Patient autonomy and metabolic bariatric surgery: an empirical perspective

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Background

Metabolic Bariatric Surgery (MBS), a surgical intervention designed for weight loss, has gained significant popularity over the past decade, emerging as a prominent option alongside medicinal treatment for weight loss [1, 2]. The popularity of the procedure did not skip Israel, where the study took place [3].

The increase in the number of MBS procedures may be ascribed, first and foremost, to medical factors. These include increasing awareness of overweight-related health hazards, the effectiveness of MBS, and the introduction of safer and more effective surgical methods [4,5,6].

Appearance standards set out by what is considered as the Western beauty ideal also fuel the motivation for MBS. For decades, a very slender body, often referred to as the ‘thin ideal’, has dominated Western media as the cultural beauty ideal [7, 8]. As a slim body constitutes a dominant component of the beauty ideal, individuals often attempt to mold their bodies to fit this perception of the ideal body [9]. Accordingly, they may show an increasing motivation to subject themselves to such weight-loss practices as excessive dieting and MBS regardless of the hazards they entail [7].

Weight bias, also referred to as fat-phobia or weight stigma, is another factor which incentivizes patients to undergo MBS. Weight bias describes the negative attitudes and stereotypes associated with larger bodies. Ultimately, weight bias can lead to an obesity stigma, which is the social label affixed to an individual who becomes a victim of prejudice. The interchangeable term 'fat-phobia' relates to an irrational fear of fatness or of being around fat people due to the negative attitudes and stereotypes about them [10, 11]. Weight bias and fat-phobia, in turn, lead to social discrimination and stigmatization, which manifest themselves in various spheres of life [12, 13], and thus may lead overweight individuals to choose MBS regardless of its risks and side-effects.

The motivation to undergo MBS is also fueled by the medical profession. In line with the aesthetic ideal of the thin body, the medical profession tends to conceptualize “obesity” as a disease which should be treated by losing weight [14]. As a result, thinness is associated with both a “healthy” as well as a “normal” body, while the overweight body is considered a “deviation” that needs to be corrected through medical measures, including MBS, regardless of its risks and side effects [15].

Financial considerations may also be responsible for the increase in the number of MBS procedures. From a public health care perspective, MBS was found to be cost-effective in the long run [16]. Moreover, health insurance coverage, the reimbursement of medical centers and insurers, and the expected revenue stream generated by MBS procedures may directly or indirectly influence health care providers’ and patients’ decisions regarding MBS [17, 18].

Regardless of what motivates physicians to recommend MBS procedures, they are obligated—by law and ethics- to ask for the voluntary and informed consent of an MBS candidate. A physician should, therefore, provide the patient with information that enables him to substantially understand the significance and implications of his decision. This includes details about the types of surgery available (restrictive and/or malabsorptive, laparoscopic), the associated risks and complications, the resulting dietary and lifestyle modifications, the expected outcomes, the surgery’s long-term effects, and alternative non- surgical treatment options [19]. In addition, physicians should allow patients to make decisions voluntarily, and not under the compelling influence of others [20].

While legally and ethically grounded, the requirement that an MBS candidate voluntarily consent to surgery raises difficulties, as both the physician and the patient may be subject to the influence of medical, social, and financial factors. Against this background, the study’s aim is twofold: first, to explore the factors and influences that affect MBS candidates during the decision-making process. Second, to discuss the question of whether the factors that were found to influence MBS candidates negate their ability to voluntarily consent to the surgery. In attempting to answer this question we will apply theories of autonomy to the empirical findings of our research.

The importance of this article is multifaceted. For one thing, and notwithstanding the growing number of MBS procedures and its unique character, few papers have discussed the issue of autonomy in deciding to undergo MBS procedures. For another, the papers which have addressed this issue focused on the duty of disclosure while the “voluntariness” condition attracted little or no scholarly attention [20,21,22,23,24,25]. Moreover, and while the question of what motivates patients to undergo MBS procedures was examined empirically in several studies, the effect of these motivations on patients' ability to voluntarily consent to undergo MBS has yet to be discussed.

The article itself is made up of six parts: “The theoretical framework” section discusses theories of autonomy, and thus establishes the theoretical framework for the discussion which follows. Sect. “The empirical study” section, in turn, presents the study’s methods and the empirical findings, while “Findings” section analyzes the empirical study’s findings using theories of autonomy. “Conclusions” section concludes the paper and offers practical insights. “Study limitations and future research” section outlines the limitations of the study.

The theoretical framework

Which conditions should be met for a decision on medical intervention to be voluntary?

The concept of autonomy plays a pivotal role in modern Western bioethics. While it is widely accepted that personal autonomy is a matter of self- governance [26], autonomy remains a complex, ambiguous and contested concept in theoretical writings [27].

One of the most influential accounts of autonomy is presented by Beauchamp, Childress, and Faden. According to their theory, three conditions should be met for a decision to be autonomous: intentionality, understanding, and non-control [26, 28]. Among the three conditions, the third condition—non-control—is the focus of the present paper. Non-control decisions are decisions made without controlling influences. In this framework, controlling influences are pressures or constraints that override or distort an individual’s ability to make decisions that reflect their values and desires, which undermine autonomy.

Building their account on the premise that the everyday choices of generally competent persons are autonomous, they presented a non-ideal theory of autonomy. This theory posits that individuals exercise autonomy even when their choices are influenced by personal inclinations, emotions, and desires [28]. Moreover, they describe acts as autonomous by degrees ranging from entirely autonomous to not autonomous at all. In acknowledging the need to determine a cutoff point between adequate and inadequate degrees of autonomy, they suggested the “substantially” test. This means that a decision is autonomous if it is substantially autonomous [26, 28]. Accordingly, and with respect to the condition of non-coercion, they perceive substantial non-control as sufficient for an act to be considered autonomous [26].

Beauchamp, Childress, and Faden continued and contended that substantial autonomous decisions are located somewhere between midpoint and fully autonomous decisions. According to their argument, the placing of the threshold point for substantial autonomous decisions is not arbitrary but is instead guided by a deliberate rationale. Specifically, this rationale seeks to enable patients to participate in the decision-making process to an extent consistent with their engagement in other areas of their lives, striking a balance that neither exceeds nor falls short of this level of involvement [26, 28].

