BARİYATRİK CERRAHİNİN ETİK SORUNLARI: SİSTEMATİK BİR İNCELEME

Abstract

Bariyatrik cerrahi (BC) obezite tedavisinde kullanılan etkili bir tedavi yöntemidir. Obezite oranının artmasıyla birlikte BC yöntemiyle tedavi edilen birey sayısı da her geçen gün artmaktadır. Etik analiz, Sağlık Teknolojisi Değerlendirme (STD)'nin dokuz boyutundan biridir. Obezitenin BC ile tedavisinde etik tartışmalar devam etmektedir. Bu çalışmanın amacı BC ile ilgili etik konuları inceleyen araştırmaları sistematik olarak incelemektir. Sistematik taramada 2000-2023 yılları arasında Pubmed veri tabanı taranmış ve 549 makaleye ulaşılmıştır. Dahil etme ve dışlama kriterleri kapsamında 10 makale çalışmaya alınmıştır. Çalışmaların yarısı genel obez bireylerde BC ile ilgili tartışılan etik konuları ele almıştır. Diğer çalışmalarda ise çocuklar, ergenler ile zihinsel ve gelişimsel bozukluğu olan engelli obezlerde etik sorunlar incelenmiştir. BC ile ilgili tartışılan etik konular; obezitenin tıbbileştirilmesi, risk ve komplikasyonlar, belirsizlik, yetersiz bilimsel bilgi, bilgilendirilmiş onam, adalet, özerklik, erişim, eşitlik, damgalama, maliyet ve toplumsal algıdır. Çocuk ve ergen obez hastaların BC ile tedavi olması, etik olarak tartışılan en önemli konulardan biridir. Türkiye’de bu hastalıkla etkin şekilde mücadele etmek, toplumun obezite ile mücadele konusunda bilgi düzeyini artırarak bireylerin sağlıklı beslenme ve düzenli fiziksel aktivite alışkanlığı kazanmalarını teşvik edecek sağlık politikaları geliştirilmelidir. Ayrıca obezite ile mücadele kapsamında yürütülen programın maliyet etkililik analizlerinin yapılması önerilmektedir.

Keywords

• Bariyatrik Cerrahi
• Obezite Cerrahisi
• Sistematik Tarama
• Etik

ETHICAL ISSUES IN BARIATRIC SURGERY: A SYSTEMATIC REVIEW

Abstract

Bariatric surgery (BS) is an effective treatment method used in the management of obesity. With the increasing prevalence of obesity, the number of individuals treated through BS continues to rise. Ethical analysis is one of the nine dimensions of Health Technology Assessment (HTA). Ethical debates surrounding the treatment of obesity through BS are ongoing. The aim of this study is to systematically review research examining the ethical issues related to BS. A systematic search was conducted in the PubMed database from 2000 to 2023, resulting in 549 articles. Ten articles were included in the study based on inclusion and exclusion criteria. Half of the studies addressed ethical issues related to BS in the general obese population. The other studies focused on ethical concerns in obese children, adolescents, and individuals with intellectual and developmental disabilities. Ethical issues discussed in relation to BS include the medicalization of obesity, risks and complications, uncertainty, insufficient scientific knowledge, informed consent, justice, autonomy, access, equity, stigma, cost, and societal perception. The treatment of obese children and adolescents with BS is one of the most debated ethical issues. To effectively combat this condition in Turkey, health policies should be developed to increase public awareness about obesity and encourage individuals to adopt healthy eating and regular physical activity habits. Additionally, conducting cost-effectiveness analyses of obesity treatment programs is recommended.

