The increase in obesity among UK’s population has been a tremendous interest in healthcare since it is seen as one of the principal factor for causing cardiovascular disease and Type 2 diabetes, costing NHS even more (MRC, 2013). The occurrence of obesity has been so common in the overall population that it has become vital for nurses to be up to date with information regarding obesity issues. Nurses should also be able to use those obtained information to prevent and help recognize those who are already obese by providing them with treatment choices and lifestyle changes information. There are many aspects of obesity treatment which require particular expertise and insights and so doing research on it helps students to gain more information and deliver good practice in the future. Therefore, this essay will be focused on bariatric surgery among adult.
Bariatric surgery is a surgery that alters the digestion process in which broken food is absorbed slowly than usual to minimize the amount of nutrients and calories absorption. This type of surgery is recommended for people who are extremely obese- body mass index (BMI) of 35 or above along with severe health problems. This procedure may be effective in reducing weight and treating comorbidities, however, it is costly and has associated risk similar to those of any surgeries (NHS, 2013).The growing number of bariatric surgery not only seems to be a significant contributor to NHS cost but also appears to increase various legal and ethical issues.
I will now identify the significant legal, professional and ethical issues related to the bariatric surgery for adult. Bariatric surgery follows the fundamental principles of patient autonomy and consent to treatment which is reinforced by the Human Rights Act (1988), Equality Act (2010) and Mental Capacity ACT (2005). The professional issues are the Nursing and Midwifery Council (2008) that states health professionals are personally responsible for their actions and errors and must be able to justify for their actions. There is also National Institute for Health and Care Excellence (2013) and National Health Service (NHS) that health professionals should be aware while treating patients. The ethical issues related to bariatric surgery are based around deontology and teleology theories and autonomy and justice (Beauchamp and Childress’s Four Principles Approach 2001).

Legal and Professional Issues
Human Right Act (1988) sets out that individuals living in the UK have right to life, protection from torture and inhuman and degrading treatment, right to liberty, freedom to speech and expression. Similarly, Equality Act (2010) also speaks in favour of equal rights to individuals. The Equality Act (2010) covers discrimination against disability, sex and race in wider society. Likewise, Mental Capacity Act 2005 allows individuals to make their own choices and should be mentally competent to give valid consent on treatment and patients who lack capacity to do so; decisions can be made on behalf of them. Hence, it interprets if an individual is capable of understanding the nature and effect of the treatment intervention such as bariatric surgery. However, Foster (2007) noted that laws must not be interpreted in a way as to put an impossible pressure on the authorities.
There are professional guidelines such as Nursing and Midwifery Council (NMC) which has a code that states nurses should be responsible for nursing decision and action. It states every nurse should treat patients as an individual and must produce evidence based judgements that are in the best interest of the patient using their professional skills and expertise. Similarly, there is National Institute for Health and Clinical Excellence (NICE) guidelines that set out approved guidance for health professionals so that they can deliver safe practice. In terms of bariatric surgery NICE guidance has clear instructions about who should be considered for surgery. For instance, NICE says bariatric surgery should be considered for the person who has a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 along with other significant illness (NICE, 2006). Likewise, there is National Health Service (NHS) that controls public health care and funding. And due to limited funding NHS is limiting numerous people for surgery despite meeting NICE criteria (The Telegraph, 2010). NMC and NICE encourage to implement safe practice by identifying and minimizing risk to patients. In the other hand, NHS is going against the NICE guideline by not putting guideline into practice and not working to evidence based standards.

