While the global prevalence of obesity is increasing [
1], the rise in the number of patients with severe obesity (body mass index (BMI) > 40 kg/m
2) has been particularly dramatic [
2]. Simultaneously, evidence has accumulated that bariatric surgery is efficacious [
3] and cost-effective [
4]. Although approximately 80% of patients with severe obesity are medically and psychologically suitable for bariatric surgery, only 10% want to pursue this option [
5]. Potentially eligible patients may decline bariatric surgery, or may be reluctant to be referred to specialist bariatric services because of previous negative interactions with health professionals, low self-esteem, or embarrassment [
6]. Recent estimates from a nationally representative cohort study of adults over 50 years old (TILDA, the Irish Longitudinal Study on Ageing) suggest the prevalence of eligibility for bariatric surgery in older adults with a BMI ≥ 35 kg m
−2 and one or more comorbidities such as type 2 diabetes (T2D) or sleep apnea was 7.4% [
7]. Despite the clearly defined efficacy, cost-effectiveness, and need for bariatric surgery, often less than 0.1% of eligible patients receive publicly funded procedures internationally. For example, in Ireland, fewer than 1 per 100,000 people receive surgery, in contrast to bariatric surgery rates of 70 per 100,000 in Sweden and France and 50 per 100,000 in the USA [
8], despite these countries having the same European laws. In addition to international variations based on different policies and health systems in different countries, socioeconomic factors play a major role in determining which eligible patients receive bariatric surgery [
9]. Adolescents frequently encounter obstacles to treatment authorization from insurance carriers, with only approximately half of eligible patients being approved by insurers, despite fulfilling criteria [
10]. Such delays and prevarication are harmful to patients. In one US study, delayed access to surgery was associated with a three-fold increased mortality over a decade compared to timely provision of surgery in patients who wanted and needed it [
11].
While some European governments have recognized obesity as a disease since 2005 and committed to develop bariatric surgical services [
12], programmatic funding is often lacking. Inadequate access to bariatric care is a source of concern and frustration for health professionals and patients. Much of the resultant discourse on the topic is subjective and emotive and has failed to influence policy. We sought to explore objectively the extent to which the failure to provide bariatric surgical care breaches the core principles of medical ethics and the human rights of affected individuals.
Medical ethical principles can be conceptualized in different ways. Immanuel Kant, one of the foremost philosophers of the eighteenth century, described deontology, the “science of duty,” as a consideration of the righteousness of any action rather than its consequences in determining how morally and ethically sound it was [
13]. Conversely, consequentialism is a class of normative ethical theories holding that the consequences of ones conduct or actions are the ultimate basis for any judgment about the rightness or wrongness of that conduct [
14]. There is also the concept of virtue ethics, which emphasize the virtue of moral character [
15]. Utilitarianism focusses on the common good [
16]. So, a deontologist would provide care to a patient because it is the right thing to do, a consequentialist would see that it would end up being good for the patient, the virtuist would do it to reflect their moral integrity, and the utilitarian would see the collective good. While each of these concepts has its merits, they were largely superseded in 1979 when Beauchamp and Childers described principlism in their textbook on the principles of biomedical ethics [
17]. These principles are autonomy, beneficence, non-maleficence, and justice and are viewed by many as the standard theoretical framework from which to analyze ethical considerations in medicine. The principles are debated (for example, utilitarianism becomes more relevant in confronting acute severe epidemics), but they do resonate with social moral norms and will form the basis for our consideration of how inadequate provision of bariatric surgical care is ethically unsound.