Development and Application of an Ethical Framework for Pediatric Metabolic and Bariatric Surgery Evaluation

Abstract

Background

As severe obesity continues to rise among youth, metabolic and bariatric surgery (MBS) will increasingly be used as a treatment of choice for durable weight loss and improvement of obesity-related complications. MBS for youth with intellectual and developmental disabilities (IDD) and for preadolescents has raised ethical questions.

Objectives

The purpose of this article is to present the creation and application of an ethical framework that supports why MBS should be considered in pediatrics based on the principle of justice without automatic exclusions. This framework also provides a guide for how to conduct a robust, ethically-grounded evaluation of pediatric patients presenting for MBS in general, and among subpopulations including youth with IDD and preadolescents.

Setting

Academic medical center, United States

Methods

An ethical framework was developed and applied through a collaboration between an MBS center at a children’s hospital and the institution’s ethics consult service.

Results

Application of the ethical framework to address four core ethical questions is illustrated using two hypothetical cases, one that highlights an adolescent with IDD and the second a preadolescent.

Conclusions

We have demonstrated the application of a novel overarching framework to conduct the ethical evaluation of youth presenting for MBS. This framework resulted from a collaboration between MBS and ethics consult teams and has the potential to be used as a prototype for other youth-focused MBS programs. Next steps include prospective data collection to test the framework to determine its validity in the target population.

1. Introduction

Standard of care for the evaluation of all pediatric patients (<18 years of age) presenting for metabolic and bariatric surgery (MBS) incorporates ethical tenets to protect individual choice and to promote health. Additionally, there are subgroups of youth presenting for MBS, including individuals with intellectual and developmental disabilities (IDD) and preadolescent children that invoke unique ethical questions for the interdisciplinary MBS team. Guiding ethical principles in these cases include justice (fairness), respect for autonomy (informed consent/assent), beneficence (doing good), and non-maleficence (avoiding harm).

As the prevalence of severe obesity in the US continues to rise across all age groups,[1] and as data for the safety, efficacy, and cost-effectiveness of MBS in pediatrics grows,[2–5] the volume of adolescents and preadolescents with medical complications of obesity who present for MBS is expected to increase.[6] At what age it is most appropriate to intervene with MBS has been debated.[7–11] In this article, we will use the term capacity to refer to an individual’s abilities to understand and participate in medical decision-making. Neurotypical children between age 12 and 17 are thought to have medical decision-making capacity, with additional support from adult caregivers.[12] For children under 12, the parent/legal guardian has primary decision-making authority, but assent from the child is sought starting at age 7, or even younger depending on the maturity of the child.[13] Similar to other diseases requiring surgical intervention to prevent or abate negative health consequences (e.g. congenital heart disease, organ transplantation), the timing of MBS should be driven by an individual risk benefit analysis.[14] However, even if the timing of MBS in youth were universally based on medical necessity, ethical issues would still remain including: evaluation of the child’s capacity to assent to a procedure that causes long-term alterations in metabolism, assessment of parental coercion, and response to disagreement about MBS between two parents or parent and child.

IDD originates before age 18 and is defined by significant limitations in both intellectual functioning (learning, reasoning, problem solving) and adaptive behavior (practical life skills).[15] Adolescents with IDD are nearly twice as likely to be obese than those without IDD.[16] Risk factors include limited physical activity, the need for weight-promoting medications, food selectivity, dysregulated hunger/satiety, and stressed support systems.[17–21] In addition to the usual impacts on physical and mental health, severe obesity for individuals with IDD can threaten their ability to live with maximal independence, and represents a second source of stigma.[22–24] Despite the increased risk of obesity and potentially greater benefits of MBS in this population, IDD has historically been viewed as a contraindication to MBS.[25,26] This stems from concerns about the individual’s ability to assent/consent and from beliefs that individuals with IDD are not able to adhere to pre or postoperative requirements, which could limit weight loss or increase risk of adverse events.[27,28] However, these assumptions have not been rigorously tested. Among adolescents with mixed etiologies of IDD who undergo sleeve gastrectomy, two recent studies found that IDD did not impact weight loss or adverse events up to two years postoperatively.[29,30]