Ethical issues
Staunton and Chiarella (1997) writes teleology is based upon results of performance (the consequence); if the result of action gives the positive result, the performance is judged to be morally right. The best known branch in teleology philosophy is called utilitarianism which describes greatest good for the greatest number and is often used in healthcare resource allocation. It can be said that this theory has been applied to bariatric surgery. According to The Telegraph (2010), many obese people are being denied for obesity surgery even though they meet NICE criteria. It could be due to the high cost of surgery and limited NHS funding; health professional may give less expensive treatment to a larger number of patients than a single bariatric surgery to one patient. Wheeler (2012) mentions health experts predict complications and help in the long term; spending money on people indulged in unhealthy behaviour could be used to treat others capable of benefitting from other treatment. However, Staunton and Chiarella (1997) argue that this theory may fail to reach the patient as an individual especially when health professionals are confronted with patients who would be deprived by limited resources.
Deontological (duty based) says, “An action is morally right if it accords with some list of duties and obligations” (Wheeler, 2012). Applying this principle to an example, let us consider the case where extreme obese woman (BMI 50) is pregnant. She also has severe orthopaedic problems and requires spinal fusion, another factor contributing to her need for surgery. The surgery will of course cause her foetus’s death even though removing the foetus is an unintended consequence of the surgery, but a side effect of it. The ethical question is: can it be morally right to perform surgery that will inevitably destroy the foetus? If we return to the philosophy of utilitarianism above, utilitarian will be arguing for an evaluation of the better outcome. Her life is seen as valued over maybe the concept of mother and foetus dying from no surgery at all. Utilitarian might argue that they want to continue the surgery because they foresee the possibility that by allowing the pregnancy to continue, the mother might die from the obesity impediment even before the child is born. Thus her death for being extremely obese might also consider the foetus’s life, thus leading to two bad outcomes instead of one. But then referring back to deontologist they will see them saying: in order to conclude if an act is morally right the action itself should be assessed independently of the result.
Saarni et.al (2011) mentions that informing and supporting patient’s autonomy is remarkably crucial as advantage and disadvantage of bariatric surgery are complex, and the result is determined by how well patient comprehends and sticks to lifelong modification such as eating habits. Wheeler (2012) however also adds by commenting, patient should be mentally competent to recognize healthcare judgement. In agreeing to Wheeler, Hofmann (2010) highlights psychiatric comorbidity could be relevant when assessing competence to consent bariatric surgery.
The bariatric surgery only for a particular condition may raise the question of justice. Wheeler states “Justice is a principle of distributing access, benefits, risks and costs fairly and equitably” (2012, p196). For example, healthcare resources are distributed in proportion as there are insufficient resources and unlimited demands. And since bariatric surgery is expensive to be carried out on every eligible person, NHS has adopted a fair distribution of scarce resources called distributive justice and so rations obesity surgery to only the utmost life-threatening cases (The Telegraph, 2010). It can be argued that putting criteria for surgery may exemplify inequality and may reflect on prejudice against some eligible people (Hofmann, 2010). On the other hand Foster (2007) writes that the courts are interested in the overall size of the fund available for NHS patients as a group so to promote rather than allocating resources for a particular purpose. By stating that distributive justice is not a fundamental human right, the House of Lords is trying to tell that every individuals medical needs cannot be fulfilled and therefore, they don’t have enforceable right to put their own hand in the public purse in order to satisfy their needs.
With critically assessed the main legal, professional and ethical issues related to bariatric surgery for an obese adult, I have found there is overlapping on ethical and legal judgement. For example how respect for autonomy involves a consideration of Mental Capacity Act (2005) in determining patient’s informed consent. In regard to moral theories: teleology and deontology moral principles: respect for autonomy and justice, I have found that all of them are right in their own views. For example, the NHS’s final decision to ration bariatric surgery could be seen as reasonably sensible move since it saves NHS funding which can then be used for more deserving. I also think the combination of all these values and principles may assist nurses in making ethical decision. However as a nurse, you should also work within law limits of the country you are working in and follow guidelines established by professional bodies.

Reflection

I will apply Gibbs reflective cycle (1988) as it is known for its simple structure that guides individuals to evaluate the event, improve and deliver better practice in future.
Description: A group was formed comprising eight members who have previously worked before. Initially, we began with a study of varied topics to base the design on. There were many topics raised during the discussion, and so the entire group decided to finalise a subject by a silent ballot. The argument was ‘should the obese pay for their care?’. After choosing, we looked for what areas needs to be researched and then allocated those fields of study to team members. The group then also selected a team leader and a sub leader.
Feelings: I felt very comfortable and accepted within a group. The atmosphere was friendly and supportive. I, however, sometimes felt agreeing on most things easily rather than challenging others. I contributed more on completing my given task, listening and giving feedback rather than coming up with creative ideas for performance. I was excited to perform during a rehearsal as our unique role was to get into characters and portray characters in a convincing strategy, however, at the same time I was nervous too because I have never done drama in front of an audience. At the performance, I felt quite confident with my script and decided not to take cue card with me. But at the end, I had difficulty remembering my dialogues and thought I completely ruined the entire play.
Evaluation: Our team collaborated well and established relationships with others to carry high performance results. There were no hierarchy system and no one tried to dominate each other’s performance. The viewpoints of each member were taken in to consideration. We had a good team approach in forming a performance, sharing ideas of what the script will be good in capturing public attention and discussing available option to problems such as a cue card for those who have trouble memorizing script. The involvement and unity of our team were strong. Despite positive features there was still little communication between subgroups and individuals, so it was not immediately apparent how much of each job was made to other members of the group.
Analysis: I began this process with a literature search and found Tuckman’s (1965) model to understand how a group is created, and those measures are Forming, Storming, Norming and Performing.
Through forming stage, it is perceived that there was easiness among team members; any thoughts and processes presented were appreciated by the team; roles and responsibilities of team members were clearly designated, and aims were acknowledged from a leader with full team consensus. At this point, group members were fully satisfied because of clear defined roles and goals assigned to the each member.
In the second meeting groups were going through storming stage as there was a conflict among team members; group members begin to challenge and disagree with one another about information that is going to be used in the media article. The storming stage was lengthy with much debate as team members spent most time in drawing towards consensus. Eventually, both sides managed to remain calm and tolerant leading to much more resolved situation. The conflict did not take any further to be damaging.
At the norming stage team members discussed characters and duties that were allocated through volunteering or mutual agreement. The group’s enthusiasm was high towards completing tasks in order to begin performance rehearsal straightway since the assessment due date was closer. It was feared that there would be conflict between writers because of sharing the responsibility, but both groups cooperated well with little struggle.
The group performed its work well and will be able to work in the future. The team put an effort to make all arguments understandable to the audience and collaborated well together.
Conclusion: It is apparent that a leader is expected to establish objectives, providing construction and monitoring member’s performance. There will always be variations in views amongst group that creates conflict and so making delays in completing the task. Applying an appropriate group intervention such as regular communication between groups is vital to ensure the success of the group.
Action plan: If this were to be done again, a lot could be improved as per our communication or have someone to take decisive leadership in order to avoid time spent.
I would be more confident in speaking up my thoughts and challenging other against their opinion with respect. I would take the initiative and communicate more when doing allocated different responsibility. I also found out that working on this project helped me become more ethically aware in considering the results of my choices.