In analyzing the condition of non-control, Beauchamp, Childress and Faden mention two types of influences: internal states and external sources (hereinafter referred to as ‘external influences’). In their model, internal states include such things as debilitating diseases, psychiatric disorders, and drug addictions which can rob a person of her or his self-directedness and thereby preclude autonomous choice and action [26].

In addressing external influences, Beauchamp, Childress, and Faden, identify three categories: coercion, persuasion, and manipulation.¹

They posit that coercion occurs if, and only if, one person intentionally uses a credible and severe threat of harm to control another, and thus displace that person’s self-directed course of action. With this being the case, three important insights arise from their definition: a. In a true coercion situation, what controls, and thus deprives a person of autonomy, is the will of another person. As such, only external influences exerted by others can be coercive. Life-threatening medical conditions are not coercive in spite of the fact that they compel actors to act in ways they would not have chosen otherwise [28]; b. coercion involves the intention to control on the part of the coercer. If an intention to control is not present, there is no coercion regardless of a person’s subjective feeling of being forced to a choice [26, 28]; c. by its very nature, successful coercion will always render acts non-autonomous [28].² The use of credible and severe threats of harm to control patients is a significant issue in various medical contexts, particularly in mental healthcare and reproductive healthcare, where the power imbalance between healthcare providers and patients can be exploited[30, 31].

Influence by persuasion, on the other hand, never precludes an autonomous act. According to Beauchamp, Childress, and Faden, persuasion is morally non-problematic because it involves the use of reason and argument. As such, it allows the actor to choose between accepting the external influence or rejecting it [26, 28].³ Examples from the medical field include expressions of support from the treating physician or family members for performing a medical procedure in light of its medical or functional benefits [32, 33].

As noted above, Beauchamp, Childress, and Faden identified ‘Manipulation’ as the third category of external influences. In this respect, they posit manipulation as a generic term for several forms of influences which essentially motivate the actor to do what the manipulator desires by means other than coercion or persuasion. Examples of such influences are informational manipulation, framing effects, social norms, inducing affective states, and playing on desires or emotions [26, 28, 29]. The medical arena provides numerous examples of how informational manipulation, framing effects, social norms, affective states, and desires or emotions can be used to influence an actor's decision-making without resorting to coercion or persuasion: Exposure to idealized appearance standards on social media and peer comparisons can increase dissatisfaction with one's appearance and lead to a greater desire for cosmetic surgery [34]; and the way a physician describes a procedure's risks when obtaining a patient's informed consent significantly influences the likelihood of consent [35].

Although they influence the actor, such measures only make an act non-autonomous if the actor could not resist them [28]. Unlike coercion, therefore, manipulation does not necessarily compromise autonomy.

Given that not all influences in this category render an act non-autonomous, there is a need for an adequate criterion for differentiating between external influences that an individual can resist—thereby maintaining autonomy—and those which the individual cannot resist – thereby compromising autonomy. The question of what distinguishes autonomy-undermining influences from influences that merely play a motivating role in the decision-making process has numerous answers [36].

Some philosophers, such as Harry Frankfurt, presented a procedural, content free, definition of autonomy [37]. Frankfurt offered a hierarchical and structural definition of autonomy. He distinguished between first order desires -which take the form of 'A wants to X (an action)', and second order desires- which take the form of 'A wants to want to X'. On Frankfurt's analysis, an individual acts freely when the desire on which he acts is one that he desires to be effective. On the other hand, if the individual does not ‘unequivocally endorse’ the motive for his actions, then he or she does not act in free will [38,39,40]. With this being the case, and if an actor's first-order desires were created by another person and are therefore not an expression of his or her true self, then the actor's act is not autonomous. Conversely, actors can be autonomous even if they are moved by desires, they cannot resist [41]. Moreover, Frankfurt does not consider autonomy to depend on whether we are responsible for who we are. He acknowledges that actors are inevitably fashioned and sustained by circumstances (natural or human) over which they have no control [42, 43]. For him, the crucial question is thus whether people identify with their first order desires on a higher level [38].

While Frankfurt presented a historical proceduralist analysis of autonomy, relational procedural theorists, such as John Christman, conceptualized autonomy as a “historical process of critical reflection” [44]. For Christman, an autonomous actor can become aware of the ways in which he or she came to possess particular preferences and understand them. This self-awareness, in turn, allows him or her to facilitate such preferences or resist them. More specifically, Christman suggests that actors are autonomous with respect to a desire if, and only if, they would not be alienated from the desire if they were to critically reflect on the historical process which led to the desire. Christman further claims that an autonomous actor should at least have the opportunity to distance himself or herself from the social context he or she lives in so he or she can critically evaluate his or her preferences without external influences. According to this approach, an actor is autonomous if he or she could see himself or herself acting against the values of his or her community under certain circumstances, even if he or she ends up adopting them [45, 46].

Procedural accounts of autonomy have been criticized as overlooking the effects of internalized oppressive socialization on individuals' motivational states [47, 48]. According to the critics, by emphasizing the formal properties of the decision-making process, this approach may classify a decision as autonomous even when the individual's core desires are shaped by deeply internalized and oppressive social norms that they are unable to resist [49,50,51,52,53].

Substantive accounts of autonomy take account of this criticism [48]. For instance, Natalie Stoljar, a feminist theorist, offers a strong substantive account of autonomy: some preferences cannot be considered autonomous because they contradict the ‘feminist intuition’ that “preferences influenced by oppressive norms of femininity cannot be autonomous”. According to Stoljar, what makes these preferences non autonomous is their holders’ inability to see that they had internalized false norms [49].

Others have proposed a weaker substantive theory of autonomy. Paul Benson, for instance, holds that autonomous persons are expected to have good self-esteem or to regard themselves as worthy to answer for their conduct. Benson further argued that actors are autonomous if they have a sense of worthiness to act, which “involves regarding oneself as being competent to answer for one’s conduct in light of normative demands that, from one’s point of view, others might appropriately apply to one's actions” [54, 55].

As the above discussion suggests, relational theories have made an important contribution to the understanding of autonomy. These theories assert that the concept of autonomy must reflect the inherently social nature of human existence, where individuals live within a web of relationships and interactions. They argue that individuals are socially embedded, shaped, and influenced by their social contexts [50, 56].

