got out of surgery and you’re tired and in pain, you have to keep walking. You feel the air travel upward, toward your shoulder. It’s 10 times more painful than your body actually healing from surgery.

(To be continued…)

Your responses and feedback are welcome!

Source: “Behavioral and Psychological Factors in Obesity,” JLGH.org, Winter 2009
Source: “Operating on the obese: what can go wrong,” Stuff.co.nz, 05/09/18
Source: “What You Should Know Before Undergoing Bariatric Surgery,” TheDoctorWeighsIn.com, 01/31/18
Source: “9 Things I Wish I Knew About Gastric Bypass Surgery Before I Had It,” WomensHealthMag.com, 01/18/17
Image by GPA Photo Archive/Attribution 2.0 Generic (CC BY 2.0)

Still More on the Mind and Bariatric Surgery

Psychological blocks and disturbances segue into more worrisome psychiatric problems, all in need of professional help. Patients experience eating disorders, stress, anxiety, depression, low self-esteem, and multiple concerns about how their bodies look and function.

Some people start out with psychological problems that drive them to overeat. Others overeat through habit and ignorance, with possibly an overlay of cultural norms, and then develop psychological problems because they are obese.

Mental and emotional kinks that existed before the weight loss surgery will, if left untreated, remain after the surgery and may even, as we saw in the previous post, become worse. Until ways are figured out to help all patients get their heads straight, bariatric surgery can never be celebrated as a magic bullet.

A couple of years ago, Rahesh Sagar and Tanu Gupta wrote for The Indian Journal of Pediatrics that increasing attention is being paid to the mental health of obese children. This quotation sums up the case:

Co-morbid psychosocial and emotional problems of obesity generally act as causal or maintaining factors of obesity and thus significantly affect the treatment outcome. Therefore it becomes imperative for the clinicians/pediatricians to broaden their clinical assessment and include screening of important psycho-social factors within the clinical examination of childhood obesity.

One writer noted that the psychological effects of bariatric surgery are more profound in the young, than in adults:

Studies indicate that the chances of depression in adolescents after gastric banding are high… When they gain weight even after surgery, people can feel shame and guilt, which adds to the obesity burden. Some studies also point towards an increased incidence of teenaged pregnancies two years after bariatric surgery in female adolescents.

Elsewhere, pediatrician Stephen R. Cook reminds the profession that after bariatric surgery, just like with an organ transplant, adequate followup care is essential. For a procedure that is both transformative and stressful, all surgical candidates need mental health support. Particularly for children, a stable home environment is essential.

In Britain, a financial services company started a campaign to resist the stigma around mental health problems, and support mental health in the workplace. The method they decided on was sport. As Childhood Obesity News has mentioned, Paralympian (and Baroness) Tanni Grey-Thompson speaks to groups about how frequent, vigorous exercise positively affects a person’s state of mind.

With a base of improved mental health to work from, a person will much more easily adopt a lifestyle that improves the body’s health. Although, of course, the two concepts are inextricably entwined, weight loss is not an explicit goal of exercise, but an inadvertent side benefit.

The CEO of Legal and General (the company name) Nigel Wilson is quoted as saying,

It is just so difficult to come up with the right solutions in the mental health area.

Very many primary care physicians and other health professionals would second that emotion. The psychological component is the elephant in the room. Progress cannot be made until obvious obstacles are addressed. To put it succinctly, a child will never be able to fight obesity, while living with parents who fight about obesity.

It may be plain as day that one parent is tuned in to all the important concepts of healthful living, while the other insists on sabotaging the good work by sneaking treats to the child out of misplaced spite, or even in a genuine, if pathetic, attempt to buy love. What, in the course of a 15-minute appointment, is a primary care physician supposed to do about that?

Your responses and feedback are welcome!

Source: “Psychological Aspects of Obesity in Children and Adolescents,” Springer.com, 11/18/17
Source: “Weight Loss Surgery Helps 8-Year-Old Lose 7.6 Kg in 20 Days,” Latestly.com, 01/08/19
Source: “Should Children Have Weight Loss Surgery?,” Healthline.com, 01/09/18
Source: “Tanni Grey-Thompson urges athletes to share their mental health struggles to help reduce stigma,” EalingTimes.co.uk, 10/23/17
Image by Chris Isherwood/Flickr

More on Bariatric Surgery and the Mind

Back in 2009, the Journal of Lancaster General Hospital published an article whose theme was the psychic effects of bariatric surgery. The results can take so long to show up, and the amount of weight loss might not meet patient expectations. They tend to lose motivation and have difficulty sticking to the mandatory post-op dietary restrictions. If emotional eating was the original problem and they haven’t gotten a good overhaul in the emotional department, the same problem will persist.

Even when weight loss is successful, some patients find the experience of living in a different anatomy so disorienting that it is difficult to cope, and they experience a perverse kind of off-brand body dysmorphia. Or the sagging, empty skin bothers them to a degree they did not anticipate.

Or if a fortress of fat was their defense against sexual interference, that feeling of being protected no longer exists, and post-traumatic symptoms can flare up. The report says,

Psychologists can assist these patients by utilizing cognitive restructuring to help them rationally evaluate their progress, as well as behavioral activation to aid them in making healthy behavior changes… Psychologists can help these patients identify their triggers for emotional eating and encourage them to develop a coping repertoire that involves more constructive behaviors rather than eating.

When Dr. Pretlow attended the European Childhood Obesity Group Congress in 2014, he was disappointed to learn that, rather than being viewed as an extreme measure and a last resort, especially for the young, bariatric surgery had become a treatment of choice. Nevertheless, the chair of the bariatric surgery session said, “Even gastric bypass surgery produces only a temporary remission” and noted that 25% of the adolescents who undergo gastric bypass surgery fail to lose weight and of those who do, 43% gain the lost weight back. .”

On the other hand, the event for the first time presented both a poster and a main session on psychology. Psychologist Carolyn Braet of Ghent University, lead author of the ECOG position paper on the psychological assessment of child/adolescent obesity, talked about the psychological causes of overeating and obesity. She mentioned psychological factors including emotional eating, disinhibited eating, and reaction to restrained eating.

The position paper stated that…

[…] dietary restraint attitudes and dieting behaviours are often observed and can be alternated with disruption and binge eating which paradoxically can lead to weight increase . It is also hypothesized that failures of (rigid) restraint behaviour cause distress which in turn promotes more emotional eating… As a result, susceptibility to abnormalities in eating patterns is likely to increase, and strict dieting as well as dietary attitudes are therefore identified as ‘risk variables for eating disturbances.’

Here’s the problem. Post-op bariatric surgery patients must eat consciously and carefully for the rest of their entire lives — with this “risk variable” hanging over their heads every day, in perpetuity. No wonder things often don’t work out! It was also pointed out in discussion that with many young patients, after the surgery, food still has to be hidden from them, which is definitely not a promising indicator for lifelong weight loss maintenance.

In the discussion period, Dr. Pretlow opined that obesity is primarily a psychological problem and most likely a behavioral addiction. Dr. Braet mentioned that while one may not necessarily believe that overeating is an addictive process, one might still acknowledge that addiction treatment methods might still be effective for treating obesity.

Your responses and feedback are welcome!

Source: “Behavioral and Psychological Factors in Obesity,” JLGH.org, Winter 2009
Image by Zaid Alasad/Flickr