References:
Bariatric News, (2012) UK report shows disparities in bariatric surgery provision [online]. Available at: http://www.bariatricnews.net/?q=news/11114/uk-report-shows-disparities-bariatric-surgery-provision Accessed at: 23/10/2013
Foster, C. (2007) Simple rationality? The law of healthcare resource allocation in England. Journal of Medical Ethics 33, 404-407 Available at: http://0-web.ebscohost.com.wam.city.ac.uk/ehost/detail?vid=7&sid=f670d921-76f9-4fdc-bd90-78c4263c3a88%40sessionmgr114&hid=118&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh&AN=2008-10381-010 (Accesed date: 23/10/2013)
Gibbs, G. (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Further Educational Unit, Oxford Polytechnic
Hofmann B (2010) ‘Stuck in the middle: the many moral challenges with bariatric surgery’moral issues on bariatric surgery, American Journal of Bioethics [online] vol. 10 (12),pp. 3-11. Available at: http://0-web.ebscohost.com.wam.city.ac.uk/ehost/detail?vid=5&sid=f670d921-76f9-4fdc-bd90-78c4263c3a88%40sessionmgr114&hid=118&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=2010884319 (accessed: 23/10/2013)

MRC Medical Research Council (2013) obesity [online]. Available at: http://www.mrc.ac.uk/Achievementsimpact/Storiesofimpact/Obesity/index.htm Accessed at: 14/10/2013
NHS (2013) Weight loss surgery [online]. Available at: http://www.nhs.uk/conditions/weight-loss-surgery/Pages/Introduction.aspx
Accessed at: 17/10/2013
NICE, (2006) Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [online]. Available at: http://www.nice.org.uk/nicemedia/pdf/cg43niceguideline.pdf
NMC (2010) The code: Standards of conduct, performance and ethics for nurses and midwives p.g. 1[online]. Available at: http://www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAndMidwives_LargePrintVersion.PDF ( Date accessed: 18/10/2013)

Saarni SI; Anttila H; Saarni SE; Mustajoki P; Koivukangas V; Ikonen TS; Malmivaara A, (2011) ‘Ethical issues of obesity surgery--a health technology assessment’, Obesity research Vol. 21 (9), pp. 1469-76 available at: http://0-web.ebscohost.com.wam.city.ac.uk/ehost/detail?vid=5&sid=f670d921-76f9-4fdc-bd90-78c4263c3a88%40sessionmgr114&hid=118&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=mnh&AN=21479827 (Accessed:23/10/2013)
Staunton, P. and Cniraella, M., 2004. Nursing and the law. 5th edn. Sydney: Churchill Livingstone.

The Telegraph (2010) NHS rations obesity surgery to save money [online]. Available at:

http://www.telegraph.co.uk/health/healthnews/7035013/NHS-rations-obesity-surgery-to-save-money.html Accessed at: 22/10/2013
Tuckman, B. (1965). Developmental Sequence In Small Groups.Psychological Bulletin . 63 (6).
WHEELER, H., 2012. Law, ethics and professional issues for nursing :a reflective and portfolio-building approach. London: Routledge.