The 2018 American Society for Metabolic and Bariatric Surgery (ASMBS) pediatric guidelines and the 2019 American Academy of Pediatrics (AAP) policy statement on pediatric MBS are closely aligned.[14,31] There is no lower age limit defined for MBS by ASMBS/AAP, and the guidelines note that neither pubertal staging nor linear growth should impact candidacy for MBS. The guidelines do differ in their definition of adolescence (ASMBS uses the World Health Organization range of 10 to 19 years and the AAP uses 13 to 18 years). Both guidelines state that any “medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens” should be considered a contraindication to MBS. However, the ASMBS statement also explicitly notes, “We do not want to exclude patients with limited decision-making capacity who suffer from severe obesity and/or co-morbidities for which surgery is the only effective therapy.” Further, it advises that “When a child does not have the decisional capacity, but is able to demonstrate the ability to make lifestyle changes required by MBS with or without…a dedicated caregiver, then MBS should be considered. Both parents and the entire multidisciplinary team with consultation of the ethics committee, where appropriate, should agree that MBS is the best course of action.”[14]

Thus, while national guidelines discourage the outright exclusion of preadolescents and individuals with IDD for MBS, and encourage consultation with an ethics committee to achieve clarity about the treatment plan, how to perform this ethical evaluation within a youth-focused MBS center has not been clearly defined.

The purpose of this manuscript is to translate these national guidelines by presenting the development and application of an ethical framework (Appendix) for the evaluation of pediatric patients seeking MBS. This framework describes key elements of the ethical evaluation for any pediatric patient presenting for possible MBS, and includes individual ethical analysis for challenging subpopulations including youth with IDD and preadolescents.

2. Methods

2.1. Setting

Metabolic and bariatric surgery center at a tertiary care children’s hospital within a US academic medical center.

2.2. Ethical Framework Development and Objectives

The framework’s structure and content were revised iteratively through collaborative group discussion, and was approved by the children’s hospital Ethics Committee. This framework is consistent with the ethical knowledge and processes defined by the Core Competencies for Healthcare Ethics Consultation of the American Society for Bioethics and Humanities.[32] This framework for pediatric MBS was designed to guide the MBS team in answering four central ethical questions: 1) Should any patients be automatically excluded from evaluation for MBS? 2) How should it be determined that the benefits of MBS outweigh the risks? 3) How should it be determined that the patient adequately understands and can cooperate with both the surgery and associated follow-up care with appropriate supports? and 4) How should the determination be made that the decision to pursue MBS was uncoerced and voluntary? Additionally, the framework can educate MBS team members about ethical principles and standardize the process by which the MBS team identifies ethical concerns.

3. Results

3.1. Application of the Framework

When a clinical concern arises from any member of the MBS team, the framework is first referenced to clarify whether an ethical question exists, to help define what that ethical question is (Table 1), and to determine if an ethics consult is needed. In actuality, ethical values are embedded in every possible clinical judgment. But, the degree of uncertainty and tension created by these ethical values varies widely depending on the clinical scenario. After the MBS team reviews and applies the framework to the clinical scenario, there are two possible outcomes: 1) the MBS team independently resolves the conflict or 2) the MBS team determines that they cannot proceed with a care plan without an ethics consult (Figure 1). The latter may occur because of uncertainty or disagreement about the ethical sensitivity/complexity of the case.

Table 1.

Translation of clinical unease to ethical questions that can be posed to an ethics consult service

Clinical Qualm	Ethical Question(s)
Should we accept this referral (e.g. for a preadolescent or individual with severe IDD)?	Does refusing to evaluate the patient for MBS violate the principle of justice?
The patient does not seem to be understanding the information presented.	How should the team approach decision-making and appropriately involve the patient?: Parental consent? Developmentally appropriate patient assent? How should patient non-disagreement be handled (i.e. no explicit agreement but also no objection)?
The family has not followed through with preoperative recommendations, but medical necessity is high.	How should the benefits of MBS be balanced against the risks of poor adherence?
The adolescent and her mother appear on edge, closed off, and acquiescent when attending visits with the child’s father, who is adamant about the surgery.	Is the adolescent being coerced? How should the team proceed to involve all parties to make sure all voices are heard and the surgery is voluntary?
The parents of an 11 year old report having tried “everything,” but there are no documented attempts at organized behaviorally-based weight management.	Should less invasive options be documented as unsuccessful before exposing the child to the risk of harm from more invasive procedures?
A 16 year old with severe IDD is reluctant to undergo MBS, but his condition is approaching a critical stage (e.g. obesity-associated heart failure) and his parents are urging the surgeons to proceed with surgery.	Should the team and parents override the adolescent’s wishes?

