Ethical practice of metabolic bariatric surgery New concepts or paradigm shift have emerged in 2025 regarding the classification of obesity as a clinically significant disease, a treatable/preventable disease and as a chronic disease with risk of progression or relapse   New definition from the Lancet Commission 2025, defines clinical obesity as a pathological state in which excess adiposity directly impairs organ and tissue dysfunction *Obesity is a disease not a risk factor or a moral failure, which removes the biases and stigma to metabolic bariatric surgery access   Modern medical practices nowadays are both the application of first do no harm and secondly to act swiftly/appropriately to prevent harm in the future *There is both a duty of care and also a responsibility to maintain the highest standards of medical practice   Hippocrates first described “primum non nocere” which translates to first do no harm in the best interest of the patient *This is the foundation principle and the highest virtue in medical practice, which also applies to metabolic bariatric surgery, emphasis on patient centred care, adequate healthcare access, delivering of equity of care and balancing the risk-benefit ratio to the patient   Some experts also described the term “primum succurrere” which translates to act swiftly to prevent greater harm, which is recommendation of appropriate patients for medical and/or interventional metabolic bariatric procedures *Modern practice of weight loss management clinics and specialist surgeons/centres now include the second principle to be the patient’s advocate and to actively recommend treatment for severe obesity for prevention of harm (medical co-morbidities and complications associated with obesity)     Ethical behaviour also includes the balance between providing a service and ensuring the patients are not financially disadvantaged after undergoing surgical treatment. Specialist should not encourage or recommend patients withdraw from their superannuation in order to be a self funded patient to receive metabolic bariatric surgery in a private hospital (details below).

Benefits of metabolic bariatric surgery   Studies on the economic benefits of metabolic bariatric surgery has reported a reduction in healthcare expenditure (in the medium and long term) by 29% within 5 years, easily offset the early cost of surgery *However decision for treatment involves complex considerations including cost-effectiveness, patient safety, resource allocation, social and cultural factors     Similar to therapeutic drugs, surgery always have risk and complications *The short term burden of anaesthetic, surgical trauma, complications and post op recovery versus the long term consequences of untreated obesity, organ dysfunction, reduced health related quality of life and premature mortality   The ethical question is not just whether harm/risk exist but whether the harm/risk is justified by the expected outcomes and whether the patient has been provided with an adequate surgical informed consent     Surgical judgement demands medical knowledge and wisdom *Knowledge based on robust scientific evidence and long term study outcomes *Wisdom to decide whether intervention is appropriate, based on ethical judgement, patient readiness to undergo a drastic, non reversible permanent surgery or accept the risk of delayed surgery, as well as the inherent short and long term risk of surgery   Not having surgery does not mean inaction, there may be non surgical alternatives to obesity management or deferring the timing of surgery until a more appropriate time in the future   Metabolic bariatric surgery entails rigorous patient assessments, transparent informed consent, technical competence and experience, avoiding non justified procedures *Avoiding bias and misinformation *Emphasis on evidence based practice and objective therapeutic medical goals where the end points of treatment include weight loss, improvement of medical co-morbidities, improve quality of life, reduce organ dysfunction, disability and mortality   Metabolic bariatric surgeries performed should be validated by Bariatric Surgery Registries *In Australia, Monash University BSR documents long term follow up results (10 years or more) regarding weight loss outcomes, resolution or T2DM, post op reflux, complication rates, hospital re-admission and revision/conversion surgery *Registries document long term disease trajectories to provide meaningful epidemiological data rather than just focusing on short term peri-operative risk

New surgical innovation   New innovation in metabolic bariatric surgery includes robotic surgery and the more malabsorption type surgery such as SADI-S, which has become popular in the last few years *However surgeons need to ensure these new procedures and platforms provide clear advantage supported by good quality data   With innovative surgical technique there is a learning curve, requiring high safety standards Also equity care may not be available, some innovative surgeries are only available to certain geographic (centres of excellence) and socio-economic groups (the privately insured)   Surgical informed consent involves a full disclosure of the surgeon’s experience and other alternatives, with discussion on the risk benefit ratio as well as the uncertainty in newer procedures