Nonetheless, relational theories must address the challenge of identifying oppressive social norms that threaten autonomy [50, 57]. Some relational theorists advocate procedural accounts of autonomy as a response to the problem of oppressive socialization, while others support substantive theories of autonomy. At the same time, however, relational theorists also acknowledge the productive influence of socialization. According to this view, social embeddedness provides individuals with a supportive social network, which, in turn, permits the development, strengthening and flourishing of their ability to make autonomous decisions [56, 58, 59].

In the context of informed consent, this perception results in the reformulation of the duties which apply to physicians. Physicians should establish conditions that allow patients to make autonomous decisions that align with their values and desires [56]. According to this approach, the role of the physician extends beyond providing information and avoiding coercive influences. As a part of the social fabric that contributes to the patient’s autonomous identity, the physician should actively promote, support, and strengthen an individual's ability to make autonomous decisions [56, 60,61,62]. For example, physicians should acknowledge that patients' capacity for autonomous decision-making is affected by their social relationships and affiliations (e.g., family pressures and internalized oppressive norms). As phrased by Stoljar, physicians "must therefore take positive steps to counteract these effects, for instance, encourage imaginative reflection on different options and create the conditions in which patients truly feel authorized to speak for themselves" [63, 64].

THE empirical study

Objective

The empirical study presented here sought to analyze which influences are present in the decision-making process regarding MBS and their effect on the patients’ decision.

Methodology

Our empirical study took place between March 2021 and August 2021. It was based on semi-structured, face-to-face, and one-to-one qualitative interviews.

Research participants were located through social networks: posts were made in Facebook groups for people who underwent bariatric surgery. Additionally, interviewed participants were asked to forward the researchers' details to others they knew who had undergone surgery and were willing to participate in the study ('snowballing').

Only adults who had undergone bariatric surgery and approached the researchers on their own initiative were interviewed. Among the respondents, attempts were made to ensure both age and gender diversity.

A preliminary phone call to the respondents provided a brief overview of the study and obtained their initial consent to participate. The interview location was determined according to the interviewees’ convenience, provided that the chosen location allowed for privacy (no possibility of being overheard) and continuous recording.

Full information was provided to each interviewee at the beginning of the face-to-face meeting. The interviewees were clearly told that they were not obligated to participate and/or could stop the interview at any stage freely and without consequences. Following this presentation, the interviewees were asked for their consent to participate in the study, for the use of the interview for research purposes, and for the anonymous publication of the findings.

The interviews were conducted based on a general guide developed specifically for the study, in alignment with its objectives. An English version of the general guide is attached (see Additional file 1).

The order in which issues were presented to the interviewees varied between interviews so as not to interrupt interviewees who wished to speak more extensively on certain topics or who introduced new issues of their own accord. The interviewees were also encouraged to speak extensively on issues they raised on their own initiative without disrupting the flow of the conversation. Significant topics introduced by the interviewees were then incorporated into the general guidelines for later interviews.

All the interviews were recorded and subsequently transcribed in their entirety.

After transcribing each interview, units of meaning were identified, and thematic categories were constructed. The analysis of each additional interview led to the creation of new thematic categories or the addition of units of meaning to existing categories. Following 21 interviews, new perspectives were added to the existing categories, but no new categories were created, leading us to conclude that theoretical saturation had been reached.

The study’s research conclusions were based on grounded theory strategy. Categories were developed systematically by grouping similar units of meaning and organizing them into logical themes, while overarching categories were constructed to integrate related themes into broader conceptual frameworks, ensuring a coherent and comprehensive understanding of the data.

To ensure the validity of the grounded theory analysis, we continually compared data within and across categories to refine and validate emerging themes. The reliability and validity of the qualitative analysis were further strengthened through the comprehensive rereading of the protocols in order to ensure that the data did not diverge from their original meaning(s) in the construction of categories, and by involving multiple researchers in the analysis process to reduce individual bias [65, 66].

The interviews were conducted in Hebrew, and the interviewees quotes presented in the Findings section were translated into English by the authors. We ensured the use of terminology that preserves the interviewees' intentions (for example, using the term Fat rather than Overweight where appropriate).

Findings

The in-depth interviews with research participants revealed that the influences on the decision to undergo bariatric surgery are varied.

Each interviewee described a unique and complex life story. For example, one interviewee, who underwent surgery at the age of 27, described hurtful remarks from her physician regarding her excess weight, as well as stigma in the workplace and a negative body image (to the extent of avoiding intimate relationships). She characterized the bariatric surgery as a choice that changed her life for the better, despite experiencing frequent vomiting as a side effect. Another interviewee, who underwent bariatric surgery at the age of 18, described how her family exerted relentless pressure on her to lose weight, even though she herself did not feel the need to do so. She explained that the surgery was a decision driven by external pressure and causes her significant distress today due to dietary restrictions. A third interviewee who underwent bariatric surgery at the age of 50 mentioned that her decision was partly influenced by observing thin models, which shaped her negative body image. Today, despite severe side effects (chronic fatigue, vomiting), the interviewee expressed satisfaction with her decision, partly due to the fact that her clothing size now matches the sizes sold in stores. Another interviewee described being overweight, which he was unable to reduce despite countless attempts at dietary changes and exercise. In consultation with his physician regarding bariatric surgery, he was told that the procedure was simple and risk-free. The interviewee, who underwent the surgery at the age of 32, described severe pain caused by it, which made him feel that it would have been better to avoid the surgery altogether.

The presentation of the influences on the decision to undergo bariatric surgery and their implications will be divided into three overarching categories: the use of reason and arguments to convince patients to undergo MBS (these will hereinafter be referred to as Category 1 influences); intentionally using threats to induce the patient to consent to surgery (these will hereinafter be referred to as Category 2 influences), and non-argumentative influences (these will hereinafter be referred to as Category 3 influences).

Most of the interviewees described more than one influence, and therefore seemingly fit into more than one category. The interviewee quotes cited below in each category are selected examples of the influences described therein and their implications.

Category 1 of external influences - the use of reason and arguments to convince patients to undergo MBS

The research participants described persuasion efforts and arguments in favor of MBS from both family members as well as their treating physicians.

Family members raised the possible health implications of excessive weight: “My mom calls me and says, listen… you don't need to end up in my condition. My mom has diabetes, suffers from every possible symptom. It seems to me that you need to do it… the decision was made after the conversation with my mom” (2).