IDD = intellectual and developmental disabilities | MBS = metabolic and bariatric surgery

Figure 1.

Clinical pathway for the ethical evaluation of the MBS patient

If an ethics consult is placed, the ethics team joins the MBS team during their patient conference to better understand the clinical context for the ethical question(s) posed. The ethics team then meets with the family, and ultimately communicates their assessment and recommendations with a note in the electronic medical record. A key role of the ethics team is to advocate for all voices to be heard (both from the MBS team and the family). MBS team members are encouraged to openly share their opinions, questions, or doubts with the ethics team, and also have multiple opportunities to share concerns without the ethics team present before coming to a decision. The final decision requires full MBS team signoff and typically results in either proceeding to surgery, recommending a non-surgical intervention, or extending the preoperative phase to allow for additional monitoring.

The framework is not designed to replace the ethics consult team, which as noted above, can provide a critical, objective advisory function. Rather, it provides guidance to the MBS team to construct pertinent ethical questions, and may be used to resolve conflict or uncertainty within the MBS team in some situations. Additionally, the outcome of the ethics consult is not a stamp of approval or denial to proceed with MBS. Rather, it provides an expert analysis of the ethical issues identified and contributes an outside perspective, which the MBS team can use as part of their decision-making process.

Two hypothetical case-based examples illustrating the application of the ethical framework and the complementary role of the ethics consult team are presented below:

3.1.1. Case 1

A 17 year old Hispanic male with body mass index (BMI) of 42kg/m², was referred by his primary care physician for MBS consideration. His past medical history includes autism spectrum disorder, IDD, and depression with behavior challenges that required atypical antipsychotic medication throughout elementary and middle school. Obesity comorbidities include hypertension (treated with lisinopril), prediabetes (A1c 6.2%), and dyslipidemia. There is a strong family history of T2D and coronary artery disease. Weight management interventions over the last year have included a reduced calorie diet with partial meal replacement monitored by a dietitian and increased physical activity at a local recreation center, which has decreased his rate of weight gain. Recent cognitive testing at school demonstrated intellectual functioning at a 4^th grade level and adaptive functioning (communication/daily living skills/socialization) at a 3^rd grade level. The patient’s mother has identified supported employment for the patient after high school. Psychosocially, the patient lives with his mother (primary caregiver), and 11 year old sister. His father has no contact with the patient. The patient used to work with a behavior therapist weekly, but is currently only seeing a psychiatrist every other month. Maternal grandmother previously provided significant respite and financial support, but recently died. The patient’s mother endorses food insecurity, receives supplemental nutrition assistance benefits, and struggles with her son’s intake of large portions, frequent requests for food in between meals, and occasional refusal to take medications.

Ethical questions:

1) Should this 17 year old with IDD whose practical life skills are consistent with that of an 8–9 year old be considered for MBS? If so, what considerations are important in the evaluation?

[Framework section III]: “Patients with IDD should not be excluded from consideration for bariatric surgery because respect for the principle of justice demands non-discrimination.” “The decision to proceed with surgery should be patient-centered rather than diagnosis-centered.”

Key considerations in this patient’s evaluation include his current health status, the patient and his mother’s personal values and goals, an understanding of what prior weight management approaches have been tried, an individualized evaluation of benefits of MBS versus risks, a comprehensive psychosocial evaluation with attention to family dynamics and support, and an assessment of the patient’s decision-making capacity.

2) How should it be determined that the benefits of MBS outweigh the risks?

[Framework section III]: “Although it is important not to discriminate against individuals with IDD, it is equally important to make sure that necessary supports exist so that where possible, these patients can attain the desired benefits and avoid the associated risks.”

Potential medical benefits of MBS in this case include a reduced risk of progression to T2D, improvement/remission of hypertension, improved lipid profile, and reduced risk of incident cardiometabolic disease.[2,3,33] Potential psychosocial benefits include reduced stigma associated with obesity as he transitions from high school to the workplace.[23] Additionally, improvements in health related quality of life, body image, and depressive symptomatology are possible benefits.[34,35]

Potential risks include [Framework section II] “anatomic complications (such as gastric leak), infectious complications (such as pneumonia), bleeding, anesthetic risk, dumping syndrome, ulcers, internal hernias, gastroesophageal reflux, suboptimal weight loss, weight regain, failure to resolve comorbidities, micronutrient deficiencies, long term effects not yet quantified, and death”.[14]

The likelihood of a subset of these risks may be greater if this patient, with appropriate family support, is unable to adhere to postoperative dietary and medication recommendations.