Primary, revision/conversion or complex metabolic bariatric procedures Primary care physician and surgeons aim to avoid unintended therapeutic consequences, avoiding unnecessary primary or revision/conversion metabolic bariatric surgeries or the therapeutic side effects and complications *Understand that weight loss results and resolution of metabolic health may be limited for some patients (for example increasing age, slower metabolism, poly pharmacy patients, the chronicity of the T2DM or being on insulin may have poorer weight loss outcomes and resolution rates of T2DM after metabolic bariatric surgery)   Insurance and access to metabolic bariatric surgical care in private hospitals in Australia is one of the major factors in helping to shape the decision for surgery *Like most other countries around the world, Australia healthcare system face financial resources

Debts and release from superannuation fund   In 2025, The Australian Tax Office (ATO) data showed a significant growth in applications for CRS especially for IVF, weight loss procedures and dental treatments *About 30% of the applications have been rejected   Australian Health Practitioner Regulation Agency (APHRA) and the Dental and Medical Boards of Australia have released a new guidance for doctors and dentists in response to ongoing concerns of inappropriate conduct when certifying conditions for compassionate release of superannuation (CRS). The Boards’ guidance clearly sets out how existing professional obligations in the codes of conduct for these professions apply when certifying that a treatment is necessary in a patient’s application for CRS. It highlights the need for practitioners with the appropriate experience and knowledge in the area to conduct thorough assessments, gaining patients’ informed consent (including financial) and certifying only treatments that are necessary for the patient’s circumstances.  ‘If you’re certifying a procedure, you should be properly assessing whether this treatment is actually necessary and is not readily available in the public health system,’ said Chair of the Medical Board of Australia, Dr Susan O’Dwyer. The guidance also includes a warning for practitioners that influencing patients to access their super early without an Australian financial services licence could be considered financial advice and result in severe penalties from the Australian Securities & Investment Commission (ASIC).  When assessing a patient, practitioners must put their patients’ best interests first, providing treatment options that are based on the best available information and are not influenced by financial gain or incentives.   Practitioners must be careful not to encourage patients to take on debt (including personal loans, mortgages) or access superannuation for treatment. Influencing patients to access their super early without an Australian financial services licence could be considered financial advice and result in severe penalties from the Australian Securities & Investments Commission (ASIC).   Doctors and dentists do not have a role in providing financial advice but should encourage patients to seek independent financial advice. The Medical Board of Australia’s Guidelines for registered medical practitioners who perform cosmetic surgery and procedures state that medical practitioners must not encourage patients to take on debt or access superannuation, to access cosmetic surgery.

Summary

The duty of care for modern medical practices nowadays is the application of first do no harm as well as to act swiftly/appropriately to prevent harm in the future based on robust evidence based medicine, ethical clinical practice and patient centred decision making

• Often this is a shared decision making process between the primary care physician, allied health members, surgeon and the patient with their family support

The ethical framework of metabolic bariatric surgery is foundational to good clinical practice and helps form patient management decisions

• Clinicians recognize that inappropriately delaying or denying metabolic bariatric surgery for eligible patients may cause harm or increase in health risk
• Metabolic bariatric surgery should only be offered to suitable candidates which requires comprehensive patient evaluation, consider surgical risk versus the risk of non-intervention and to provide a fully transparent informed surgical consent
  • Also taking into consideration patient’s readiness for surgery, psychosocial factors and personal values
• Understand the importance of the patient’s role, compliance and commitments to multidisciplinary team approach and monitoring of long-term outcome

Medical education and research date, meta-analyses and systemic reviews help form clinical guidelines and medical recommendations together with government and/or private health care insurance reforms are needed

• To fill in the gap between inadequate or compromised patient care and lack of access to specialist services and private hospital care