Bariatric Surgery and Discipline
Benjamin GayedBariatric surgery refers to the surgical management of weight-related health concerns. This field has arisen over the last 20 years as we have begun to understand the impact of obesity on health. Diabetes, cancer, heart disease, and lung disease are just a few of the well-known complications of obesity. We have come up with several ways to promote weight loss surgically, and studies have shown there are health benefits with these procedures (ie less diabetes, heart disease, etc) in addition to feeling generally better and having more energy.
There are two general mechanisms of surgical intervention for obesity. One mechanism is restrictive – that is, a physical restriction on the amount of food the stomach can contain to force a reduction in caloric intake. The other mechanism is malabsorptive. This method entails re-arranging the bowels so that the food has less time to be digested and absorbed. The two most common procedures (currently) are gastric banding and gastric bypass. Gastric banding is a purely restrictive intervention which involves placing a plastic ring around the top of the stomach to reduce its volume. Gastric bypass has several variations, the most popular being the “Rouy-en-Y” gastric bypass procedure which is both restrictive and malabsorptive. [In this method (for anyone who cares to know) the stomach is stapled to a reduced size of about 20 mL at the esophageal junction, and this smaller stomach as separated from the rest of the stomach and hooked with the esophagus directly to the jejunum. The rest of the stomach along with the duodenum and beginning of the jejunum are separated from the distal small and large bowels, are reconnected near the newly created junction of the “small stomach” and the distal jejunum leaving a blind pouch consisting of the duodenum and “large stomach”.]
Now, for a person to be eligible for a bariatric procedure, his or her body mass index (BMI) must usually be sufficiently elevated to > 40, though there are some exceptions (normal is <25, obese is >30). Other eligibility requirements for these procedures include: failure of non-surgical weight loss methods with medical supervision, no uncontrolled psychiatric illness or substance abuse problems, medically stable, medically compliant and able to tolerate major surgery.
These procedures are effective, reliably resulting in weight loss of 60-75% of excess body weight. Further it is difficult to “beat” the procedures by overeating. Current data shows that most people keep the weight off for 20 years and counting. These procedures are effective at lowering weight, and more importantly, they improve health by lowering rates of co-morbidities. So why do they make me so uncomfortable?
I have begun to question whether these procedures are destructive by undermining discipline. My question presumes several things:
- that all people who have an elevated BMI as a result of excess fat do so because of poor diet and possibly inadequate exercise
- that these people can lose weight by sufficiently altering diet and exercise patterns
- that this altering may occur by force of will, ie that no one has an organic (biochemical) inability to lose weight
- that we have been created to take all things (food and drink included) in moderation, and that this discipline creates and encourages “health” physically and spiritually
- that short-cutting this need for moderation, discipline, with bariatric surgery, while resulting in improvements in physical health, at least in the short-term, will result in some detriment to spiritual wellness
In addition to discipline, there are 3 other classic Western cardinal virtues as outlined in Greek philosophy including justice, wisdom and courage. These virtues are “good”. That is, they have normative value. The cardinal virtues are not only good, but produce good. It is my strong feeling that the converse is also true. In other words, if discipline is good and creates good, to obtain quickly what was designed to be obtained with discipline undermines this “good”. And, though I do not have specific concerns regarding bariatric procedures, this belief is why I am uncomfortable with this type of surgery.
September 4th, 2008 at 11:13 am
You see this same principle with average Joe Blows who win the lottery and then end up poorer than they were before they won all their money. Without the discipline — the habits, self-control, and modes of thinking — necessary to correctly put the money to use, its presence does the person little good. It gives them some thrills — nice cars, big houses, etc. — but it doesn’t change them.
Contrast that with someone like Henry Ford. When asked what would happen if he lost his entire fortune, Ford replied (without a hint of mockery or irony) “I’d make it all back in five years.” Yes, he had confidence, but he also had the discipline and experience gained from years of building his fortune. In the same way, a person who gains through technology what humans only gained through experience loses at least some of the value of the thing he gains. In some cases (like winning the lottery or having a gastric bypass) he loses nearly all of it.
September 4th, 2008 at 5:48 pm
I assume that Paul heats his food over an open flame (started with flint, not matches) lest he lose some of the value of his meal by warming it up over the stove and in the microwave.
September 5th, 2008 at 9:23 am
Man, I’m the rule guy today.