3) How should it be determined that the patient adequately understands and can cooperate with both the surgery and its associated follow-up care with appropriate supports?

[Framework section III]: “Patients who have limited or no ability to assent or cooperate should have those limitations taken into account when weighing the risks and benefits of proceeding with surgery. Attempts should be made to compensate for these limitations with analysis of the risk-benefit to the patient, additional support from parents/guardians and the treating team, and an honest and transparent description of the likely outcomes given these limitations.”

The pediatric psychologist evaluated the patient and determined that he had limited decisional capacity based on his communication, understanding, appreciation, and reasoning during clinical encounters.[36] The patient had difficulty with: (1) expressing a strong preferred treatment choice, (2) showing a grasp of the fundamental meaning of surgery, (3) acknowledging treatment consequences, and (4) being able to manipulate information received about treatment. However, during monthly preoperative visits, his level of understanding of what MBS was and what he had to do to lose weight and to remain safe after surgery was appropriate for his level of developmental functioning. The MBS team set clear written expectations for the preoperative period, which included achieving weight stability, self-monitoring intake of water and protein using a phone application, and developing a system for taking medications more consistently. Additionally, the mother was asked to identify a second source of support. Subsequently, the patient’s maternal aunt was identified as an additional caregiver and regularly attended patient appointments.

4) Can the choice to pursue MBS be uncoerced and voluntary?

Here, the ethical framework [section III] incorporates the 2018 ASMBS recommendation that “When a child does not have decisional capacity, but is able to demonstrate the ability to make lifestyle changes required by MBS…both parents and the entire multidisciplinary team with consultation of the ethics committee, where appropriate, should agree that MBS is the best course of action”.[14]

The ethics consult team was consulted at the 3^rd preoperative visit, met with the family and with the mother’s consent, conducted interviews with the patient alone, mother alone, then patient and mother together. The ethics consultants asked about their understanding of the possible surgery, why they wanted the surgery, and what the challenges would be. They also asked each about their confidence to perform the tasks (e.g. following the dietary progression, taking vitamins daily) enumerated by the MBS team. They determined that the patient expressed an independent desire for the surgery stating, “I don’t want to get diabetes and I think this will help me.” Thus, while the patient’s reduced decisional capacity limited the team’s reliance on the patient for assent, the patient importantly expressed no disagreement with the option of moving forward with surgery.

The MBS team debriefed with the ethics consult team, and concluded that the benefits of MBS to the patient outweighed the potential risks, particularly given the demonstration of committed family support, and that the patient was considering surgery without undue influence from his mother. The MBS team recommended proceeding with surgical preparation.

3.1.2. Case 2

An 8 year old non-Hispanic white female, BMI 50 kg/m² with past medical history of moderate obstructive sleep apnea and left-sided slipped capital femoral epiphysis requiring surgical stabilization 6 months prior was self-referred by her parents for MBS evaluation. Family history is significant for severe obesity in several maternal relatives. The patient’s mother underwent sleeve gastrectomy 2 years ago and has maintained a 25% weight loss. The patient is neurotypical and excels in school. She is an only child and lives with her mother and father. She has experienced bullying about her weight since first grade and receives counseling at school for this concern. Prior attempts to achieve weight stabilization have focused on lifestyle changes recommended by her pediatrician. Parents say they “have tried everything” and nothing seems to slow her rapid weight gain. Mother expresses that “she doesn’t want her daughter to suffer like she did” and knows the surgery will be the best option.

Ethical questions:

1) Should an 8 year old be considered for MBS?

[Framework section V]: “A decision by the bariatric team to offer bariatric surgery to a preadolescent would be based on the same obligations of justice not to discriminate against medically appropriate patients based solely on age.” [Framework section II. 2.]: “Patients and families should first be offered more conservative and less invasive options for treatment and should have either not responded to those treatments or have patient-specific factors that make the particular patient a poor candidate for those treatments.”

At the first preoperative visit, the MBS medical provider’s assessment revealed that the family had not yet been offered intensive non-surgical approaches for weight loss. At the pediatrician’s suggestion, they had increased daily fruit/vegetable intake and physical activity, and decreased screen time and sugar-sweetened beverages (all consistent with Stage 1 Prevention Plus treatment).[37] They had not yet engaged in a structured weight management program with dietitian or physical activity support (Stage 2), and were not aware that she could qualify for a medically-supervised dietary approach (e.g. meal replacement, high protein very low carbohydrate meal plan) or anti-obesity medications (Stage 3–4).[37]

2) How should it be determined that the benefits of MBS outweigh the risks?

