Kamin-Friedman Shelly, Karako-Eyal Nili, Hildesheimer Galya
The School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, 199 Aba Khoushy Ave. Mount Carmel, Haifa, Israel.
The Haim Striks School of Law, The College of Management Academic Studies, 2 Elie Wiesel St. Rishon, Rishon LeZion, 75190, Israel.
BMC Med Ethics. 2025 Feb 3;26(1):20. doi: 10.1186/s12910-025-01177-6.
Metabolic Bariatric Surgery (MBS) has gained significant popularity over the past decade. Legally and ethically, physicians should obtain the patient's voluntary and informed consent before proceeding with the surgery. However, the decision to undergo MBS is often influenced by external factors, prompting questions about their impact on the patient's ability to choose voluntarily. In addressing this issue, the study focuses on two key questions: first, which factors influence MBS candidates during the decision-making process, and second, whether these influences undermine the candidates' ability to make decisions voluntarily, according to theories of autonomy.
The study employed a qualitative methodology, conducting 21 in-depth semi-structured interviews with adults who had undergone bariatric surgery. The conclusions were drawn from an inductive analysis of the interview data conducted using a grounded theory approach, and by applying theories of autonomy to the empirical findings.
Our study indicates that interviewees were exposed to different external influences, which had diverse effects on the interviewees' decision to undergo MBS. Category 1 influences included intentional attempts to induce people, through arguments and reason, to accept the attitudes advocated by the persuader in support of the surgery. Applying theoretical accounts of autonomy to these influences suggests that they did not compromise the interviewees' autonomy. Category 2 influences included threats made by a physician or a family member. These influences were found to undermine autonomy. Category 3 influences included emotional manipulation, informational manipulation, and the construction of medical and social norms. Manipulations and norms were experienced differently by different interviewees, and their impact on autonomy varies depending on the theoretical framework applied.
Acknowledging that the influences exerted on MBS candidates may undermine their ability to make autonomous decisions regarding surgery, we suggest reformulating the duties that apply to medical practitioners with respect to informed consent to MBS. Medical practitioners who discuss the option of MBS with candidates should be aware of the various factors that influence this choice, and actively promote the candidates' ability to make autonomous decisions.
在过去十年中，代谢性减肥手术（MBS）越来越受欢迎。从法律和伦理角度来看，医生在进行手术前应获得患者的自愿且知情同意。然而，接受MBS的决定往往受到外部因素的影响，这引发了关于这些因素对患者自愿选择能力影响的问题。在解决这个问题时，该研究聚焦于两个关键问题：第一，在决策过程中哪些因素会影响MBS的候选者；第二，根据自主性理论，这些影响是否会削弱候选者自愿做出决定的能力。
该研究采用定性方法，对21名接受过减肥手术的成年人进行了深入的半结构化访谈。研究结论来自于对访谈数据采用扎根理论方法进行的归纳分析，并将自主性理论应用于实证研究结果。
我们的研究表明，受访者受到了不同的外部影响，这些影响对受访者接受MBS的决定产生了不同的效果。第一类影响包括通过论证和推理有意诱导人们接受劝说者所倡导的支持手术的态度。将自主性理论应用于这些影响表明，它们并未损害受访者的自主性。第二类影响包括医生或家庭成员的威胁。这些影响被发现会损害自主性。第三类影响包括情感操纵、信息操纵以及医学和社会规范的构建。不同的受访者对操纵和规范的体验不同，它们对自主性的影响也因所应用的理论框架而异。
鉴于对MBS候选者施加的影响可能会削弱他们就手术做出自主决定的能力，我们建议重新制定适用于医生在MBS知情同意方面的职责。与候选者讨论MBS选项的医生应意识到影响这一选择的各种因素，并积极促进候选者做出自主决定的能力。