Physicians presented the surgery’s health advantages: “The family physician recommended… that I should undergo the procedure and that it could benefit my health” (17); “when she saw my blood test results, she recommended that I undergo the procedure” (17).

The interviewees noted that they chose to accept the arguments raised by family members and physicians. It is apparent that they did not feel compelled by these arguments and that the final decision was their own: “I decided… the family data, if you look at my mom and her illnesses” (2). “The family doctor recommended it to me… it was purely my decision” (17).

The interviewees also agreed in hindsight with the persuasive arguments: “Does obesity cause diabetes? Does obesity cause heart attacks? That's what they say. I specifically choose to believe it… I was fine with my body… I was afraid of diabetes… I wanted to be healthy“ (2). Furthermore, they described the decision to undergo the surgery as reflecting their views: ”Obesity does not proceed in good directions… today I know there is no other option” (2), and as made out of a sense of capability and self-esteem: "I am the type who is interested, who asks, who checks, who doesn't just go along with 'okay, you are the doctor and you decide'" (17).

Category 2 of external influences - intentionally using threats to induce the patient to consent to surgery

The use of threats as a method to influence the decision about surgery was described by two interviewees. One interviewee described a case when her OBGYN specialist conditioned the provision of future medical treatment on her losing weight: “there was an OBGYN who told me ‘Don’t bother coming [to my clinic again] if you don’t lose weight’” (8).

Even if the interviewee had a practical option to remove the "threat" by consulting another OBGYN, the interviewee's low self-esteem (which the threat certainly did not help), prevented her from controlling her choices: “It’s a kind of despair… I was very desperate. My body image, my self-image, I didn’t like my appearance. I’m telling you that I wanted to die, I truly wanted to die… there was something I couldn’t stand…in my self-image” (8).

In a retrospective analysis of the decision to undergo surgery, the same interviewee expressed self-criticism about her decision-making process: “I feel like I'm analyzing myself at this moment. That I… that I behaved either avoidantly or in denial… when I decided to have the surgery, I was in denial, and it was as if it didn't affect me” (8).

Another interviewee reported a threat from her father: “… He even weighed me before I could use the car” (1). This interviewee admitted that she chose the surgery under these circumstances, which is not surprising considering her young age at the time (18 years old): “It was really an issue. Today, he regrets it… but yes, that's how it was… and then I ended up having surgery. I didn’t really care; I thought, okay, this is it, the best solution—only surgery will save me… I was 18… I was kind of a kid… At 18, I wanted to do it, but looking back, you could sign up for a gym, take six months… enjoy yourself. Why do you need to deal with all that nonsense? (1)”.

Category 3 influences - the use of non-argumentative influences

These influences can, by and large, be divided into three sub-categories: emotional manipulation, informational manipulation, and the construction of medical and social norms.

Emotional manipulations

Alongside the use of threats, reason and arguments, interviewees described how others played on their emotions and desires. One of the interviewees, for example, mentioned material incentives offered to her to undergo surgery: “My father said: ‘I'll give you 100 NIS [about 30 USD] for every kilogram you lose’” (1). Other family members and spouses made offensive statements concerning obesity: “they told me it wasn’t pretty” (21); “My husband kept complaining that I was fat” (16). Offensive statements were also expressed by attending physicians: “I have ingrown toenails; I went to a surgeon… he told me, ‘Yes? [what is the problem]’. I told him ‘I have a problem [ingrown toenails].’ He said ‘that’s what's troubling you? your weight isn’t troubling you?… I stepped outside the clinic and cried. I actually cried” (16).

Some offensive statements assumed the form of offensive accusations, explicitly or implicitly blaming the interviewees for their obesity: “They always kept telling me: ‘what's wrong with you? Don't you feel like pulling yourself together?’… all my life… my grandmother, my grandfather, my uncles, and aunts” (1); “He told me ‘I don't understand, so you’re midway through a process, so why don’t you lose weight?’ [and I told him] ‘It’s tough, don’t you understand?’” (8).

Offensive accusations were also made by some attending physicians: “He [the physician] tells me ‘Believe me, I’ve travelled the globe and I never saw any fat person in all kinds of impoverished tribes. There are no fat people where there is no food’” (19); “I told him [the physician]: but I can’t manage to lose weight, and he says ‘so eat less’. I remember being very deeply offended when I left the clinic” (3).

Interviewees also described repeated references to their excessive weight. An interviewee described how “everyone started talking about how I was fat. Like… it was a constant topic in family discussions” (3). Repeated references to interviewees' overweight were also common among physicians. According to one interviewee: “My family physician …she always recommended that I contact a nutritionist… and there were the occasional specialists… they would always, like, recommend a nutritionist […]" (20); Interviewees also noted being repeatedly weighed regardless of the medical reason for their presence at the clinic: “She would always weigh me […]. She would weigh me regardless of why I would come to the clinic… it felt thoroughly unpleasant” (20).

Interviewees further described how physicians ascribed any complaint they made to their excessive weight: “I had pains in my foot … and when I came to complain about the pains… the orthopedic specialist did in fact tell me… that my body finds it difficult to handle the load… that is very belittling… it feels very unpleasant” (20); “My family physician… I would come to the clinic because I had a headache, [but she would say] it was my weight” (1).

The effect exerted by such emotional manipulations on the participants’ decision to undergo the surgery was not uniform. One interviewee mentioned that she decided on the surgery because she couldn't handle the emotional manipulation: “They always told me, ‘You are so beautiful, why don't you lose weight?’… and then I decided to have the surgery"(1). In hindsight, she states that she disagrees with the reasons for choosing the surgery: "The issue of obesity… there's always talk about it… today, I'm an adult and I know… I disconnect from what people say around me and do what makes me feel good" (1).

In contrast, another interviewee who described emotional manipulation by the attending physician noted in hindsight that she did not pay attention to his words at the time: "I told him I'm done and moved on" (19) and repressed the accusations he made: "He was so unpleasant and disgusting, really, he was so blunt that I pretty much repressed it" (19). The same interviewee clarified that she later made the decision for surgery based on convincing arguments from another doctor, without any manipulation: "Until one day… a lovely doctor started to explain… she convinced me" (19). The interviewee justified her decision to undergo surgery even in hindsight: "I was in such a health condition that this was the solution" (19) and took pride in her decision-making ability: "When I get into something, I check everything around. I know what the process will be." (19).

