To review the most important moral challenges following from the widespread use of bariatric surgery for type 2 diabetes for patients with BMI < 35 kg/m2, although high quality evidence for its short and long term effectiveness and safety is limited. Methods Extensive literature search to identify and analyze morally relevant issues. A question based method in ethics was applied to facilitate assessment and decision making. Results Several important moral issues were identified: assessing and informing about safety, patient outcomes, and stakeholder interests; acquiring valid informed consent; defining and selecting outcome measures; stigmatization and discrimination of the patient group, as well as providing just distribution of health care. The main sources of these challenges are lack of high quality evidence, disagreement on clinical indications and endpoints, and the disciplining of human behavior by surgical interventions. Conclusion A lack of high quality evidence on the effect of bariatric surgery for the treatment of T2DM in patients with BMI < 35/kg/m2 poses a wide variety of moral challenges, which are important for decisions on the individual patient level, on the management level, and on the health policy making level. Strong preferences among surgeons and patients may hamper high quality research.
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