Total Joint Arthroplasty in Patients Who Are Obese or Morbidly Obese: An Ethical Analysis

The selection of TJA candidates among patients with obesity remains a complex issue. Utilizing the 4 core ethical principles can guide decision-making regarding patientswith obesity. Shared decision-making resulting in a decision to perform early arthroplasty may be successful in respecting beneficence, as performing the procedure promptly will provide pain relief and improve mobility and quality of life. Although the principle of nonmaleficence would argue against this choice because of the higher complication rates for early TJA, delaying the surgical procedure may increase morbidity, including depression, narcotic use, ambulatory dysfunction, and comorbidities associated with immobility. Through joint decision-making, standardized informed consent, and reasonable expectations regarding the goals of arthroplasty, offering a surgical procedure to patients with obesity may best respect patient autonomy. Incentives against treating patients who are obese, including reimbursement, operating room availability, and qualitymetrics, are not just and do not capture howmuch an individual may benefit from TJA. TJA is not appropriate in all patients with obesity ormorbid obesity, and many patients benefit from a multidisciplinary weight loss trial. However, there are ethical arguments for considering these patients for a surgical procedure, and arguments that hard BMI limits are not ethically sound and that they do not capture the nuanced medical needs of each patient. As new implants, techniques, and the resulting outcomes continue to advance, so will operative decision-making for this patient population.