Keywords

• Bariatric Surgery
• Obesity Surgery
• Systematic Review
• Ethics

References

1. Albaugh, V. L. & Abumrad, N. N. (2018). Surgical treatment of obesity. F1000Research, 7 (617), 1-13. http:// doi: 7 10.12688/f1000research.13515.1
2. Boles, R. E., Moore, J. M. & Glover, J. J. (2020). The role of ethics consultation in decision making for bariatric surgery in pediatrics. Seminars in Pediatric Surgery, 29(1), 1-8. http:// doi: 10.1016/j.sempedsurg.2020.150884.
3. Buchwald, H. (2005). Consensus conference statement bariatric surgery for morbid obesity: Health ımplications for patients, health professionals, and third-party payers. Surg Obes Relat Dis, 1(3), 371-381. http:// doi: 10.1016/j.soard.2005.04.002.
4. Craig, H., le Roux, C., Keogh, F. & Finucane, F. M. (2018). How ethical ıs our current delivery of care to patients with severe and complicated obesity? Obesity Surgery, 28(7), 2078-2082. http:// doi: 10.1007/s11695-018-3301-1.
5. Celio, A. C. & Pories, W. J. (2016). A history of bariatric surgery. Surgical Clinics of North America, 96(4), 655-667.
6. Dixon, J. B., Anderson, S. J. & Hamdorf, J. (2023). Ethical challenges in delivering surgical ınnovation: Llaparoscopic bariatric-metabolic surgery and sentinel node biopsy for melanoma: An Australian perspective. Obesity Surgery, 33(4), 1295–1296. http:// doi: 10.1007/s11695-023-06504-7.
7. Donato, K. A. (1998). Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Archives of Internal Medicine, 158(17), 1855-1867. https://doi.org/10.1001/archinte.158.17.1855.
8. Ekmekci, P. E. & Güner, M. D. (2019). Evaluation of ethical analyses in seven reports from the European network for health technology assessment. International Journal of Technology Assessment in Health Care, 35(4), 273. https://doi: 10.1017/S0266462319000485.