Informational manipulation

Some interviewees described severe physical side effects of the surgery, both in the short term: "I was in excruciating pain"(13); "What followed that period was crazy exhaustion… tiredness I can't even begin to describe"(2); and in the long term: "I didn’t respond well to the surgery… I can’t stop vomiting, I’m not losing weight, I go everywhere and vomit. I have no quality of life"(1); "It’s a difficult surgery… I didn’t get my period for six months, my hair fell out, and suddenly I had a ton of pimples on my face… today, if I don’t take Omeprazole or another medication in the morning, I could die from the pain"(1); "When you cross the line, it’s real physical pain in your lungs and around your stomach. You feel pain… you breathe heavily"(3).

Psychological side effects were also described: "Until you’re really there, you don’t fully understand that you… you can’t eat"(4); "You’re not eating, you’re not drinking… suddenly, the thing you used to do in your daily life… I used to love eating… suddenly you don’t have that, and mentally you’re already shattered because they took away your best friend, which is food"(1).

Some participants reported regaining weight after the surgery: "At first, for about six months, I somehow managed to hold on… now I’m 125 kg. It’s another battle with everything"; and some participants described complications following the surgery: "My bladder didn’t wake up after the anesthesia, and they put in a catheter… it was one of the most unpleasant things" (13); or the need for repeat surgery: "I had the gastric sleeve, and a year later I had to do the full bypass"(19).

However, information about the expected side effects of the surgery, risks, and chances of success was provided to the interviewees based on statistical probabilities, sometimes emphasizing the positive aspects of choosing surgery.

Some interviewees described how physicians framed MBS as the “default” or “best” solution for weight reduction: “Ever since I turned 16, my family physician kept on saying… what about surgery?… it was like the entire medical side of things would only support that as a solution” (1); “[…] she (the surgeon) said that there is no other solution. It is the only solution that obese people have. She said that it is a solution that is quick and that it changes lives” (4); “[…] that’s exactly the impression I got from her… that she doesn’t really see any other solution. She said that it’s the golden solution. That eventually everyone ends up getting it. […] because the chances of losing such a large amount of weight on your own are almost nil… I felt that she was very pushy” (4); “I had normal blood tests, everything was normal. I was simply overweight, and I couldn’t lose weight. No one told me: ‘listen, you are a young woman, you are [otherwise] healthy, [go] do some sports, try and take a year to help yourself.’ They encourage you: ‘it is great for you, you’re young, your whole life is ahead of you, that’s how you treat obesity” (1).

Another framing effect relates to the surgery’s side effects. Some interviewees noted that physicians minimized the surgery’s side effects: “He said that I would feel pressure…and that’s it. Nothing beyond that, nothing” (16); “They present it to you with very rosy spectacles… [they say that] ‘after you undergo the surgery you will eat less’… they don’t say it causes problems in the future”(1); “They say that when you are discharged after surgery, you won’t be able to eat for a week or two, and that you will have to adhere to a very specific diet. Everything seems very fine on the surface… it’s an adjustment [period] and then you go back to your normal life… no one says it’s hard” (1).

Other interviewees reported a similar framing of the surgery’s risks and success rates. They asserted that physicians described the surgery as having minimal risks and high chances of success: “[…] she [the physician] said that the chances of success … are very high” (6); “It sounds like ‘let’s do it, it’s possible, it’s easy!” (13); “She [the physician] said: ‘what are you worried about? it’s nonsense, it's an hour-long surgical procedure” (6); “No one told me it was a dangerous operation. I realized how dangerous it was in retrospect” (9).

As with emotional manipulations, the effects of information manipulations on the interviewees are also not uniform. An interviewee who mentioned that the surgery was described to him by the surgeon as a simple and easy procedure later claimed that the decision to undergo the surgery did not match the costs he perceived as acceptable for losing weight. Furthermore, and in hindsight, he explicitly expressed alienation from the decision: "Even though I know I was fat and had a problem, but if I consciously experienced such pain, I don't know if I would have gone through with it. Although I don't remember the pain now, I do remember this decision" (13). Feelings of alienation from the decision to undergo the surgery considering its risks were expressed by another interviewee: “[…] I wouldn’t have undergone the surgery if they told me about this in advance” (1).

In contrast, an interviewee who mentioned that the surgery was presented to him as the ultimate solution, and that "the damage to quality of life is small compared to the improvement in quality of life" (4), agreed that in his view "the benefit" of the surgery outweighs "the cost": "I am at a critical stage where I am looking for a life partner and I don't want to compromise or come from a place of 'I deserve less because I am fat… I knew that in some way my life was going to change. Yes, I did approach it knowing I won't be able to eat like I used to" (4).

Constructing medical and social norms

The interviewees reported that being overweight was perceived by their physicians as a “disease”: “She said that obesity is a disease at the end of the day… It's a disease that you carry with you, and it causes complications eventually” (4); “I was healthy… Yes, you could call it healthy, but there are things that could develop in the future, and it's not certain that I will be healthy in the future while I presently suffer from being overweight” (20).

The medical conceptualization of overweight as a disease was also described by interviewees as “dictating” their perception of their body as “abnormal”: “I never managed to reach a target weight, that is, a weight that would define me as slim” (4); “I never wanted to be skinny, but I did want my weight to be normal.” (20).

However, even when retrospectively evaluating the decision for bariatric surgery, the interviewees justified the perception that a "healthy body" or a "normal body" is a thin body, given the health implications of overweight: "I'm not sure I will be healthy in the future when I suffer from being overweight" (20); "She (the doctor) said the right things. That obesity is ultimately a disease… a disease that eventually causes you complications" (4).

Alongside the medical conceptualization of overweight as a disease, the interviewees described a social perception whereby an overweight person is less "attractive": “I think that it is something [which is] very universal. Being overweight currently means being less beautiful” (11); “You start being different” (14); “You always compare yourself to others, you want to look better [i.e., more beautiful]” (16).

Interviewees further described how the “standard” sizes of clothing, which often reflect the Western perception of the ideal body, intensified their feeling of inferiority: “A person who has been overweight their whole life dreams of finally fitting into a pair of jeans” (2); “I remember that buying clothes was always a nightmare. I can only buy clothes that fit me and only at certain stores” (4).