[Framework section V]: “The decision should be based on an assessment of the balance of potential benefits and harms for the individual patient….Parents should be informed that it is possible that novel harms could be discovered after their child undergoes the surgery….A conservative approach would defend waiting to expand surgery in preadolescent children until more is known, or at least limiting surgery to those most at risk of immediate obesity-related complications.”

Potential medical benefits of MBS in this patient include preventing progression of her hip disease with overall improved physical function,[38,39] improvement of obstructive sleep apnea,[40,41] and reduced risk of incident cardiometabolic disease.[42] Potential psychosocial benefits include reduced bullying, improved self-esteem and quality of life.[43] The same anatomic, infectious, and nutrition-related risks of MBS mentioned in Case 1 apply here; however, the duration of exposure/time to develop these risks is longer for children undergoing MBS at a younger age (e.g. possible gastroesophageal reflux after sleeve gastrectomy or impact of progressive micronutrient deficiencies), which may increase the need for additional medical or surgical interventions later in life[44,45]. Additionally, while there is no evidence to support that MBS is detrimental to typical growth and pubertal progression, data specifically evaluating longitudinal changes in bone health, linear growth, and the hypothalamic-pituitary-gonadal axis after MBS in youth is very limited.[11,46]

3) How should it be determined that the patient adequately understands and can cooperate with both the surgery and its associated follow-up care with appropriate supports?

The patient’s capacity to assent to surgery and to cooperate with perioperative recommendations is most appropriately determined by the pediatric psychologist. This evaluation was significant for low parent reported quality of life for physical comfort and social life. When separated from her parents, the patient indicated that she thought she could lose weight if she had more healthy foods at home, someone to exercise with, and something to help with cravings, which were really strong when she felt sad and bored. Given the patient’s young age, decisional capacity was assessed using simple words and short questions matched to developmental stage and presented with her mother out of the room. The patient expressed: (1) a desire to work on lifestyle-based strategies, (2) an awareness that surgery was an option but she was scared about it, (3) that surgery cannot be undone but she had a limited ability to describe irreversibility in detail, and (4) she showed some understanding that lifestyle behavior changes could lead to improved outcomes (manipulation of information related to treatment). Based on this evaluation, the patient did not assent to surgery.

In this neurotypical preadolescent, an additional ethical issue for medical decision making is that informed consent would be provided by the parents [Framework Section V]: “for an elective invasive and irreversible procedure…with the assumption that the child would be able to consent once older”, and may not have come to the same decision. This is a possible risk that should be openly discussed with the family.

4) How should it be determined that the choice to pursue MBS is uncoerced and voluntary?

[Framework Section V]: “Although the presumption is that patients should be old enough to assent to this procedure and cooperate, an ethical justification can be offered for the rare exceptions to this presumption, given that the requirement for assent for adolescents with IDD can be waived, with the provision of expanded supports from their families to cooperate with necessary management. It is less clear that children who are able to assent and refuse to do so should be candidates for bariatric surgery.”

The ethics team was consulted at the 2^nd preoperative visit, and met with the family. They conducted separate interviews with the parents and child, which revealed the parents’ strong preference to pursue MBS “to get ahead of medical problems she is destined to develop”. In clear contrast, the child stated, “I want to lose weight so people stop making fun of me and I know my mom and dad want me to have surgery. But, I’m scared of surgery. Can I try a diet first? I’ll try harder to eat the right things. I really don’t want to do this – but I don’t want to make my mom and dad mad.”

[Framework Section V]: “Even though preadolescent children may lack the ability to fully understand, they are still owed respectful treatment. One of the hardest judgements is about when to override a child’s objection. Based on obligations to provide respectful treatment and maintain trust and cooperation, the presumption should be not to override objections except in the rarest of circumstances.”

The ethics consult team documented a note with an ethical analysis of the case in the electronic medical record and debriefed with the MBS clinical team, after which the MBS team came to a clear consensus that 1) the child’s dissent was paramount and outweighed current medical necessity to perform MBS and 2) there were several intermediate, more conservative treatment options they could connect the family with to achieve the primary shared goal of BMI reduction and comorbidity improvement. The MBS team communicated to the patient/family that they would remain available as a resource and could re-evaluate the medical necessity for MBS in the future.