Keith, TOO rule 2. I. on slippery slope. Consider yourself dinged.
Paul did not rule out the use of technology in his comment, nor is he necessarily a hypocrite for using a microwave. Paul pointed out that the gain in expending the fixed cost toward attaining an end without technological advance is lost when using said technology. Nothing more.
September 15th, 2008 at 11:27 am
“No one has an organic (biochemical) inability to lose weight.”
I am not sure if this is scientifically verifiable. What is verifiable, is that obesity is a pandemic which is relative to time and place. In the 1950’s in America, obesity was not a problem. Same with China today.
Medical, behavioral, and biochemical variables controlled for across time and space– which is still somewhat difficult to do… fast food, preservatives, lack of affordable fresh food0– Benji is right that we must infer that moral variables, at a societal level, are the responsible factor. But having assumed that, should we necessarily discourage bariatric intervention?
Not necessarily. If individual biochemical downstream effects from individual moral corruption were directly related, then Benji’s well-founded aversion to bariatric surgery would be incontrovertible. But aren’t we faced with other possibilities? What if societal moral corruption was tranferable onto innocent individuals, who otherwise demonstrate remarkable levels of discipline? What if food has become an impulsive/addictive disease for some people, like gambling or kleptomania? (Biochemically related to dopamine, treated with neuroleptics & antidepressants.)
What if addictive diseases (which fluctuate in any society) are not only an outcome of a gluttonous and slothful, morally relative society, but that further, what if persons who were abused by their parents, or suffering from atypical, severe neurovegetative depression are unable to control their eating habits? In that case, there is no direct individual relationship to morality. The temporal consequences of sin are shared amongst humanity.
What if it is the job of medicine to ‘clean up’ after some of the transferable physically corruptive effects of immorality? Such as HIV, hepatitis C therapy… in addition to bariatric surgery? What if it is the job of medicine to play that ‘redemptive’ role in society… in which we offer a ‘physical’ form of forgiveness for the downstream effects of immorality?
September 17th, 2008 at 7:21 pm
Thanks for your comments, Tom. Interesting thoughts, but I do not agree with everything you propose.
I did overstate (and oversimplify) the biochemical basis of obesity, and there is certainly a genetic/biochemical component which seems to defy caloric intake. It is my faith that causes me to believe that there is a “right” form for each person. And it is possible despite my above statements that, like any organic disease, obesity may also be something a person cannot simply overcome by will alone. Remarkably similar to homosexuality in that regard. Outside of God’s intentions for us, but seemingly “against a person’s nature” to defy.
I do respectfully disagree with the idea that medicine may function to correct the physical sequelae of societal degradation. Here I am once again focusing on the portion of the population’s obesity which is caused by “overeating” and “underactivity.” It seems to me that if in fact some obese people are obese because they did not learn discipline because mom or dad was abusive, or not around, or just lazy, or just did not model discipline, and that the parent’s poor modeling was in fact the result of some other person’s poor treatment of the parent, etc, if this is the case, it seems even more important that these people learn discipline rather than being given short-cuts out of the consequences. Still following your “sin amongst humanity” model, whomever the last person to behave appropriately (ie disciplined) in the ancestral lineage was, he or she probably was so as a result of dealing with or seeing the consequences of a lack of discipline. With this in mind, not only does it seem less than ideal to offer this type of short-cut, it seems to be robbing these people of God’s designed way of re-instilling these characteristics and battling societally prevalent sins.
September 17th, 2008 at 7:27 pm
Where’s the logical limit? How do you, in a principled way, distinguish between those whom you should aid and those whom you should leave to learn lessons of discipline that may or may not be within their capacity? How do you reconcile your model to the Biblical command to give alms to the beggar–who should, under your model, be left to learn the hard lessons of idleness.
September 17th, 2008 at 9:14 pm
I am not entirely sure you are addressing me, but I will assume so given the last bit.
Good question.
The answer is to not discriminate and to not provide bariatric surgery to anyone. Though there are health benefits, I think the other less desirable implications outweigh these benefits.
Your question also begs the question of how to reconcile these same Christian principles with governmental disbursement of funds. With this is mind, it is not as simple as just offering an operation to someone. There are insurance considerations and post-operative complications. I may not be doing the patient a service by operating, even if I provide a technically proficient procedure and the patient adheres to post-operative recommendations. Also, there is nothing these surgeries provide which the patient cannot get without the surgeries (meaning needs such as clothes, food, etc…in other words not including so-called “ideal body weight” which is not a need). I can provide necessities in the form of money (alms), when a person would really be going without.