Some interviewees expressed criticism of the "thinness ideal" and described the suffering and the feelings of inferiority it caused them. They reported being subject to sanctions in childhood: “you are less popular at school” (14); “[…] it was not easy being a full-figured girl as a child” (20); “I remember PE [gym] classes in school… there were always the jokes [about my weight]” (4). And there were also sanctions in adulthood—in the form of discrimination in getting jobs: “slim people are preferred in job interviews” (3); “They will hear what I have to say, that I am reliable and have experience. But external appearance is something that really got in my way” (6); or in finding a spouse: “who would want me when these are my measurements? It would not be aesthetic” (6); “A woman would naturally want a slimmer man” (11); “I always felt that it [my weight] stopped me from finding a spouse” (20).

One interviewee described the "thinness ideal" as leading to social avoidance: “At weddings, I would remain seated and not dance because I was ashamed of my appearance, or because I was ashamed of being the dancing fat lady or the one the guests would gossip about… I did not want to eat out because I was fat. And why should people see the fat lady eat?"… (3); “I didn’t ever have sex with men… because I was ashamed to […]” (3). She explicitly described that her choice of surgery stemmed from a social norm with which she does not agree: “It’s really sad that at the end of the day you live according to what society directs you toward” (3).

In extreme cases, the oppressive social norms caused psychological distress and harmed the interviewees' self-esteem. They further described these feelings as what triggered the decision to undergo the surgery: “I reached a point where my mental state was so grim that I decided I had to start rescuing myself” (5); “I told myself that it was better for me to die in the operating room than to remain fat” (8); “It’s a kind of despair… I was very desperate. My body image, my self-image, I didn’t like my appearance. I’m telling you that I wanted to die, I truly wanted to die… there was something I couldn’t stand…in my self-image” (8).

On the other hand, other interviewees seemingly chose the surgery out of "agreement" with the social norms, despite these norms being oppressive and depriving them of the ability to direct their lives as they wished: “Aesthetics only. That means that it was not a health issue…. Felt I was fat, and I wanted to lose weight” (12); “It’s like having plastic surgery. You don’t have to get plastic surgery. You want to look good” (12).

Discussion

Our empirical study indicates that interviewees were exposed to different external influences. It also suggests that these influences had diverse effects on the interviewees' decision to undergo MBS.

As Beauchamp, Childress, and Faden’s account of autonomy suggests, the mere fact that the decision-making process regarding MBS was made in the presence of external influences does not necessarily preclude voluntariness. A decision to undergo MBS may not be entirely free of external influences, but still satisfy the threshold of substantial voluntariness, and therefore be autonomous. It is therefore necessary to examine the distinct categories of influences and explore their effects on the decision-making process.

Category 1 of external influences includes intentional attempts to induce people, through arguments and reason, to voluntarily accept the attitudes advocated by the persuader in support of the surgery as their own. Patients make medical decisions in consultation with their partner, family, and friends. These close others influence surgical decisions not only by assistance with understanding the decision and its consequences, but also by communicating an opinion about surgery and persuasion attempts [32]. Support expressed by treating physicians for undergoing surgery also influences patients [33].

In this respect, our study found that family members and physicians raise the possible health implications of excessive weight and the surgery's success in causing weight loss. Nonetheless, interviewees exposed to argumentative methods retained their capacity to critically evaluate their preferences (e.g., the desire to be healthy) and reflect on their values and desires. Subsequently, they reaffirmed and endorsed their decision to undergo MBS. Therefore, and according to Christman, their decision can be considered substantially autonomous, as the use of argumentative means did not undermine their ability to engage in a historical process of critical reflection on their preferences.

The same conclusion arises from Benson's weak substantive account of autonomy: providing the interviewees with valid reasons for the surgery maintains their sense of self-esteem and self-worth. As the interviewees themself note, they perceive themselves as being accountable for their decision to undergo the surgery and conceptualize it as their own, regardless of the involvement of the physician and family members.

Indeed, it is possible that some participants have reconsidered their decisions regarding undergoing surgery after engaging in such discussions. However, according to Frankfurt, if, as a result of these discussions, they developed a desire to undergo the surgery—one they fully endorsed and wished to actualize, for instance, due to a desire to improve their health—then their decision can be considered autonomous.

Category 2 of external influences includes threats made by a physician or a family member [30, 31]. According to Beauchamp, Childress, and Faden, influences of this nature may negate autonomy if the influencer intentionally uses a credible and severe threat of harm to control another and thus displace that person’s self- directed course of action.

In two cases reported in the findings—a father who threatened his 18-year-old daughter that he would prevent her from driving his car until she lost weight, and a physician who threatened a patient that she would withhold treatment until the patient lost weight—the threats sought to control the threatened individuals’ decision making. The question is therefore whether these threats displace their self-directed course of action.

Christman's account of autonomy would support the conclusion that such threats substantially undermine the interviewees' autonomy. Being young, having no car of her own and being dependent on her father’s consent to use the car, the interviewee that was threatened by her father did not have the opportunity to decide independently of this external influence. Moreover, and in retrospect, she expressed feelings of alienation from both the historical process which led to the decision to undergo the surgery and the decision itself. Similar conclusions apply to the other interviewee who was threatened by her physician. She explicitly described her decision-making process as non-reflective and disconnected from her real desires. Benson's weak substantive account of autonomy supports the same conclusion. The interviewee explicitly stated that she considered her life not worth living, which indicates that she experienced very low self-esteem and lacked a sense of self-worth necessary to take meaningful action. Furthermore, in retrospect, she did not view herself as accountable for the decision, describing herself as being "in denial" and emotionally detached from the choice she made.

According to the study’s findings, most external influences mentioned by the interviewees are Category 3 influences, which include emotional manipulation, informational manipulation, and the construction of medical and social norms.

As suggested by the theoretical framework, emotional manipulations can assume many forms. The interviewees in our study described others playing on their emotions and desires, such as inducing feelings of guilt for not losing weight or offering financial benefits for losing weight. Participants also reported offensive statements about their weight and accusations which blamed them for their condition. Repeated references to their weight by family members and physicians, regardless of their relevance to the discussion or the required medical treatment, were mentioned too. Reports of direct hurtful and derogatory comments from family members were also noted in previous research [33].