4. Discussion

As the utilization of MBS in pediatrics increases to help mitigate the morbidity and early mortality associated with severe obesity,[47] centers offering MBS will increasingly encounter clinical situations that may challenge personal and professional values and raise ethical questions. While the latest national guidelines for MBS in youth reflect movement toward a patient-centered approach, with recognition of the need for equitable consideration for subpopulations previously excluded by many,[14,31] additional resources are needed to disseminate and facilitate widespread adoption of these recommendations. One aspect of this work is the development of practical, standardized tools that can guide the evaluation of any child presenting for possible MBS in an ethically sound way. The ethical framework we present in this paper is a starting point to achieve this broader objective.

The primary intended audience for the framework is MBS programs serving pediatric patients. However, the core ethical principles, approach, and ethical analysis of the subpopulations outlined may be valuable for medical pediatric weight management programs or primary care providers when considering a referral for MBS evaluation, ethics consultation services, and adult MBS programs. Further, while we have illustrated initiation of an ethics consult from the healthcare team, families can also be empowered to request an ethics consultation if they are struggling with moral distress or ethical questions of their own.

An adaptation of this framework to adults presenting for MBS could similarly highlight individuals with IDD, but may also include those with medical or psychiatric conditions acquired later in life that impact decision-making capacity (e.g. traumatic brain injury, dementia, schizophrenia), and adults over age 60.[48–50] Differences in the ethical evaluation of adults versus youth may include: who assumes the role of the primary caregiver (typically a parent for youth, but could be a sibling or spouse for adults) and in what environment (commonly the family home for youth, but could be an assisted living facility for adults). Other practical elements for an adult-focused framework could include guidance about choosing a supported decision making versus power of attorney versus guardianship model,[51] the expected timeline for implementing these supports in relation to the MBS timeline, and a description of the consent/assent process in each scenario.

There are limitations to the content and application of the framework as presented. First, although ethics consultation services are widely available across US hospitals, not every MBS center or provider will have access to a qualified ethics consult service when an ethical question arises.[52] Platforms for long distance consultation including telehealth have connected geographically remote and resource-limited settings to ethics expertise.[53]

Next, one could suggest potential bias in relying on a framework that allows the decision about whether or not to involve the ethics service to be made by the clinical team (Figure 1). An alternative approach could be to define specific triggers (e.g. age or diagnosis) for an automatic ethics consultation. We contend that using an ethical framework is a stronger approach and actually promotes counter bias by deepening the team’s understanding of how ethical values are embedded in all clinical judgments. It promotes discussion of ethical issues as part of clinical practice, and makes more explicit the decision to seek outside assistance in the form of an ethics consult.

The framework reflects our single center’s experience over a discrete period of time. However, the framework is adaptable, and future versions could be strengthened by incorporating feedback and experiences from other MBS programs, and by integrating new data about MBS outcomes among individuals with IDD and for preadolescents as it becomes available.

Finally, this paper aims to clarify national guidelines by developing a model for ethical evaluation of youth presenting for MBS. However, this model has not yet been empirically validated. Planned next steps to test the framework include prospective data collection on preoperative variables, MBS completion rate, and clinical outcomes (weight loss, comorbidity improvement, postoperative complications) for patients evaluated with versus without the ethical framework across youth-focused MBS programs. Thus, while some pediatric MBS programs may use this framework to organize their approach to assessing patients in an ethically-sound manner, more data are needed before adoption can be recommended.

5. Conclusions

We present a novel overarching framework for the ethical evaluation of youth presenting for MBS, and highlight its application to two ethically complex clinical scenarios. Extensions of this work may include implementation of a standardized ethical evaluation for pediatric MBS candidates nationally, and further investigation to determine if this standardized approach promotes equitable access to MBS and/or improved clinical outcomes.

Supplementary Material

Appendix_Framework

Appendix: Ethical framework for metabolic and bariatric surgery at a children’s hospital

Highlights:

• We present a novel ethical framework for the evaluation of pediatric MBS candidates

• Application of the framework to ethically challenging pediatric patients is shown

• The framework and cases may be a practical tool for other MBS programs

Abbreviations:

MBS

Metabolic and Bariatric Surgery

IDD

Intellectual and Developmental Disabilities

ASMBS

American Society for Metabolic and Bariatric Surgery

AAP

American Academy of Pediatrics

BMI

body mass index