9. Gopalakrishnan, S., & Ganeshkumar, P. (2013). Systematic reviews and meta-analysis: Understanding the best evidence in primary healthcare. Journal of Family Medicine and Primary Care, 2(1), 9. https:// doi: 10.4103/2249-4863.109934.
10. Hofmann, B. (2010). Stuck in the middle: the many moral challenges with bariatric surgery. The American Journal of Bioethics : AJOB, 10(12), 3–11. https:// doi: 10.1080/15265161.2010.528509.
11. Hofmann, B. (2013). Bariatric surgery for obese children and adolescents: A review of the moral challenges. BMC Medical Ethics, 14(1). https:// doi: 10.1186/1472-6939-14-18.
12. Jordan, K., Fawsitt, C. G., Carty, P. G., Clyne, B., Teljeur, C., Harrington, P. & Ryan, M. (2022). Cost-effectiveness of metabolic surgery for the treatment of type 2 diabetes and obesity: a systematic review of economic evaluations. European Journal of Health Economics. https:// doi: 10.1007/s10198-022-01494-2.
13. Kremen, A., Linner, J. & Nelson, C. (1954). An experimental evulation of the nutritional ımportance of proximal and distal small ıntestine. Annals of Surgery, 140(3), 439–448. https:// doi: 10.1097/00000658-195409000-00018.
14. Martinelli, V., Singh, S., Politi, P., Caccialanza, R., Peri, A., Pietrabissa, A. & Chiappedi, M. (2023). Ethics of bariatric surgery in adolescence and ıts ımplications for clinical practice. International Journal of Environmental Research and Public Health, 20(2). https:// doi: 10.3390/ijerph20021232.
15. Moore, J. M., Glover, J. J., Jackson, B. M., Coughlin, C. R., Kelsey, M. M., Inge, T. H., & Boles, R. E. (2021). Development and application of an ethical framework for pediatric metabolic and bariatric surgery evaluation. Surgery for Obesity and Related Diseases, 17(2), 425-433. https:// doi: 10.1016/j.soard.2020.09.014.
16. NIH. (1992). Gastrointestinal surgery for severe obesity: national ınstitutes of health consensus development conference statement. American Journal of Clinical Nutrition, 55(2 SUPPL.). https:// doi: 10.1093/ajcn/55.2.615s.
17. NIH. (2000). The practical guide: ıdentification, evaluation, and treatment of overweight and obesity in adults. In National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK2003/ adresinden 21 Nisan 2024 tarihinde alınmıştır.
18. Puia, A., Puia, I. C.,& Cristea, P. G. (2017). Ethical considerations in bariatric surgery in a developing country. Clujul Medical (1957), 90(3), 268–272. https:// doi: 10.15386/cjmed-733
19. Purnell, J. Q. (2023). Definitions, classification, and epidemiology of Obesity. https://www.ncbi.nlm.nih.gov/books/NBK279167/ adresinden 20 Nisan 2024 tarihinde alınmıştır.
20. Sağlık Bakanlığı. (2021). Obezite ve metabolik cerrahi klinik protokolü. Ankara.
21. Saarni, S. I., Anttila, H., Saarni, S. E., Mustajoki, P., Koivukangas, V., Ikonen, T. S. & Malmivaara, A. (2011). Ethical issues of obesity surgery--a health technology assessment. Obesity Surgery, 21(9), 1469-1476. https:// doi: 10.1007/s11695-011-0386-1.
22. Samuels, S. L. & Rossi, W. C. (2018). How forcefully should clinicians encourage treatment when disagreement persists about obesity risk? AMA Journal of Ethics, 20(12), E1126-E1132.
23. TEMD. (2017). Obezite tanı ve tedavi kılavuzu. Türkiye Endokrinoloji ve Metabolizma Derneği, Ankara.
24. Tessier, D. J., & Eagon, J. C. (2008). Surgical Management of Morbid Obesity. Current Problems in Surgery, 45(2), 68-137. https:// doi: 10.12688/f1000research.13515.1
25. TÜİK. (2023). Obezite oranları. TÜİK. https://data.tuik.gov.tr/Bulten/Index?p=Turkiye-Saglik-Arastirmasi-2022-49747 adresinden 25 Nisan 2024 tarihinde alınmıştır.
26. Van Veldhuisen, S. L., Gorter, T. M., Van Woerden, G., De Boer, R. A., Rienstra, M., Hazebroek, E. J. & Van Veldhuisen, D. J. (2022). Bariatric surgery and cardiovascular disease: a systematic review and meta-analysis. European Heart Journal, 43, 1955-1969. https:// doi: 10.1093/eurheartj/ehac071.
27. Welbourn, R., Hollyman, M., Kinsman, R., Dixon, J., Liem, R., Ottosson, J., Ramos, A., Våge, V., Al-Sabah, S., Brown, W., Cohen, R., Walton, P., & Himpens, J. (2019). Bariatric surgery worldwide: Baseline demographic description and one-year outcomes from the fourth ıfso global registry report 2018. In Obesity Surgery, 29(3): 782–795. https:// doi: 10.1007/s11695-018-3593-1
28. WHO. (1998). Obesity preventing and managing the global epidemic: Report of a who consultation on obesity. https://iris.who.int/handle/10665/42330 adresinden 15 Nisan 2024 tarihinde alınmıştır.
29. WHO. (2021). Obesity. https://www.who.int/news-room/facts-in-pictures/detail/6-facts-on-obesity adresinden 16 Nisan 2024 tarihinde alınmıştır.
30. WHO. (2024). Obesity and overweight. WHO. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight adresinden 16 Nisan 2024 tarihinde alınmıştır.
31. World Obesity. (2021). https://www.worldobesity.org/about/about-obesity/obesity-classification adresinden 16 Nisan 2024 tarihinde alınmıştır.
32. Yumuk, V., Tsigos, C., Fried, M., Schindler, K., Busetto, L., Micic, D. & Toplak, H. (2015). European guidelines for obesity management in adults. Obesity Facts, 8(6), 402-424. https:// doi: 10.1159/000442721.