The effect exerted by such influences on the interviewees' autonomy is not always clear, nor is it uniform, as people vary dramatically in their susceptibility to emotional manipulation. Moreover, an individual's state of mind at a specific time and situational factors may all affect her or his vulnerability [28].

At the end of the day, the issue we are concerned with is whether the interviewees found the manipulation resistible. One of the interviewees reported that she found the emotional manipulation exerted on her to be irresistible and admitted that she agreed to undergo the surgery because she was unable to handle it, and not because she wanted to undergo the surgery. As these findings suggest, and consistent with Frankfurt's perspective, her decision to undergo the surgery was not autonomous because it was driven by a desire she neither wished to act upon nor reflectively identified with. Moreover, the same interviewee retroactively found fault in her reasons for choosing the surgery. Being alienated from her decision after critically reflecting on it suggests, in line with Christman's view, that her decision to undergo the surgery was not substantially autonomous.

On the other hand, another interviewee experienced emotional manipulation from her physician but refused to undergo the surgery. It was only later, and after receiving valid reasons from another physician, that she decided to undergo the surgery, a decision which she reaffirmed and endorsed in retrospect. Thus, and notwithstanding the emotional manipulation she experienced at some point, her final decision to undergo the surgery should be considered autonomous.

Over and above emotional manipulation, interviewees also described the deliberate use of framing strategies by physicians.

Bariatric surgery is performed as an elective procedure, allowing the surgery date to be scheduled in advance and enabling a pre-surgery meeting aimed at providing patients with necessary information. Given that bariatric surgery involves a risk of complications [67] and requires lifelong lifestyle changes, comprehensive patient education is crucial for ensuring that individuals can make an informed choice about undergoing the procedure. Providing details on anticipated weight loss and potential complications forms a key component of this educational process [68]. Nonetheless, some of the study participants noted that their physicians described the surgery as simple, underplaying the risks involved in the surgery, highlighting its success rates, underplaying side effects, and presenting the surgery as the “default” for weight reduction.

Like emotional manipulation, the effect of informational manipulation on the interviewees’ autonomy was not uniform. Some, for example, were unaware that they were being subjected to informational manipulation. They followed their physician’s presentation of the surgery as having high chances of success, few side effects, and low risks, and adopted the position that MBS is the default weight loss treatment. These interviewees were also not aware that this was the physicians’ way of presenting things and not accurate. Being unaware of the information’s framing and its effect on their perceptions, these interviewees were incapable of critically reflecting on their preferences and of consciously deciding whether to endorse or reject them [28].

Moreover, some of the interviewees who chose to undergo the surgery based on the framed information, expressed retrospective feelings of alienation from the decision by noting that they would not have undergone the surgery if they were fully aware of its side effects. They also explicitly disagreed with the framing chosen by the physician and believed that the surgery’s benefits did not justify the risks involved. Both Frankfurt and Christman would regard such decisions as not autonomous, as they do not align with the interviewees' second-order desires (e.g., avoiding surgery with significant side effects and risks), and considering the interviewees' retrospective alienation from the decision. In contrast, there was another interviewee who perceived the description of the surgery’s 'benefits' and 'costs' as reflecting his situation and interests. Therefore, and even if the physician framed the surgery’s side effects as insignificant compared to its benefits, his decision accorded with his first-order desires. Moreover, it seems that the information provided to the interviewee did not affect his ability to critically reflect on his reasons for undergoing the surgery and reaffirm them in hindsight. In this case, informational manipulation, insofar as it existed, did not compromise the participant’s autonomy.

External influences were not limited to those exerted by specific others (e.g., physicians, family members and friends). Interviewees often mentioned medical norms regarding the healthy body as a motivation for undergoing the surgery. A Systematic Review and Meta-analysis aimed to determine the impact of bariatric surgery on weight loss, operative mortality outcome, and obesity comorbidities, found that Bariatric surgery in morbidly obese individuals reverses, eliminates, or significantly ameliorates diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea [69]. Accordingly, medical reasons have also been described in the literature as a motivating factor for undergoing bariatric surgery [70].

Based on the current study findings, interviewees who reported being subject to the medical conceptualization of (morbid) obesity as a disease retrospectively endorsed the perception that excessive weight is a risk factor for illness. As the decision to undergo the surgery accorded with their first-order preferences and real desire to be healthy, and as they reaffirmed the reasons for choosing surgery after critically reflecting on it, being exposed or even affected by the medical norm about obesity, does not make their choice of MBS substantially non-autonomous.

Alongside medical norms, social norms also influence the decision to undergo bariatric surgery. Social norms that idealize thin bodies have profound and often detrimental effects on individuals with larger bodies, impacting multiple aspects of their lives.

In the workplace, individuals with obesity frequently face discrimination during hiring processes, due to biases that associate overweight with laziness or lack of discipline. Even within their jobs, employees with obesity may encounter barriers to promotion and significant wage gaps, particularly among women [12]. Beyond employment, social stigma leads to exclusion and isolation, as individuals with obesity are often subjected to stereotypes, derogatory remarks, and social rejection. These experiences reinforce negative body image and perpetuate feelings of failure and shame for not conforming to societal ideals of thinness [33]. The psychological consequences of such stigma include heightened risks of anxiety, depression, and eating disorders [7]. Furthermore, systemic exclusion extends to institutional and public domains. In healthcare, overweight patients often report being dismissed or blamed for their health issues, regardless of underlying conditions [13]. Similarly, public spaces and transportation are frequently designed without consideration for larger bodies, exacerbating a sense of marginalization [11]. Cultural representations and consumer practices further reinforce these exclusions; mainstream fashion often neglects larger sizes, and media perpetuate the thin ideal as synonymous with success and desirability [11, 71]. Together, these factors illustrate how fat individuals face pervasive structural and social inequities, rooted in societal norms that uphold thinness as the ideal standard of worth and belonging [72].

In our study, a distinction between two types of Interviewees is present with respect to social perceptions about the ideal body as well as social pressures. The first type is interviewees who did not embrace social perceptions of the ideal body as their own, but who found social pressures to be irresistible. Also included in this category are interviewees who expressed criticism towards the social ideal of the thin body and retrospectively disapproved of their decision to undergo the surgery.

