The Ethics of Aesthetic Use of Anti-Obesity MedicationsTuesday, June 13, 2023
Given the widespread culture desire for thinness (a term, I first heard used by my dear colleague Lee Kaplan), it should be no surprise to anyone that for many, the primary motivation for seeking a doctor’s prescription (and yes, you do need one!) for an anti-obesity medication (AOM) may well be appearance rather than health.
This may seem frivolous and perhaps vain, but what are the real downsides of using AOMs outside their medical indication?
For one, there is the risk associated with using any medication. Although the newest generation of incretin-based AOMs are considered safer than anything that has come before, there can be unpleasant (e.g. nausea, vomiting, diarrhoea), and sometimes (albeit much rarer) more serious (e.g. gall-bladder colics, pancreatitis, malnutrition) adverse effects. There are also important contraindications to their use (e.g. pregnancy, history of medullary thyroid cancer).
However, once these risks have been discussed and the individual decides that this is a risk they are willing to take, does it really matter whether the person is primarily motivated by aesthetic or health reasons? In fact, I have heard many colleagues tell me that they are happy to harness their patients’ aesthetic motivation to get them to take these meds for health benefits.
As important as these discussions are and as much as we need to have serious conversations with individuals who are clearly only interested in losing weight for appearance sake, in practice, there is usually a considerable overlap between the cultural desire for thinness and the need to lose weight for health reasons.
Thus, even in people with a BMI as low as 25, around 50% of individuals will have some health issue that is likely to get better with weight loss. For others, who may appear healthy, weight loss may reduce the risk of future diseases that run in their family (e.g. type 2 diabetes, heart disease, osteoarthritis, etc.).
As we get to higher BMI levels, the proportion of people with significant obesity related health problems increases to over 85% in those with a BMI over 40. This still leaves some people with a high BMI, who are pretty healthy and for whom the only benefit of weight loss (if desired) would be largely aesthetic, but these are clearly the exceptions.
So where do the ethics come into all of this – obviously, we operate under the dictum – primum non nocere – which means that we need to carefully weigh potential benefits against potential risks of treatment. However, this also includes weighing the risk of treatment against the risk of not treating (this point is often forgotten).
Although this may appear straightforward for populations, where I can calculate statistical probabilities of risk and benefit – it remains less clear when I deal with an individual where personal preferences, individual risk tolerance, beliefs, cultural pressures, etc. become part of the equation and thus part of the decision process.
This touches on issues of individual autonomy, where everyone has the right to make their own decisions about their bodies and the risks they are willing to take (or not) – especially, if they are the ones bearing the costs.
As readers will notice, this issue is by no means unique to obesity – so there is much to learn from other conditions. Indeed the entire field of aesthetic medicine (not to mention reproductive health) has long grappled with these issues.
My approach has always been to first discard all judgement of my patient. My job is to inform and offer advice to the best of my knowledge. Whether or not we can then agree on the best course of action, which may not always be the one I recommend, will vary from person to person – but, it’s never for me to judge.
Disclaimer: I have received honoraria as an independent medical, research and/or educational consultant from various companies including Aidhere, Allurion, Boehringer Ingelheim, Currax, Eli-Lilly, Johnson & Johnson, Medscape, MDBriefcase, Novo Nordisk, Oviva and Xenobiosciences.