I would be interested to hear Tom’s response to the same question of who gets it and when and how do you decide since he elected to argue in favor of providing these procedures.
September 18th, 2008 at 5:20 pm
“…if this is the case, it seems even more important that these people learn discipline rather than being given short-cuts out of the consequences.”
This presumes the universal possibility of virtuous weight loss, which is already one of your premises.
We are in agreement that it would be foolish for doctors to claim that, since all human ailments are due to Adam and Eve’s lack of virtue, we are all victims, and there should be no limit for interventions that reverse the consequences of vice.
Our disagreement lies, and reasonably well, on the point at which a intervention becomes morally-enabling to human beings. Your position seems to be, that when pathological conditions fluctuate rapidly over time depending on the virtues of society at large, the chain of causation is so acute as to render virtuous recovery possible, and surgical intervention morally-enabling. It seems another premise though, in your system, is that we can infer direct moral-to-physical causation, from sloth directly to obesity. (Combining your first three premises)
The problem is, I don’t see how this sort of causation can be universally proven for obesity. Just because it is a rapidly fluctuating societal illness, and presumably has clear moral causes, that still doesn’t prevent causes other than primary sloth. Genetic and biochemical theories for addiction (to food) could still be supported, remembering that addiction and depression are functional illnesses, which in order to manifest must inevitably latch onto some concrete substrates (food, drugs, guilt, blame, identification w/ abuser or aggressor) which are provided to them by society. These societal substrates are entirely arbitrary, non-addictive, and change over time.
To conclude, you essentially equate bariatric surgery with needle-exchange programs or the morning after pill, i.e. using technological interventions which are directly morally-enabling. I don’t disagree that in some bariatric cases, this is definitely true. In order to tell the difference, I suggest that the first two elegibility criteria you mention be strictly followed. Failure of non-surgical weight loss must include some time spent at an intensive live-in weight loss program. Depression must also be managed, so as to give them a ‘fair-shot’ motivation-wise.
Ultimately, the limits of the human will cannot be delineated. In situations where we don’t know whether an intervention is enabling for everyone, or redemptive for an individual, let’s err on the side of helping the individual, no?
As an aside, I think it’s unethical to use surgery for what are essentially neurotic conditions: ‘My nose is too big…’ ‘My boobs are smaller than hers…’ But why? It’s not because the conditions aren’t biologic, without physiologic sequelae. It’s that surgery doesn’t treat those conditions, because it does not interrupt the pathologic chain of causation. Whereas bariatric surgery does, by stopping over-eating.
September 28th, 2008 at 10:02 pm
A few weeks ago, Parade Magazine featured an article that reported the findings of a study from Melbourne, Australia confirming what many of us have known definitively for a number of years now. Type 2 diabetes can, through weight loss attributed to bariatric banding surgery, be reversed.
bariatric beds
October 3rd, 2008 at 2:10 pm
What you have said is well-stated, and convincing. What I have to say is more of a restatement of my previous arguments, not because you did not understand, but because I can state them more clearly. That said, I am not going to directly challenge anything you have said, except perhaps for erring on the side of helping the individual, as you will see. It seems in the end we are falling on opposite answers in response to the question “if you don’t exactly know what the effect of your action is, but you know it is likely some good and some bad, do you act anyway?”
This discussion reflects the principle of double-effect, but from a different perspective than that in which it is usually discussed. This principle is often called upon when discriminating end of life (palliative) care from euthanasia. The argument goes: if you give someone morphine with the primary goal of alleviating pain (the first effect), and you give so much morphine they happen to go into respiratory arrest and die (the other effect), that is ok. With euthanasia, the primary intent would be death, which is not ok.
If you buy into this doctrine of double effect, the criteria which make an act acceptable include:
1. that the nature of the act itself be morally good or neutral
2. that the intent of the act is to achieve the morally good outcome and not the bad one
3. the good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm.
In our present discussion, I consider surgery a morally neutral act, and the intent would be to improve physical well-being. Check for criteria 1 and 2.