According to Frankfurt, a decision to undergo the surgery made by these interviewees was not autonomous, as it did not reflect their second-order desires. While their second-order preference was to maintain their current weight or to take less invasive measures to lose wight, the social norms deprived them of the ability to lead their lives in a reasonable manner. Their decision to undergo surgery was made out of a lack of choice, given the current social reality.

Christman's historical account of autonomy leads to the same conclusion. Compelled as they were to undergo the surgery by social norms and social pressures, these interviewees retrospectively criticized the "thinness ideal" as well as their decision to undergo a surgery which they now felt alienated from.

The second type of Interviewees are those who internalized social norms (hereinafter referred to as 'second type' Interviewees). Some of them consciously endorsed social perceptions about the ideal body while others applied weight stigmas and negative stereotypes about overweight to themselves.⁴

Frankfurt’s account of autonomy suggests that in choosing to undergo MBS all second-type Interviewees acted autonomously notwithstanding the endorsement of the social beauty ideal or the application of negative social stereotypes to the self. According to Frankfurt's account of autonomy, the origin of the interviewees’ second-order desire to lose weight is irrelevant as their decision to undergo surgery was autonomous if it was compatible with their second-order desires. Therefore, acting on a desire shaped by social beauty ideals or negative stereotypes about overweight does not make their decision non-autonomous.

Christman’s account of autonomy leads to the same conclusion. All second-type participants were aware that social norms or negative stereotypes affected their perception of the ideal body as well as their own body. They were also aware that these influences motivated them to undergo surgery. Moreover, they embraced the desire to fit their body to the beauty ideal through surgery in retrospect. As such, and according to Christman, they made an autonomous decision although they were acting upon oppressive desires.

Substantive theories of autonomy, on the other hand, offer a different analysis. According to these theories, the fact that second-type interviewees were self-aware with regard to their motives for surgery and the fact that they endorsed them does not suffice for qualifying their decision as autonomous.

Stoljar, for example, is likely to point to the fact that a considerable percentage of individuals who choose to undergo MBS are overweight women whose desires are formed by oppressive norms about the ideal human body and by patriarchal norms about the ideal feminine body.⁵ According to Stoljar, our female Interviewees acted against feminist intuition when they chose surgery, driven by distorted social perceptions of the ideal body. As such, their decision to undergo surgery is less than autonomous. As men increasingly feel a similar need to adhere to social norms of appearance [76], such feminist claims are equally applicable to men as well as women.

Benson, in turn, would suggest that second- type interviewees whom social norms have led to feel distress due to their inability to lead their lives as they wish did not act autonomously when deciding to undergo the surgery. These interviewees were unable to exercise independent judgment due to the suppression of self-worth caused by social reality and societal attitudes toward overweight individuals.

Conclusions

The present study indicates that the decision to undergo MBS is driven by medical, personal, and social factors. The decision-making process is shaped by a variety of influences, including those exerted by family members and friends, physicians, and social perceptions of the ideal body. Theoretical accounts of autonomy suggest that the impact exerted by these influences on the interviewees' autonomy is also varied.

One category of influences reported by the interviewees was argumentative influences exerted by family members and physicians who tried to convince them to undergo MBS for valid reasons. Applying theoretical accounts of autonomy to these influences suggests that they did not compromise the interviewees’ autonomy to make decisions regarding MBS. On the other side of the spectrum, however, were threats made by a physician or a family member, which do undermine interviewees' autonomy.

As the present study’s findings indicate, many of the interviewees reported that they were exposed to emotional manipulation, informational manipulation, and social as well as medical norms of the ideal and healthy body. These influences were experienced differently by different interviewees. Furthermore, the impact these influences exerted on the interviewee’s autonomy varies depending on the theoretical framework applied to the findings’ analysis.

Notwithstanding these differences, the present study’s findings suggest that, as a whole, this type of influence poses a real danger to MBS candidate autonomy.

Acknowledging that the influences exerted on MBS candidates may undermine their ability to make autonomous decisions regarding surgery, we propose several recommendations.

To begin with, medical practitioners must recognize that obesity is surrounded by social stigma and prejudice. It is essential for any healthcare provider to understand the numerous unjust and harmful social pressures to which individuals with obesity are subjected. Medical practitioners who discuss the option of MBS with potential candidates should also acknowledge that individuals with overweight or obesity often face unfair treatment, and emotional pressures. More specifically, it requires practitioners to be attentive to the fluidity of the boundaries between the medical reasons for undergoing MBS, the influences exerted by specific others, and social norms.

Moreover, if we accept the conception that physicians are part of the social fabric that contributes to MBS candidates’ autonomous identity, then we should encourage physicians to actively promote, support, and strengthen the latter’s ability to make autonomous decisions. To begin with, physicians should exercise caution by refraining from exerting undue and unfair pressures on patients. They should also take reasonable measures to explore whether the choice to undergo MBS is not the result of emotional manipulation from others. We also recommend that physicians make reasonable efforts to improve candidates' understanding of the actual risks associated with the surgery, its potential outcomes, and possible side effects. Medical practitioners should further make reasonable efforts to explore MBS candidates’ motivations for choosing MBS, invite them to critically reflect on their decision-making process, and encourage them to examine whether their decision aligns with their authentic values and real self.

Furthermore, the role of social norms in the formation of a surgery or non-surgery decision should be acknowledged and discussed. It is also equally important that medical practitioners become aware of the social influences that affect the way in which they establish their own medical recommendations to patients regarding MBS.

Finally, policymakers who articulate the informed consent guidelines for MBS should consider the special context within which decisions about MBS are made, as well as the influences that may hinder patients’ ability to make autonomous decisions.

Study limitations and future research

The in-depth interviews on which the research is based were conducted, in part, a long time after the interviewees had undergone bariatric surgery. Therefore, the factual information obtained relied on memory and may be inaccurate. However, the research focused on the interviewees' subjective feelings (such as distress or a sense of harm), which were authentically described and have withstood the test of time.

The study's recommendations address the caregivers' responsibility to understand the factors influencing the decision to undergo bariatric surgery and to strengthen patients' ability to make autonomous decisions. However, for these recommendations to become operational, further research is needed with practitioners performing bariatric surgery to examine the barriers to open and collaborative communication with patients.