Bariatric surgery, which often involves banding of the stomach, is a widely used procedure for treating severe obesity. Another approach that relies on an implantable “stom­ach pacemaker” also appears poised to assist those struggling with sig­nificant weight gain.

Many people have already benefited from these kinds of sur­gical interventions, enabling them to shed a great deal of weight, im­prove their health and get a new lease on life. 

At the same time, however, it’s important for us to examine such interventions from an ethical point of view. It’s not simply a matter of weight loss, achieved by any means whatsoever, but a rational decision made after carefully weighing the risks, benefits and alternatives.

Bjorn Hofmann, a medical ethicist who writes about the ethical issues surrounding obesity-correc­tion techniques notes,

 “Bariatric surgery is particu­larly interesting because it uses surgical methods to modify healthy organs, is not curative, but offers symptom relief for a condition that is considered to result from lack of self-control and is subject to significant prejudice.” 

The healthy organ that is modified is the stomach, which may be either banded or surgically modified with staples to create a small stomach pouch. This causes food to be retained in the small pouch for a longer period of time, creating a feeling of fullness, with the effect of reducing how much a person ingests at a single meal. 

Like any surgical technique, bariatric surgery has risks associ­ated with it: Mortality from the surgery itself is less than one per­cent, but post-surgical leakage into the abdomen or malfunction of the outlet from the stomach pouch can require further surger­ies. Nearly 20 percent of patients experience chronic gastrointesti­nal symptoms. Wound infections, clot formation, vitamin deficien­cies, cardio-respiratory failure, and other complications like gall­stones and osteoporosis can also occasionally arise.

A new device, sometimes described as a “pacemaker for the stomach,” was recently approved by regulators at the Food and Drug Administration. This re­chargeable and implantable device blocks electrical nerve signals between the stomach and the brain and helps to diminish the feeling of being hungry. The cost for the small machine, along with its surgical implantation, is expected to run between $30,000 and $40,000, making it competitive with various forms of bariatric surgery.

Because the stomach pacemaker does not modify the stomach or the intestines as organs, but instead re­duces appetite by blocking electrical signals in the abdominal vagus nerve, some of the surgery-related compli­cations associated with modifying or stapling the stomach are eliminated. Other surgical complications related to the insertion of the device into the abdomen have sometimes been ob­served, however, as well as adverse events associated with its use, like pain, nausea and vomiting. 

Bariatric surgery, it should be noted, is not universally successful in terms of the underlying goal of losing weight and some patients ultimately regain the weight they lose either through enlargement of the stomach pouch or a return to compulsive eat­ing patterns or both. Results have been similarly mixed for patients re­ceiving the stomach pacemaker: some lose and keep off significant amounts of weight; others show only negligible improvements when they are unable to adhere to the needed life-long changes in eating habits.

Among the ethical questions that need to be considered with re­gard to surgically-based approaches are: Should an expensive, invasive and potentially risky surgery be rou­tinely used for an anomaly that might be addressed by modifications in diet and eating habits? What criteria should be met before such surgery is seriously considered? 

It is also of ethical importance that physicians and surgeons not be unduly influenced by device manu­facturers to utilize their various stom­ach banding apparatuses or their pacemaker devices.

In 1991, the National Institutes of Health developed a consensus statement on “Gastrointestinal Sur­gery for Severe Obesity” that offers guidance for clinical decision making. The statement notes that, beyond having a serious weight problem, pa­tients seeking therapy for the first time for their obesity should “gener­ally be encouraged to try non-surgical treatment approaches including die­tary counseling, exercise, behavior modification and support."

These broad guidelines are in­tended to spark discussion on the part of patients and their medical team: How much support has an in­dividual really received prior to looking into weight reduction surgery or stomach pacemaker insertion? Some patients may have tried dili­gently for years to lose weight, while others may have made only cursory, poorly-supported efforts. The need for support is also likely to continue following bariatric surgery or after the implantation of a stomach pace­maker. 

In sum, there are notable differ­ences between such surgical inter­ventions and traditional weight loss techniques involving exercise and diet. With the surgical techniques, due diligence will be required both prior to and following such interven­tions, particularly in light of the on­going discussions about the cost-ef­fectiveness, safety, risks and out­comes of interventional surgery for the overweight patient.

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