Criteria 3 is where I take issue. I question whether the good effect of preventing the co-morbidities associated with obesity (diabetes and heart disease, etc.), to the extent that can be affected through surgery, justifies causing the latent effect of undermining the virtue-instilling process of weight loss through discipline (whatever portion of weight loss that is). It is hard (impossible?) to say definitively this undermining is more detrimental than the organic illness because we are comparing apples and oranges to an extent in comparing physical to other forms of health. But I also believe not all fruit is equally valuable. I believe this process is detrimental, and it is hard to quantify how much so. The doubt makes me uncomfortable with the procedure.
It is appealing to “err on the side of helping the individual”. But “…what will it profit a man if he gains the whole world and forfeits his soul? Or what will a man give in exchange for his soul?”
Though I am placing a premium on ’spiritual welfare’ (for lack of better classification) this is in addition to the physical risks of surgery, especially in light of the fact that obesity places people at higher risk of peri-operative complications. (Though the outcomes are similar to non-obese people undergoing surgery if appropriate care is taken, mostly clot prevention). Don’t forget a certain portion of these people will be left in physically worse shape than prior to surgery (or dead), whether they achieve weight loss and resolution of other illnesses or not.
You hit the proverbial nail on its head when you said our “disagreement lies, and reasonably well, on the point at which [an] intervention becomes morally-enabling to human beings.” I do not know where that point is, but we would agree would say these procedures are morally enabling on some level to some people.
You also said, “We are in agreement that it would be foolish for doctors to claim that, since all human ailments are due to Adam and Eve’s lack of virtue, we are all victims, and there should be no limit for interventions that reverse the consequences of vice.” I agree, and I would take these statements a step further describing illness on a spectrum of moral causation. On one end are ailments with no moral causation such as a broken leg or a cold. Treatment is not morally enabling if there is not a moral component. On the other end of the spectrum, there are conditions which are entirely morally-grounded without physiologic basis. This gets back to our previous discussion of what is healthy and whether that matches with what is normal. Purely cosmetic procedures might arise from vanity or envy. There is not an ‘unhealthy’ physiological basis for the size of someone’s nose. Nothing fatal, certainly. ‘Correcting’ in this case would be morally enabling.
Obesity seems to fall in a middle ground with respect to what portion of it is morally-rooted. Worse, the portion of obesity within each person for which sloth or gluttony may account, and that portion which is caused by biologic factors likely varies. (Again with respect to what is healthy and what is normal, I have to state that just because a person’s BMI falls in the obese range does necessitate that they are unhealthy or need ‘fixed’).
It is possible that there are some patients in whom the impact of will on weight-loss is insufficient to improve health, and ideally we could provide these patients with surgery. But as discussed above, since I cannot tell whom that is, I would err on the side of not offering these surgeries to anyone because I do not understand fully implications of this act. For similar reasons I am uncomfortable with palliation to death, because I do not fully understand the implications of death. I am erring on the side of not acting when I do not understand the implications fully. Maybe I am erring on the wrong side, and I am open to changing my stance.
October 8th, 2008 at 10:54 pm
Ben, it seems to me that your framework would drastically alter the “Do no harm” Hippocratic framework of physician ethics. Take your “ailments with no moral causation”–the examples you used were a cold and broken leg. What if the patient caught cold because they were out all night carousing with prostitutes? What if the leg had been broken during a bungled attempt to rob a gas station?
November 29th, 2008 at 12:25 pm
Benji– great post. I am proud to be engaged in a discussion truly singular in its collegiality, sustained technicality, and ethical/clinical applicability.
For a given series of obese patients, we have a ‘complemental series’, a series in which two determinants coexist: pathologic neurochemistry & immoral sloth. I have assumed that in some cases (and you in all cases) that it is nigh impossible to quantify the difference between the two deteminants–or to ‘judge the heart’ so to speak. For any given complemental series of individuals, it is impossible to know when you are looking at the extreme bookends… when you do not have access to the entire series at once.
C. S. Lewis alludes to such multivariate analysis in Mere Christianity, in the chapter ‘Morality & Psychoanalysis’. “When a man who has been perverted from his youth and taught that cruelty is the right thing, does some tiny little kindness, or refrains from some cruelty he might have committed, and thereby, perhaps risks being sneered at by his companions, he may, in God’s eyes, be doing more than you and I would do if we gave up life itself for a friend.” … Lewis is able to identify such an individual, at the bookend so to speak, of a series… but in the form of hypothesis. He merely believes the possibility is real, but how about a GI surgeon in a clinic, who (we agree) ought to be ethically cautious, and must distinguish at random?
