COMMENTARY

Weight Cutoffs for Elective Surgeries: Bias or Economics?

Yoni Freedhoff, MD

Disclosures

October 16, 2019

Is access to elective surgeries a human right? For patients with severe obesity, this isn't simply an interesting philosophical question. Rather, the answer is one that could change the trajectory of their lives. From breast reductions to knee replacements, fertility treatments, and more, weight as an exclusion criterion is a regular reality. But is it good medicine?

Defenders of weight-based denial of care will often point to increased surgical risks or complications as the rationale for a BMI cutoff. But increased risks can be covered by obtaining informed consent, as is done with other conditions and circumstances that increase risks but—unlike obesity—don't preclude consultation, let alone surgery.

Some studies actively refute the presumptive risks. Multiple publications have suggested that weight-based restrictions for breast reductions should be abandoned, and others have found that the degree of pain relief after knee replacements is greater in those with obesity, while functional improvements are comparable. And finally, at least here in Canada, national recommendations have called for an end to BMI-based cutoffs for fertility treatments.

Recently, this question led to a legal challenge in the Canadian province of Nova Scotia. Melody Harding was seeking a breast reduction but was told that because her BMI was above 27, she was ineligible for provincial coverage. Frustrated, she wrote to the Nova Scotia Human Rights Commission, and 2 years later, their intervention led to the removal of Nova Scotia's BMI cutoff for reduction mammoplasty. Whether other cases and similar outcomes in other provinces will follow remains to be seen, but given the evidence and the precedent, I suspect they are inevitable.

Surgical Economics

But what drives the cutoffs? If it's not surgical outcomes, is it old-fashioned weight bias and paternalism, with doctors thinking that these cutoffs will motivate people to lose weight? Or worse, that people with obesity should not receive care because they have brought their miseries onto themselves by not moving more and eating less? That might be true for some, but a conversation I had with a plastic surgeon has me thinking that there are far more mundane considerations afoot. 

We chatted about human rights, obesity, and elective surgeries. When I suggested that weight bias might be behind the cutoffs, he very quickly dismissed that as unlikely. More likely, according to him, are the boring realities of operating on patients with severe obesity: The surgeries take longer; may be more technically difficult or demanding; may require specialized equipment, training, or knowledge; and though not life-threatening, may also involve the surgeon spending more time dealing with complications or medical management postoperatively. He argued that weight-based cutoffs are about simple, dispassionate, surgical economics. And at least in regard to increased operative time and postoperative superficial skin infections, the medical literature is in agreement.

No Clear Answers

When it comes to strategies for improvement, there are some obvious considerations, including reevaluating the evidence for and validity of existing weight-based cutoffs; ensuring surgical remuneration is commensurate for longer, more technically difficult cases and follow-up courses; improving clinical training to ensure that surgeons are comfortable dealing with common comorbidities associated with these more medically complicated patients; and recognizing weight bias as a subject worthy of careful attention in medical education.

Without robust medical evidence to the contrary, obesity alone should never preclude a patient from the consideration of surgery, and informed consent is the tool with which to handle risk increases that are comparable to those of other conditions that don't themselves preclude conversation. Anything less is weight-based discrimination.

But if the basis of that discrimination is logistical, can surgeons be required to take on more complicated or lengthy cases, or to buy equipment specifically to work with patients with obesity? Is there a precedent for that in any other area of medicine? I don't know the answers to these questions and would love to hear your thoughts in the comments.

Yoni Freedhoff is an associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada's most outspoken obesity experts and the author of The Diet Fix: Why Diets Fail and How to Make Yours Work.

Follow Yoni Freedhoff on Twitter: @YoniFreedhoff

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