As to the question of who to do bariatric surgery on, I will now concede that: in those for whom it is difficult to assess the aspect of gluttony and sloth, I say, it is still better to intervene, for the following reasons:
1) to be virtuous in the first place, you must be alive, not dead. i would, of course, in no wise dare to argue that every life preserving intervention isn’t harmful to virtue.
2) a bariatric bypass in this case (of doubt about gluttony/sloth) interrupts the merely downstream effects of vice. It can reduce gluttony by giving it less of a downstream substrate for enjoyment… thus it is analogous to any sacramental intervention for sin which uses physical phenomena to achieve a spiritual end.
3) and perhaps… even for those who ‘eat through’ the stomach band, and for whom there is a tinge of moral enabling in the intervention (because the patient may think that the doctor’s worldview is to replace the need for personal virtue with technology), maybe even then the intervention alone provides additional moral strength by virtue of the doctor’s effort in solving the problem. in some people, the will is so weak that it takes the redemptive interventions of others to get it back on its feet. i think the reason this is so, is because so much human immorality is shared amongst us, we cause each other to stumble, and we suffer for each others sins all the time. this social aspect of immorality, is redeemed on the flip-side by interventions which are socially and redemptively oriented: interventions which say ‘it’s everyone’s fault inasmuch as your own’.
4) bariatric surgery does not interrupt the stream of causation at a point prior to its habitual consummation, which would be (in my opinion) a true violation of natural law and an example of moral enabling: a bionic stomach that allows obese patients to be unrestrained gluttons even while losing weight.
5) might we also argue that, in order to discourage the vice of fornication, we ought not provide antibiotics to those who, annually, contract syphilis in Amsterdam? (but not condoms… the difference, to me whether antecedent causes are involved vs. downstream sequelae). It is true that syphilis is not reversible without treatment, whereas obesity (theoretically most of the time) is, but we could also perversely argue that by not treating syphilis, we are discouraging a behavior which leads to other, new STDs? Are we not obligated to heal criminals with the same precision and compassion as anyone else? (Jeremy’s point, posted above: a criminal that breaks their leg while robbing a gas station, we still ought to treat). Is this not the redemptive function of medicine, to say in a way, ‘you don’t deserve this treatment but you get it anyway’? Might we also argue, regarding obesity, that we ought not prescribe statins, because they (like bariatric surgery) grant survival and the ‘livability’ of the obese state, while doing nothing for a person’s encouragement-to-virtue?
All of these reasons especially #5 do not apply to those for who I would determine the intervention to be enabling (those for whom there is little biochemical component, have no signs of depression, addictive tendencies, or who refuse to exercise or live through a challenge period).
Regarding the proportionality of physical benefits vs. moral dangers and their proportionality, (your number three criteria for double effect), you said: “I question whether the good effect of preventing the co-morbidites associated with obesity… justifies causing the latent effect of undermining the virtue-instilling process of weight loss through discipline… It is hard to say definitively this undermining is more detrimental… we are comparing apples and oranges… but I also believe not all fruit is equally valuable.”
My #2 and #3 above suggest that, when in doubt about the proportionality, we can surmise that: physical interventions may sometimes have a sort of upwards causation toward moral health, and that this is analogous to the role of the sacraments in moral and religious life.
Double effect cannot be used to justify palliative sedation in my opinion, not because death is a more serious outcome necessarily for the patient than is pain-relief… but because for the doctor, it is always more grave to hasten death than to refuse to alleviate suffering. In the case of bariatric interventions, the reason I don’t think double effect applies, is because: the intervention does not interrupt the moral causation of physical sequelae (#4 above), but has instead a rather dubious sideways or backwards effect on gluttony. Thus we are still dealing with apples and oranges, but the oranges (physiologic benefits) may enhance the apples (virtues) inasmuch as their acidity causes them to prematurely. Finally, the proportionate gravity of effects is somewhat up to the patient, and when (unlike in the case of condoms for syphilitics instead of antibiotics) the intervention does not harm natural law or weaken the individual will, then we ought to err on the side of giving the shadow of doubt to the individual will instead of to virtue alone, which is not the will itself, but a specific orientation thereof.